UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE: NO 24 WHITES ROAD CHENNAI – 600 014
PROPOSAL FORM FOR ALL RISKS INSURANCE

SCOPE OF COVER

This Insurance Policy provides cover against Loss or Damage to Gold and Silver Ornaments, Jewellery,
Watches, Cameras and other valuables due to Fire, Theft or Accident from any Fortuitous cause,
anywhere in India except as detailed below :
EXCLUSIONS
The Insurance Policy does not cover :-
(a) Loss or damage arising from War, War like operations, Civil Commotion, Terrorism,
Depreciation, wear and tear, moth, mildew, vermin, the process of cleaning, dyeing, repairing,
over winding of clocks and watches, mechanical derangement, electrical breakdown, breakage of
glass, china and articles of brittle nature, theft from unattended vehicles, detention or
confiscation by Customs or other Authorities and consequential loss.
(b) Money, Securities, Manuscripts, Deeds, Bonds, Bills of Exchange, Promissory Notes, Stock or
Share Certificates, Stamps, Business Books and documents, articles dispatched under contract of
affreightment
THE FOREGOING IS ONLY A BROAD INDICATION OF THE COVER OFFERED. FOR
DETAILS PLEASE REFER TO ANY OFFICE OF THE COMPANY
This type of Insurance is also available under Section III of Householders Policy
NOTE : PLEASE ANSWER EVERY QUESTION AND FULLY
1. (a) Name of Proposer in Full
(In BLOCK LETTERS)
(b) Residential Address
(c) Occupation / Profession & Address
Paid Up Capital (if applicable) :
2. Property to be insured
SR NO. FULL DESCRIPTION OF PROPERTY SUM
INSURED RS.
(Make/Weight/Carritage/Yr. Of Mfg./Type/Model, etc.)
(Ensure that the property is correctly described and insured for full value to get adequate Indemnity)
3. Has Jewellery been recently examined and
valued by an approved Valuer? If so,
furnish the Valuation Certificate. _____________________________
4. Whether cover is also required out-side India.
If yes, give details : _____________________________
5. Is the risk currently insured against Fire,
Theft or All Risks? If so, please state: _____________________________
(a) Name of the Company _____________________________
(b) Policy No. & Period
6. (a) Have you suffered any loss or damage ______________________________
to Jewellery and/or valuables in the past?
(irrespective of whether insured or not)
(b) If so, give full details thereof as under
_______________________________________________________________________
Date of Occurrence Details of Loss Amt. of Loss Rs. Name of the Insurers
7. Has any Company in respect of All Risks Insurance
(a) Declined your Proposal ? _________________________________
(b) Cancelled or refused to renew your Policy?_________________________________
(c) Accepted your proposal on special terms &_________________________________
conditions?
Period of Insurance FROM ____________________ TO_____________________
I/We do hereby declare that the above statements and answers are true and that I/We have not
withheld any information whatsoever regarding the proposal. I/We agree that this proposal and
declaration shall be the basis of the contract between me/us and The New India Assurance Co.
Ltd., whose Policy for the Insurance proposed is acceptable to me/us. I/We undertake to
exercise all ordinary and reasonable precautions for safety of the property as if it were
uninsured.
PLACE :
DATE: Signature of 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
ACCEPTED BY DATE & TIME RATE REMARKS
CODES - OFFICE /DEV. OFFICER / AGENT /BROKERCOLLECTION
/ SCROLL NO POLICY NO.