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

PROPOSAL AND QUESTIONNAIRE FOR COMBINED FIRE, BURGALRY &
MACHINERY BREAKDOWN INSURANCE FOR PUMPING SETS

(Information given herein will be treated in strict confidence)

1. (a) Name of the Proposer: __________________________________________

(b) Postal Address: _______________________________________________

(c) Situation of the Pumping set: ____________________________________

2. Nature of business: ________________________________________________

3. Name of the firm supplying and servicing the pumping set: _________________

4. Have you suffered any loss due to fire, burglary or machinery breakdown, is so, give full particulars:

DESCRIPTION OF PUMPING SET

PUMP DRIVING UNIT Electric Motor Diesel Engine Make: Make: Make:
Section: _______ ___ H.P. _________ RPM ________ H.P. ____ RPM _____

Delivery: __________ Serial No. ____________ Serial No. ______

Serial No.: _________ Year of Make_________ Year of Make______

Year of make: ________ AMPs ______ No of cylinder ____
Centrifugal

Type: ________ Voltage___________ Stroke _____
Turbine Type: Squirrect Cage/ Slip Ring Bore _______
Submersible

5. Sum Insured Rs. __________________________
State the date when the Insurance is to commence
Date ________________ Month _______________ Year _______________

Period of Insurance will be from time of commencement and date till midnight of the previous date and month of next year for annual policy.

I/We hereby, declare and warrant that the above statements are true and complete and that I/We have withheld on information whatsoever which is material for the acceptance of this proposal. I/ We agree that declaration and the answers given above shall be the basis of the contract between me/us and the Company and shall be deemed to be incorporated in such contract. And that if any untrue statement he contained therein the said contract shall be absolutely null and void. I/We undertake to exercise all reasonable precautions for the safety of machinery and I/We agree to accept the policy in the form issued by the Company subject to the terms, exceptions and conditions prescribed or endorsed on the policy.

Place: _____________

Date: ______________ Signature: ________________

The liability of the Company does not commence until this proposal has been accepted by the Company and the premium paid.

N.B. (i) Burglary cover available only if the pumping is housed in permanent enclosure
(ii) If insufficient space above for any answer please continue on separate sheet and attach hereto.

PROHIBITION OF REBATES:
The following is an extract of Section 41 of Insurance Act 1938
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 the premium shown in the policy; nor shall any person taking out or renewing continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses of rebates of the Insurer.
2. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to five hundred rupees.

Risk Acceptance (For Office Use)

Development Officers Comment

Signature:

Date: