UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE NO: 24 WHITES ROAD CHENNAI – 600 014
Carrier’s Legal Liability Insurance-Basic Cover Proposal Form

(Note: A separate form should be completed for each vehicle or a statement giving the followingparticulars 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 and area of operation.
a) Whether owned or on hire purchase.
b) Registration No.
c) Make and 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 and type of body.
g) Area of operation of the vehicle (Geographical)
h) Whether the carrier has fixed schedule for servicing and maintenance of the vehicles. If so, give
details.
i) Whether a detailed logbook is maintained for the vehicle.
5. Particulars of comprehensive motor insurance policy:-
(i) Name of Insurer
(ii) Policy No.
(iii) Period
(iv)No claim bonus for current year.
6. Certified copies of forwarding notes, waybills, 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. Specify the nature of cargo normally carried.
9. 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.
10. 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 any special
conditions.
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 the carrier is willing to bear himself?
DECLARATION
I / We warrant that the above statements, made by me/us or on my/our behalf are true and Complete
and I/we agree that the Proposal shall be the basis of the contract between me/us and the Insurers. I /we
agree to accept a policy in the Insurers usual form for this class of Insurance.
Place
Date: Signature of Proposer
Insurance Act 1938
Section 41 of the Indian Insurance Act, 1938, reads as follows 41 (1) 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 or
part of the commission payable or any rebate of premium shown on the policy, nor shall any person
taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed
in accordance with the published prospectuses or tables of the Company.
Any person making default in complying with the Provisions of this section shall be punishable with
fine which may extend to five hundred rupees.
13.