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

CARRIER’S LEGAL LIABILITY INSURANCE (BASIC COVER)
PROPOSAL FORM

BRIEF PARTICULARS OF COVER

The Policy indemnifies the Insured against his legal liability for actual physical loss of or damage to goods or merchandise directly by fire or accident to the vehicle subject to the terms, provisions, exclusions, exceptions and conditions therein or endorsed thereon.
NOTE - A separate form should be completed for each vehicle or a statement giving the following particulars should be attached to this form.
1 Name of carrier

2 Address of Principal Office

3 (a) Whether the carrier is an individual, partnership, private limited or public limited Company.
(b) Date of Registration
4 Particulars of vehicle & Area of Operation:
(a) Whether owned or on hire purchase
(b) Registration No.
(c) Make & Year built
(d) Licensed Carrying Capacity
(e) Type of body of the vehicle, i.e. whether open, side-walled, closed body, tanker or special products carrier.
(f) Is there a trailer attached? If so,
its nature & type of body.
(g) Area of operation of the vehicle
(Geographical)
(h) Whether the carrier has a fixed schedule for servicing & maintenance of the vehicles, if so, give details.
(i) Whether a detailed log book is maintained for the vehicle?
5. Particulars of Motor Insurance Policy:
(i) Name of Insurer
(ii) Policy No.
(iii)Period
(iv) Scope of Cover
(v) No Claim bonus for current year
6. Certified copies of forwarding notes, way bills, consignment notes or other documents relating to any contract of carriage.
7. (a) Practice followed for granting open delivery or damage or shortage certificate.

(b) Whether goods are weighed before booking in all cases?

(c) Whether adequacy of packing is checked in all cases and where deficient is the fact recorded in the consignment note?
8. Was any insurance of carriers legal liability effected during the previous three years? If so, please give the names of insurers, scope of cover, period of cover, rate of premium and claims record.
9. Has any insurer, in connection with any of the risks proposed for insurance, ever.
(a) declined your proposal?
(b) refused to renew or cancelled your policy?
(c) required any increased premium or additional or reinstatement premium or imposed special conditions?
10. Specify the nature of cargo normally carried.

11. (a) Limits of liability required to be
covered per accident.
(b) Whether Riot and Strike risk to
be covered.
12. What amount out of each claim is the carrier willing to bear uninsured.
I/We HEREBY DECLARE AND WARRANT that the above statement are true and complete. I/We desire to effect an insurance with the Company and I/We agree that this proposal and declaration shall be the basis of the contract between me/us the Company and I/We agree to accept a policy subject to the conditions prescribed by the Company.
Place……………………. Date……………….. 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. 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