The Oriental Insurance Company Limited
Head Office, A-25/27, Asaf Ali Road, New Delhi-110 002

HOUSEHOLDER’S INSURANCE
PROPOSAL CUM SCHEDULE

Agency Policy No.
Insured: Period of Insurance
1. Name of Proposer in Full: From_____A.M./P.M.
2. Residential Address: To Midnight_______
3. Occupation:
Section No. DESCRIPTION OF PROPERTY SUM
INSURED
Rate
Per
mille
Premium
(for the use of
the Co.)
I
FIRE &
ALLIED
PERILS
A. BUILDING OF CLASS-A (CONSTRUCTON
ONLY)
B. CONTENTS : belonging to the Porposer and members
of his family permanently residing with
him/her______
a) Further, Personal affects and Household
goods (no one articles other than furniture
is deemed to be more than 5% of the sum
proposed for Insurance under this Section
Unless separately specified hereunder and
value stated)
S. No. Description Value
_____ __________ ______
_____ __________ _____
_____ __________ ______
b) Other it ems s (to be specified separately
S. No. Description Value
_____ __________ ______
_____ __________ _____
_____ __________ ______
II
BURGLARY
HOUSR
BREAKING
INCLUDING
LARCENY
OR THEFT
CONTENTS:
All contents in the premises stated at the above address________
NOTE: Insruance on contents should be for value equivalent to
the value mentioned under item-B above.
III
ALL RISKS
JEWELLARY AND VALUABLES
Description of Jewellary and Valueables
S. No. Description Value
_____ __________ ______
_____ __________ _____
_____ __________ ______
(if space not sufficient please attach separate sheet giving details)
IV
PLATE
GLASS
Description of Plate Glass and its value
S. No. Description Value
_____ __________ ______
_____ __________ _____
_____ __________ ______
V
BREAK
DOWN OF
DOMESTIC
APPLIANCES
Description of all Electrical, Electronic and Mechanical
appliances, apparatuses or Gadgets belonging to the proposer.
S. No. Description Year of Make Value
____ _________ __________ ________
____ _________ __________ ________
Total:-___________
VI
T.V. SET
Make Model Year of Make Value
____ ______ _________ _____
____ ______ _________ _____
____ ______ _________ _____
VII
PEDAL
CYCLE
Make and Year of Frame No. Value
Name Including
Manufacturer Manufacture accessories
____ ______ _________ _____
____ ______ _________ _____
____ ______ _________ _____
VII
BAGGAGE
INSURANCE
Details of personal Baggage, Personal effects and other articles
carried during the period of Travel anywhere in India.
Baggage Description Value
_______ ___________ _____
_______ ___________ _____
_______ ___________ _____
IX
PERSONAL
ACCIDENT
Name Age Occupation Relationship Details of Table Name Rate as
With proposer existing Benefits of per
Infirmity/ Assignee Tariff
Disability & address
1.
2.
3.
NOTE: for assignment of benefit in case of death please see below
X
PUBLIC
LIABILITY
A) Public Liability
B) W.C. Liability (for domestic servants/Driver)
S. No. Name Occupation
Note:
1. The liability of the Company does not commence until the Total Premium Rs.
proposal has been accepted by the Company and the full premium Less:discount for covering
paid. More than 4 Section…%
2. The sum inured stated against each Section shall be the maximum
limit of liability/ indemnity under the Policy during the Policy Rs.
Period, for the said section. NET PREMIUM Rs.
I/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 on the basis of the cont5ract between me/us and the Insurance
Company. I/We further declare that the sum Insured herein represent the full value of the property
described herein.
Plance
Date Signature of Proposer
ASSIGNMENT CLAUSE FOR PERSONALACCIDENT INSURANCE-SECTION IX
I__________do hereby assign the money payable in the event of my death by the ORIENTAL
INSURANCE COMPANY LTD. to____________(relation to insured/Insured Person) and I further declare
that his receipt shall be sufficient discharge to the Co mpany.
Dated this_____________day of________________200
WITNESS: 1) Name:
2) Adddress:
Signature of Proper
(TO BE COMPLETED BY INSURANCE COMPANY)
SPECIAL CONDITIONS: INSURANCE COVER HEREIN APPLIES TO SECTION
NOS______ABOVE.
IN WITNESS WHEREOF SIGNED BY AND ON BEHALF OF THE COMPANY AT _________ON
_____________DAY OF ________200__
FOR THE ORIENTAL INSURANCE CO. LTD.
