UNITED INDIA INSURANCE COMPANY LIMITED
CONTRACTOR’S PLANT & MACHINERY INSURANCE
PROPOSAL FORM
(The Liability of the Company does not commence until this Proposal has been accepted by the Company and premium paid)
(Information given herein will be treated in strict confidence)

PUT A TICK Mark wherever applicable
(a)Proposer’s Name ____________________________________________
(b)Proposer’s Trade or Business ___________________________________
(c)Proposer’s PostalAddress _______________________________________
_____________________________________________________________
(d) Location of Operation (site of property to insured)____________________
(e)Nearest Railway Station and Distance ___________________
1.Do the items listed represent the entire machinery used by you at the above location
2.(a)Are you at present Insured :(a)Yes/No
(b)If so, with whom ?(b)
3. Has any Company
(a)Declined to insure any of the machinery now proposed ?(a) Yes/ No
(b)Required an increased premium or imposed special conditions? (b)Yes / No
(c) Requested for repairs or made other special stipulations for risk improvement ?(c)Yes / No
4.(a)Are you aware of any defects/damage existing in the machinery.(a)Yes / No
(b) If so, give details there of(b)
5.Do you own or use any equipment other than that described above working on the same site ?
6.Is any of the equipment now proposed
(a) Licensed for road use ? If so, give details (a)________
(b)Covered by any other insurance ? If so give details (b)________
_________________________________________________________________
7. (a) Are you the owner of the proposal equipment ? If yes will you be hiring out ?
(b) If the equipment is hired ;
(i) is insurance you responsibility ?
(ii) is maintenance and operation your responsibility ?
8.Are the premises where the equipment operates well guarded ?
_________________________________________________________________
9. (a) What is the site condition where the equipment will be utilised ?
(b) Are the equipment likely to operate on reclaimed or soft ground ?
(c) Are ground conditions such that equipment are exposed to the risk of toppling over ? If so, give
details ?
(d) Is the site susceptible to flood, sea damage, storm, cyclone or other natural calamities ? If so,
give details and safety precautions taken.
_________________________________________________________________
10. Will equipment belonging to other contractors operate on the same site ?
11.Do you have trained and qualified operators ? Are there any statutory rules governing the
appointment ?
12. Which of the equipments are required to inspected and certified for operation by statutory
rules ?
13. (a)Has your machinery sustained any damage from break down or other cause during last 3
year ? (a) Yes /No
(b)If so give details of damage/s and Repairing cost (b)
14. (a) Are regular periodical inspections of the machinery carried out ?
Yes /No
(b) If so, by whom and at what intervals?
15.On payment of additional premium do you wish to cover :- (If yes, provide limits of indemnity)
(a) Express freight (excluding Airfreight), overtime and Holiday rates of wages(a) Rs....... No
(b) Owners surrounding property. (b)Yes Rs....... / No
(c) Clearance & Removal of Debris (c)Yes Rs....... / No
(d) Third Party Liability :
(i) For any one accidents (d) Yes(i) Rs........./No....
(ii)For all accidents during the period (ii) Rs............
16.Period of Insurance From To
SCHEDULE OF MACHINERY TO BE INSURED
GUIDE NOTES :
I. Each Machinery should be entered separately with necessary specifications as mentioned in
Schedule Column No. 3
II. The Sum Insured must be calculated on the present day new replacement value of the Machinery
to be insured including provision for packing, freight and also value of foundations, erection cost
customs duty, etc. to afford full protection under this Policy.
III. If any of the Machines is a ‘Stand By’ this fact should be mentioned.
IV. All portable Machines must be so designated. All items in the open must be so described
separately.
Sr.No. Quantity Description
Type,Model,Capacity of
Machine/Serial
No.HP/KVA
Volts,AMPS,RPM
Maker’s Name
and Country
of Origin
Year of Make Sum Insured
1 2 3 4 5 6
I/We the undersigned hereby declare that the above statements and particulars are true and
complete and I/We declare and agree this declaration and the answers given above shall be held to
be promissory and shall be the basis of the contract between me/us and the Company.
Place : _______________
Dated : ______________ Proposer’s Signature ___________