The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001
PROPOSAL FORM FOR PLATE GLASS INSURANCE

BENEFITS OF THE POLICY

The insurance is against loss of insured Glass occasioned by Breakage but excludes breakage caused through Fire, Gas, Heat or any loss that could be covered by a Fire Policy, Earthquake War Invasion, Foregin Enemy, Hostilities or Military or Usurped Power, Riot, Civil Commotion, Strikers Locked-out workers or persons taking part in labour disturbances ,Terrorism & sabotage risks.

Some of the excluded risks can be covered by special arrangement, on payment, of an additional premium.
PLEASE ANSWER ALL QUESTIONS FULLY

Proposer’s Name__________________________________________________________
Address________________________________________________________________

Occupation_____________________________________________________________

1. Situation of the Premises in which the glass is contained.
2. Name of the Business carried on in the premises
3. Are the Premises situated at the corner of a street or exposed to any special risk ?

4. Are you Proprietor or Tenant ?
5. Is there any glass in the Premises not included in the Schedule? If so, specify it.
6. Is there at present any broken or damaged glass. If so, described its position and size.
7. Have there been any previous Breakages ? If so, give particulars.
8. Has the risk been previously insured? If so,
a) The Name of the Insurance Company___________________________
a) Policy No.__________________________
b) Period _________________________
c) Rate Charged________________________
d) Any special terms and conditions imposed _________________________________________________

9. Has any Company refused to accept or continue your insurance or increased the premium thereof ?
PARTICULARS OF GLASS TO BE INSURED
Position of each square of pane of glass Size of each square of pane Description of glass: state whether plain plate or Plain Sheet painted Rough silvered Embosed Stained Bent or ornamental Value Premium
Height in Cms. Width Cms.
Note: In the event of the loss all Glass is consider plain unless the contrary is specially stated in the Policy. No Lettering, Embossing Silvering, or any ornamental work is considered unless stated in the policy.

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 the 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.

Date:______________ Proposer’s Signature_________________________

Proposal form completed by
Proposal Introduced by: Name and signature of Agent/ Broker / Inspector

PROHIBITION OF REBATE
Section 41 of the Insurance Act, 1938
1. “No person shall allow, or offer to allow, either directly or indirectly as inducement to any persons 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 or part of the commission payable or any rebate of the premium show on the policy nor shall any person taking out or renewing or continuing a Policy accept any rebate except such rebate as may be allowed in accordance with the published prospectuses or table of the insurer.
2. Any person making default in complying with the provisions of the section shall be publishable with fine which may extend to five hundred rupees.

Note: Insurance is the subject matter of solicitation.