UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE: NO 24 WHITES ROAD CHENNAI – 600 014
COMMERCIAL PACKAGE KIT (COMPACT) INSURANCE
Proposal Form

DO/BO Code: Fresh Proposal /
Renewal
Dev. Officer Code: Agency Code:
1.
Name of the Insured: 1.
2.
Address for communication: 2.
3.
Description of Business / Profession: 3.
4.
a) Address of the premises to be insured (If
different from 2 above
b) Please indicate whether the premises is own or
rented
c) Do you wish to cover the building under
Section I? If so whether under Reinstatement
Value (RIV) basis or Market Value (MV)
basis?
(please contact our office for exact definition of
RIV and MV)
4. a)
b) Own / Rented
c) Yes / No
If yes, on RIV / MV
basis
5.
Has any of the items covered under the following sections/ endorsements
suffered any damage previously? If so, give details of the same in the following
format. Attach a separate sheet, if necessary.
Date of
Occurrence
Details of
Loss
Amount of Loss
(Rs.)
Name of the Insurance
Company
6.
Give details of previous insurance, if any
7.
Has any Company in respect of any of the items proposed for insurance
hereunder
a) Declined your proposal?
b) Cancelled / refused to renew your Policy?
c) Accepted your proposal on special terms and conditions?
8.
Please indicate the Sections to be covered under the Policy by putting a tick
mark in the appropriate column.
Sectio
n No.
Description of property Sum Insured
(Rs.)
Rate (Rs. Per
1000)
I. Fire
&
Allied
Perils
A. Building. (Refer 4 (c) above)
B. Contents (Incidental stock to
be declared specifically)
(Please attach a separate list).
C. Tenant’s Legal Liability
Rs-----------
Rs-----------
Rs----------
II.
Burgla
ry &
House
breaki
ng
Contents
(Please attach a separate list)
Rs ---------
III.
Electrical
&
Mechanica
l
Appliance
s
Item Serial
No.
Year of Mfg. Rs ------------
Please attach a separate list
Note: All items without
selection have to be declared
for Insurance
IV.
Electronic
Appliance
s
Item Serial
N
o.
Year of
Mfg.
Rs ------------
Please attach a separate list
Note: All items without
selection have to be declared
for Insurance
V. Money
Insurance
Please indicate the amount to
be insured
a) In transit
Max. Limit per carrying
Rs----------
b) In Safe
c) In Till
Rs ------------
Rs ------------
Rs ------------
VI.
Personal
Accident
NamAeg e Designation
Capital
Sum
Insured
(Rs.)
Rs ------------
Please attach a separate list
VII.
Infidelity /
Dishonest
y of
employees
Name Designation Limit
of
lia
bili
ty
Rs. 6.00 on
the Sum
Insured
selected
+ Rs. 10
per
person
on the
number
of
persons
to be
covered
Please attach a separate list
VIII.
Legal
Liability
A. Towards Third Parties
AOA= AOY= Sum Insured
Rs. ----------
As per W. C
Act
B. Towards Employees
Est.
No
.
of
em
p.
Nature
of
W
or
k
Est. Wages
Please attach a separate list
IX. Fixed
Glass /
Sanitary
Fittings
Description of plate glass /
sanitary fittings Rs ------------
Please attach a separate list
X. Neon /
Glow Sign
/ Hoarding
Description Year of Mfg.
Please attach a separate list Rs.------------
9.
Do you wish to cover any of the following endorsements? If so, please indicate
the endorsements to be covered under the Policy by putting a tick mark in the
appropriate column.
A.
Do you wish to cover baggage?
If yes, please indicate the amount to be covered.
(If you wish to cover Travelling Advance and
Business Sample, please specify and the value
thereof)
Yes / No.
B.
Do you wish to cover the Loss of Profits? If yes,
please indicate
a) Sum Insured for
i. Gross Income
ii. Additional Expenditure
iii. CA’s Fees
b) Indemnity Period opted for (Indemnity
period cannot exceed 12 months)
Yes / No
Rs -----------
Rs -----------
----------- months
C.
Do you wish to extend this Policy to cover
students towards Personal Accident? If yes,
please indicate
a) limit of liability
i. per student per accident
ii. per accident for all students
iii. per year for all students for all accident
(This endorsement also covers hospitalisation
expenses arising out of accident the limit for
which depends on the Compensation limit
chosen for a student)
Rs. ---------------
Rs. ---------------
Rs. ---------------
D.
Do you wish to cover Professional Negligence?
If so, please indicate Limit of liability for the
establishment
a) per accident
b) per year
Rs. ---------------
Rs. ---------------
E.
Do you wish to cover occupants Benefits?
If so, please specify the limits for the following
sub-sections
(AOY = Any One Accident)
(AOY = Any One Year)
(AOO = Any One Occupant)
a) Loss of belongings
b) Legal Liability towards
i. Valuables under care, control and custody
ii. Food and beverages
iii. Extra facilities such as health clubs, beauty
parlours, shops, swimming pools, indoor
and outdoor sports
iv. Aqua sports facilities
v. For inclusion of skydiving, skiing and hang
gliding
c) Personal Accident for occupants
AOO AOYfor
all
occupants
a)Rs. 5,000/-
Rs.1,00,000/-
b)AOA (Rs.) AOY
(Rs.)
c) AOA (Rs.) AOY
(Rs.)
F.
Do you wish to cover additional rent for
alternative accommodation as consequent of fire
to insured premises?
If so, please indicate the amount for which the
coverage is required?
Limit of Indemnity:
The sum(s) produced by multiplying the
monthly additional rent or actual additional rent
whichever is lower by number of months for
which the Insured Premises was unfit occupancy
or the maximum indemnity period of 12 months.
The sum insured is the maximum liability of the
Company under this Endorsement.
Monthly Additional Rent:
a) If the Insured is owner-occupant it is
calculated by dividing 10% of the Sum
Insured under Section 1(A) by 12 (twelve).
b) If the Insured is tenant, it is calculated by
dividing the 25% of the Sum Insured on
contents under Section I (B) by 12.
Rs.-------------------
For Office Use only
Total Premium
Add: Premium for endorsements No.
Sub-Total (I)
Less: Section Discount covering
more than ------sections / Endorsements
sub Total (II)
less: Renewal Discount for ----- Renewal
sub-Total (II)
NET PREMIUM
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
Note:
1. Section / Renewal Discounts are applicable on all sections/endorsements
except Sections I,III, IV, VIII and Endorsements B.
2. Section I is compulsory. The policy should be taken for a minimum of 5
sections including Section I.
The liability of the company does not commence until the proposal has been
accepted by the company and the full premium paid to the Company.
We hereby declare that the particulars contained herein are true and correct and that
no material fact has been withheld, misstated or misrepresented and also that this
proposal cum schedule forming part of the company’s standard policy shall be the
basis of contract between us and the Insurance Company. We further declare that the
sum insured herein represents the full value of the property described herein.
Place :
Date : Signature
of Proposer
Section 41 of The Insurance Act 1938
Prohibition of Rebates
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 on the policy
nor shall any person taking out or continuing a policy accept any rebate except
such rebates as may be allowed in accordance with the prospectus or tables 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 Rs. 500/-