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

PROPOSAL FOR SPECIAL CONTINGENCY INSURANCE

1. (a) Name of proposer (in full)

(b) Address

(c) Occupation, Trade or Business

(d) Paid up Capital (if applicable)

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2. (a) Property to be covered

(b) Identification marks (if any)
and make / model

(c) Is the property in perfect
condition?

(d) Whether purchased new or
second hand & date of purchase

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3. Perils to be covered
(specify clearly)
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4. (a) Price paid by the proposer

(b) Sum Insured (for each item
separately) (attach a separate
sheet, if necessary)

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5. (a) Location/s

(b) Do you wish to cover the
property whilst in transit?
If so, what would be the mode
of transport?

(c) Whether accompanied by the
Insured / employees?

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6. PREVIOUS INSURANCE HISTORY

(a) Has the property been insured
in the past or at the present
time? If so, give full particulars
(b) Have you ever sustained loss in
the past? Give full particulars
(c) Has any Insurance Company ever
declined a proposal from you or
terminated your policy?
Give particulars and reasons
(d) Has any Insurance Company
imposed any restrictions?
Give particulars and reasons
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7. State all other information
material to the risk

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8. Period of Insurance From ___________To___________

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I/WE HEREBY DECLARE AND WARRANT that the above statements are true and complete. I/WE desire to effect an insurance with the Company and I/WE agree that this proposal and declarations shall be basis of the contract between me/us and the Company and I/WE agree to accept a policy subject to the conditions prescribed by the Company.

DATE: PLACE: 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. Please answer every question and fully 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.