NATIONAL INSURANCE CO. LTD
(Subsidiary of General Insurance Corporation of India)

ADDRESS OF THE POLICY ISSURING OFFICE
Regd. Office : 3, Middleton Street, Calcutta – 700 071

PROPOSAL-CUM-POLICY SCHEDULE FOR HOUSEHOLDERS’ INSURANCE

The Company : NATIONAL INSURANCE CO. LTD Agency
Attached to and forming part of Policy No
Proposer’s Name(in full)
Residential Address
Occupation :
Period of Insurance
.
(a) From AM/PM on
To Midnight of
(b) Any subsequent period for which the Insured shall pay
and the Company shall agree to accept the Renewal Premium.
Section No. Description of Property Sum
Insured
Rates
per mille
Premium (for the
use of the Co.
I
FIRE &
ALLIED
PERILS
A. BUILDING OF CLASS –A(CONSTRUCTION
ONLY)
CONTENTS : belonging to the Proposer and members
of his family permanently residing with him/her
NOTE :
No one article other than furniture is deemed to be more
than 5% of the Sum Insured under this Section unless
separately specified hereunder and value stated.
Sl. No. Description Value
(If space is not sufficient please attach separate sheet
giving details)
Rs.
Rs.
0.60
0.60
Rs.
Rs.
II
BURGLARY
HOUSE
BREAKING
INCLUDING
LARCENY OR
THEFT
CONTENTS
All contents in the premises stated at the above address
NOTE : Insurance on contents should be for Value
equivalent to the value mentioned under Section 1-B
above
Rs.
2.40
Rs.
III
ALL RISKS
Jewellery & Valuable described as under
Sl. No. Description Value
1. If the space is insufficient please write on a
separate page and attach herewith.
No one article or pair of article is deemed to be
more than 10% of the sum Insured Under this
Section unless separately Specified and value
stated.
IV
Plate Glass
DESCRIPTION OF PLATE GLASS Rs. 10.00 Rs.
Description of all Electrical,
Electronic and Mechanical
Appliances. Appartuses or Gad-
Gets belonging to the prosper
Year of
Make
Value
V
Breakdown of
Domestic
Appliances
Total
Rs.
2.50
Rs.
Name of
Manufacture
Make Model Year of
Make
VI Value
T.V.SET
Rs.
10.00
Rs.
Make &
Name of
Manufacture
Year of
Manufacturer
Frame No Value
Including
accessories
VII
Pedal
Cycles
Total Value
Rs.
20.00
Rs.
VII
Baggage
Insurance
Details of Personal Baggage. Personal effects and other articles carried
during the period of travel anywhere in India
Rs.
7.50
Rs.
Name Age Occupation
Relationship
with
proposer
Details of
existing
Informly
Disability
Name of
Assignee
Table
of
Benefit
opted
Rs.
As per
Tariff
Rs.
IX
Personal
Accident
NOTE : (I) for Table of Benefits see attached Information sheet.
(ii) for Assignment of benefits in case of death (pl. see
reverse)
X
LIABILITY
(A) Public Liability
(B) W.C. Liability for domestic servants
Rs.
0.50 As per
W.C.Tariff
Rs.
TOTAL PREMIUM Rs.
Less:
Discount for covering % Rs.
More than 4 section
__________________
NET PREMIUM Rs
__________________
NOTE : The Liability of the Company does not commence untill the
Proposal has been accepted by the Company and the full premium paid.
I/We hereby declare that the particulars contained herein are true and correct and that no material fact been withheld, misstated or
mispresented and also that this propsal-cum-schedule forming part of the Company’s standard policy shall be the basis of the
contract between me/
Place: ______________ Date __________ Signature of the Proposer
ASSSIGNMENT CLAUSE FOR PERSONAL ACCIDENT
I ________________________do hereby assign the money payable in the event of my death by National Insurance Company
Limited to
Shri/Smt ____________________my ____________and I further declare that his receipt shall be sufficient discharge to the
Company.
Place : Date : Signature of the Proposer
Assignment witnessed by
Sl. No. N a m e A d d r e s s S i g n a t u r e
1.
2.
Note : In case of more than one person is covered separate Assignment clause is required to be signed by each proposer on a sheet
of paper duly witnessed by two persons and to be attached with this Proposal-cum-Policy Schedule.
( TO BE COMPLETED BY THE INSURANCE COMPANY )
SPECIAL CONDITIONS : INSURANCE COVER HEREIN APPLIES TO SECTION NOS……..ABOVE.
In witness whereof this Policy has been signed
At _______________this ______________ day of _____________200
Note : This Schedule and the attached Policy shall be read together and any word or expression to which a specific meaning has been
attached in any part of this Policy or of the Schedule shall bear the same meaning wherever it may appear.
For and on behalf of
National Insurance Company Limited
AUTHORISED SIGNATORY