THE NEW INDIA ASSURANCE COMPANY LIMITED
Regd. & Head Office:New India Assurance Building,87,Mahatma Gandhi Road,Fort,
Mumbai 400 001

PROPOSAL FOR MACHINERY INSURANCE

(The liability of the Company does not commence until this proposal has been accepted by the Company and premium paid)

(Information given herein will be treated in strict confidence)

PUT A ( ) MARK WHEREVER APPLICABLE

(a) Proposer's Name ____________________________________________
(b) Proposer's Trade or Business ___________________________________
(c) Proposer's Postal Address _____________________________________
___________________________________________________________
_____________________________
(b) Address where plant to be Insured is located ______________________
(e) Nearest Railway Station and Distance ____________________________

1. Do the items listed represent the whole of the Plant Yes/No
2. (a) Are you at present Insured : (a) Yes/No
(b) If so with whom ? (b)
3. Has any Company -

(a) Declined to insure any of the machinery now
Proposed ? (a) Yes/No
( b) Required an increased premium or imposed
special conditions

(c) Requested for repairs or made other special(b) Yes/No
stipulations for risk improvement ?
4. (a) Are you aware of any defects/damage existing (a) Yes/No
in the machinery.

(b) If so, give details thereof (b)
5. (a) Has your machinery sustained any damage from
breakdown or other cause during last 3 years ? (a) Yes/No
(b) If so, give details of damage/s and repairing cost(b)
6. (a) Are regular periodical inspections of the machinery (a) Yes/No
carried out ?
(b) If so, by whom and at what intervals ? (b)
7. On payment of additional premium do you wish to If yes, provide limits
cover :- of indemnity
(a) Express Freight (excluding Airfreight), overtime
and Holiday rate of wages (a) Rs. No.

(b) Owners surrounding property (b) Rs. No

(c) Third party Liability (c) Rs. No.
8. Period of Insurance From To

SCHEDULE OF MACHINERY TO BE INSURED
GUIDE NOTES
1. Each Machinery should be entered separately with necessary specification as mentioned in Schedule column No. 3
2. The sum Insured must be calculated on the present day new replacement value of the Machinery to be insured including provision for packing, freight and also value of foundations, erection costs, customs duty, to afford full protection under this Policy.
3. If any of the Machines is a 'Stand by' this fact should be mentioned.
4. All portable Machines must be so designated. All items in the open must be so described separately.
5. Separate value for foundations masonry and brickwork or oil in transformers and other electrical equipments are to be specified if cover is required.
Sr. Quantity Description Type, Model Maker's Name & Year of Make Sum Insured
No. Capacity of Machine/ Country of Origin
Serial No. H.P./KVA Volts
AMPS, RPM
1 2 3 4 5 6

I/We the undersigned hereby declare that the above statement and particulars are true and complete and I/we declare and agree that this declaration and the answers given above shall be held to be promissory and shall be the basis of the contract between me/us and the Company.

Place :_________________

Dated :_________________ Proposer's Signature_____________

PROHIBITION OF REBATES

Section 41 of Insurance Act 1938

1. 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 live or property in India, any rebate of the whole or 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 such rebate as may be allowed in accordance with the published prospectuses or tables of the insurer.

2. Any person making default in Company with the provisions of this section shall be punishable with fine which may extend to five hundred rupees.