OFFICE ADDRESS:
Authorised Signatory
The Oriental Insurance Company Limited
Head Office, A-25/27, Asaf Ali Road, New Delhi-110 002
HOUSEHOLDER’S INSURANCE
List of Articles covered/to be covered
Cover Note No. ……………………..(To be filled uop by the inspector or issuing office)
Policy No. . ……………………
Name of the Insured/Proposer. ……………………
Address of Insured’s. ……………………. ……………………. ……………………. …………
Residential premises. ……………………. ……………………. ……………………. ………………
Occupation. ……………………. ……………………. ……………………. …………………….
Section -A
Clothings (Please include Gents/Ladies/Children’s Clothings while giving the approximate value)
Amount
a) Cotton ……………………
b) Woollen. ……………………
c) Silken. ……………………
d) Others. ……………………
Sub Total (A) . ……………………
Section-B
Kitchenware/Crorckery/Cultery etc.
a) Utensils . ……………………
b) Gas Burner and Cylinder . ……………………
c) Crockery . ……………………
d) Cutlery . ……………………
e) Cooking Range . ……………………
f) Oven . ……………………
g) Others . ……………………
Sub Total (B) . ……………………
Section-C
Furniture /Fixture
a) Sofa Set . ……………………
b) Dining Tables . ……………………
c) Dressing Tables . ……………………
d) Beds . ……………………
e) Study Tables . ……………………
f) Carpets with size . ……………………
g) Almirahs . ……………………
h) Decorative Pieces . ……………………
i) Curtains . ……………………
j) Any other item i) . ……………………
ii) . …………………
iii) . ……………………
Sub Total (C) . ……………………
SECTION-D
Miscellaneous items Proposer Estimated Value
a) Toys . ……………………
b) Household linens . ……………………
c) Books . ……………………
d) Boxes/Suitcases . ……………………
e) Any other item . ……………………
Sub Total(D) . ……………………
Section-E
Electrical/Mechanical Appliances
Make Model Amount
a) Refrigerator …….. ……… ………..
b) Airconditioner …….. ……… ………..
c) Heater/Toster …….. ……… ………..
d) Video …….. ……… ………..
e) Sewing Machine …….. ……… ………..
f) Radio/Transistor …….. ……… ………..
g) Iron …….. ……… ………..
h) Washing Machine …….. ……… ………..
i) Table/Ceiling Fans …….. ……… ………..
j) Lamps …….. ……… ………..
k) Cooking Range …….. ……… ………..
l) Oven …….. ……… ………..
m) Any other item …….. ……… ………..
i) …….. ……… ………..
ii) …….. ……… ………..
iii) …….. ……… ………..
Sub Total (E) …………….
Section-F
Valuables Make Model Amount
a) Watches ……. …….. ……….
b) Timepieces ……. …….. ……….
c) Other Articles
(Cameras, Costly Pen
set etc.) ……. …….. ……….
i) ……. …….. ……….
ii) ……. …….. ………
iii) ……. …….. ……….
Sub Total(F) …………..
Section-G
Jewellary
1) Silverware Weight No. of Articles Amount
i) ……… …………….. ……….
ii) ……… …………….. ……….
iii) ……… …………….. ……….
2) Gold Items Make14/22) No. of Articles Weight Amount
i) Bengles ……… …………….. ………. ……….
ii) Neklace ………. …………….. ………. ………..
iii) Kangan/Kara ………. ……………. ……….. ………..
iv) Rings ………. ……………. ……….. ………..
v) Tops ………. ……………. ……….. ………..
vi) Ear Rings ………. ……………. ……….. ………..
vii) Other Items ………. ……………. ……….. ………..
a) ………. ……………. ……….. ………..
b) ………. ……………. ……….. ………..
c) ………. ……………. ……….. ………..
d) ………. ……………. ……….. ………..
e) ………. ……………. ……….. ………..
Sub Total (G)……………
Section –H
T.V. Set Make Model Amount
i) ……. ……… ………..
ii) ……. ……… ……….
Sub Total(H)……………
Section-I
Pedal Cycle
i) ………. …….. ………..
ii) ……….. ……. ………..
Sub Total(I)……………
Section –J
Details of Personal baggage
(Only if Section viii is to be covered)…………………………………………………………………………
i) Description of Baggage & Packages Excluding valuables………………
Sub Total(J)……………
GRAND TOTAL RS…………………………..
Signature of the Proposer
Date:
NB: Number of diamonds set on the Jewellery to be declared separately, if value of any
single diamond exceeds Rs. 2,500/- kindly attach a valuation certificate from a reputed
jeweler.