The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001

PROPOSAL FORM FOR LIFT INSURANCE
BENEFITS OF THE POLICY

The Company indemnifies insured within agreed limits of amounts in respect of his Legal Liability for accidental injury to a person caused by or in connection with the use of the insured Lift/s.
In addition to the indemnity the Company also pays all costs and expenses incurred with its written consent in defending claims.
LIMITS OF INDEMNITY
In respect of any one person In respect of any once accident In all in any one year
Rs. 1,500 Rs. 3,000 Rs. 5,000
Rs. 3,000 Rs. 5,000 Rs. 10,000
Rs. 5,000 Rs. 10,000 Rs. 20,000
Rs. 10,000 Rs. 20,000 Rs. 40,000
Cover is also obtainable for other higher amounts in multiples of Rs.5,000/- in respect of any person double such amount in respect of any one accident and four times such amounts in any one year.
THE FOREGOING IS ONLY A BROAD INDICATION OF THE COVER OFFERED. FOR DETAILS PLEASE REFER TO ANY OFFICE OF THE COMPANY.
PLEASE ANSWER EVERY QUESTION AND FULLY
Proposer's Name (in full) :
Address :

Business or Trade : Paid Up Capital (if applicable) :
Details of the Lift/s :
Number Name of Makers Type (Passenger or goods lift) Motive Power Carrying/ Capacity (incl. Attendant) Date of Erection No. of Floors served Size

1. Address of Premises in which the lift is
situated
2. Is Proposer's interest as Tenant or
Landlord ?
3. (A) What is the attendant's Age ?
3. (B) And how long has he been in-charge
of lift ?
4. (A) Will each lift shaft be completely
enclosed ?
4. (B) Will each lift shaft be fitted by gate ?
4. (C) Will each lift cage be fitted with gate
which is securely fastened when shut ?
4. (D) Are the lift and the approaches to
the lift well protected ?
5. By whom and how often are inspection
made ?
6. Have any accidents of any kind
occurred ? if so give particulars
7. Have any claims been made against you
during the last three years ? if so give
particulars
8. Has the risk been previously Insured ?
If so,
(a) The Name of Insurance Company
(b) Policy No.
(c) Period
(d) Rate Charged
(e) Any special terms & conditions imposed
9. Has any Company refused to accept or
continue your insurance or increased
the premium thereof ?
LIMITS OF INDEMNITY REQUIRED (See Schedule on the reverse)
Rs. ________ in respect of any one person.
Rs. ________ in respect of any one accident.
Rs. ________ in all in any one year.

I / We hereby declare and warrant that the above statements are true and complete. I / We desire to effect an Insurance as described herein with the Company and I / We agree that this proposal and declaration shall be the basis of the contract between me / us and the Company, and I / We agree to accept Policy subject to the conditions prescribed by the Company.

Dated 20 Proposer's Signature _______________

Note 1.The liability of the company does not commence until the proposal has been accepted by the
Company and full premium paid.
2. If space is found insufficient, please attach separate sheets for details.
3. Premium will be quoted on application.
4. Insurance is the subject matter of solicitation.
PROHIBITION OF REBATE -- Section 41 of the Insurance Act 1938
No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole part of the commission payable or any rebate of the premium shown on the policy nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebates as may be allowed in accordance with the published prospectuses or tables of the Insurer.
Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to Five Hundred Rupees.
FOR OFFICE USE -
MARKETING / DEVELOPMENT OFFICER'S REPORT
The Proposer is known to me/my agent / Broker for___years and I recommend acceptance of this proposal.

Name and Code No. Signature of Dev. Officer / A/AO-D

ACCEPTED BY DATE & TIME RATE REMARKS
CODES - OFFICE /DEV. OFFICER / AGENT /BROKER-
COLLECTION / SCROLL NO POLICY NO.