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

PROPOSAL FORM FOR TELEVISION, VCP & VCR INSURANCE

BENEFITS OF THE POLICY

The Insurance is against (i) loss or damage to the TV Set/VCP/VCR described in the schedule or any part thereof due to any cause whatsoever except as hereinafter mentioned. (ii) All sums which the insured shall legally become liable to pay due to accidental bodily injury to any person not being a member of the Insured’s family or household or in his service. (iii) Accidental damage to property not belonging to the insured or any member of his family or household or any person in his service provided that the liability of the Company shall not exceed in all under (i) the Sum Insured mentioned in the schedule and under (ii) & (iii) Rs.25,000/- for all claims arising out o any one event.
In addition, the Company will also bear all legal expenses incurred with the consent of the Company in defence of any claim.
THE FOREGOING IS ONLY A BROAD INDICATION OF THE COVER OFFERED. FOR DETAILS PLEASE REFER TO ANY OFFICE OF THE COMPANY

(1) a. Name of the Proposer (in full) :

b. Address

c. Occupation

(2) Address at which the Television Set :
is installed

(3) a. Was the Television Set installed by :
a qualified technician
b. Date of Installation :

(4) SCHEDULE OF TELEVISION, VCR, VCP TO BE COVERED:

Description of Set Additional Date purchased Sum Insured
(Name of Maker) & Apparatus and price paid
Type, Year of Mfg

(5) Has the risk been previously Insured?
If so;
a. The name of the Insurance Co. :
b. Policy No.
c. Period
d. Rate Charged :
e. Any special terms and conditions :
imposed

(6) Have you ever suffered any loss or :
incurred any legal liability in connection
with any Television Set?
If so, give details

(7) Has any Company or underwriter any time :
a. Declined your proposal :
b. Required an increased premium or :
special condition
c. Cancelled or refused to renew the :
Insurance

(8) For what period is insurance required: From to

(9) If the set is portable do you require insurance:
when the set is taken away from the premises

I/We hereby declare that the above statements and answers are true and correct and that no material fact has been withheld, misrepresented and that I/We agree that this proposal and declaration shall be the basis of the contract between me/us and the New India Assurance Co., whose standard policy for the insurance proposed is acceptable to me/us.
PLACE :
DATED: SIGNATURE OF THE PROPOSER

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. Insurance is the subject matter of solicitation.
4. Premium will be quoted on application.
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