The New India Assurance Co. Ltd.
Regd. & Head Office : 87, M.G. Road, Fort, Mumbai-400 001.

SHOPKEEPERS' INSURANCE PROPOSAL

AGENCY
INSURED : PERIOD OF INSURANCE FROM :

1. NAME OF PROPOSAL IN FULL TO :
2. FULL BUSINESS (SHOP) ADDRESS
3. NATURE OF BUSINESS / TRADE

SECTION NO. DESCRIPTION OF PROPERTY SUM INSURED Rs. RATES Per Mille PREMIUM Rs.

I
FIRE AND ALLIED PERILS (A) BUILDING (OF CLASS-A CONSTRUCTION ONLY)
SHOP OWNED BY INSURED
SOLELY OCCUPIED/PARTIALLY OCCUPIED
(B) CONTENTS : (Excluding Money/Valuables)
(1) Furniture Fixture Fittings
(2) Stock in trade consisting of
Note : Total Sum Insured under items A & B above should not exceed Rs.10.00,000/- 2.25

2.25
II
BURGLARY AND HOUSE BREAKING CONTENTS : All contents in the shop Premises stated at the address above
NOTE : Insurance on contents should be for value equivalent to the value mentioned under Item I (B) above. 2.50
III
MONEY
INSURANCE (A) In transit (Not exceeding Rs.50,000/- per any one carrying)
(B) In safe (2% of the sum insured under Section-I or Rs.20,000/- whichever is less).
(C) In till/counter (1% of the Sum Insured under Section-I or Rs.10,000/- whichever is less) 2.50
2.50

2.50
IV Make & Name of Manufacturer
1.
2.
3. Year of Mfg. Frame
No. Accessories attached if any 20.00
V
PLATE
GLASS DESCRIPTION OF PLATE GLASS INCLUSIVE DIMENSIONS

(10% of the Sum Insured under Section-I or Rs.1,00,000/- whichever is less) 10.00
VI
NEON & GLOW SIGN (Incl. Theft of the whole sign) Description

Year of Mfg. Price Paid Mfgr. By 10.00
(2% of the Sum Insured under Section-1 or Rs.20,000/- whichever is less)
VII
BAGGAGE INSURANCE Carrying trade samples and/or personal effects of Insured/Partner

(2% of the Sum Insured under Section-I or Rs.20,000/- whichever is less) 7.50
VIII
PERSONAL ACCIDENT (Age Group between 16-65 Details of Existing infirmity/Disability Occupation Table of Benefits opted Name of Assignee & Relationship
Name
1.
2. Age
NOTE : (I) for Table of Benefit see information sheet.
(ii) for assignment of benefits in case of death (Please see below)
IX
FIDELITY
GUARANTEE (Excluding Salesmen & Commission Agent) Amount of Guarantee 10.0
Name
1.
2. Designation Salary (P.M.)
(10% of the Sum Insured under Section-I or Rs.1,00,000/- whichever is less)
X
PUBLIC
LIABILITY (A) Public Liability (5% of the Sum Insured under Section-I (1) or Rs.50,000/- whichever is less) Nature Monthly
(B) Workmen's Name of Employee of work Wages
Compensation
Liability :
XI
BUSINESS
INTERRUPTION As mentioned under Section I As is Section IB As in Section IB
TOTAL PREMIUM
Less : Discount for covering more than 4 sections
%
NET PREMIUM Rs.

Rs.
Rs.
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.

I/WE HEREBY DECLARE THAT THE PARTICULARS CONTAINED HEREIN ARE TRUE AND CORRECT AND THAT NO MATERIAL FACT HAS BEEN WITH HELD, MISSTATED OR MISREPRESENTED AND ALSO THAT THIS PROPOSAL-CUM-SCHEDULE FORMING PART OF THE COMPANY'S STANDARD POLICY SHALL BE BASIS OF CONTRACT BETWEEN ME/US AND THE INSURANCE COMPANY. I WE FURTHER DECLARE THAT THE SUM INSURED HEREIN REPRESENTS THE FULL VALUE OF THE PROPERTY DESCRIBED HEREIN.

I/We also declare that the aggregate value of the Building and contents/stock-in trade relevant to coverage of the cover dose not exceed Rs.10,00,000/- (Rupees ten lacs) whether insured under one or more policies or whether one, or more offices of the subsidiaries.

PLACE DATE Signature of Proposer

-2-

ASSIGNMENT CLAUSE FOR PERSONAL ACCIDENT INSURANCE-SECTION VIII
I do hereby assign the money payable in the event of my death by The NEW INDIA ASSURANCE CO. LTD., to __________________ (relation to the Insured) and I further declare that his/her receipt shall be sufficient discharge to the Company.
Dated this _____________________________________ day _______________ 19 ________________ at ___________________
Witness
1. Name
2. Address Signature of the Proposer

(TO BE COMPLETED BY INSURANCE COMPANY'S)
SPECIAL CONDITION : INSURANCE COVER HEREIN APPLIES TO SECTION NOS _____________________________ ABOVE For The NEW INDIA ASSURANCE CO. LTD.
OFFICIAL ADDRESS :
DATE :