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

SHOPKEEPER’S INSURANCE
PROPOSAL CUM SCHEDULE

Agency Policy No.
Insured: Period of Insurance
Name of Proposer in Full: From_____A.M./P.M.
Full Business (Shop) Address: To Midnight_______
Nature of Business/Trade:
Section No. DESCRIPTION OF PROPERTY SUM INSURED Rate
Per
mille
Premiu
m
(for the
use of
the Co.)
I
FIRE &
ALLIED
PERILS
A. BUILDING OF CLASS-A (CONSTRUCTON ONLY)
shop owned by Insured Solely occupied/Partially occupied
B. CONTENTS (excluding money valuables)
1. Furniture, Fixture and Fittings
2. Stock in trade consisting of
3. Goods in Truxt
Note: Total sum insured under items A & B above should not exceed
Rs. 5,00,000
II
BURGLARY
HOUSR
BREAKING
INCLUDING
LARCENY
OR THEFT
CONTENTS:
All contents in the shop Premises stated at the above
address________
NOTE: Insruance on contents should be for value equivalent to the
value mentioned under item-B above.
III
MONEY
INSURANCE
a. In Transit (not exceeding Rs. 50,000/- per any one
carrying)
b. In safe/Steel Cupboard Cash Box(2% of sum insured
under Section I or Rs.10,000/- whichever is loss)
c. In till/counter (1% of the sum insured under Section I or
Rs. 5,000/- whichever is loss)
IV
PEDAL
CYCLE
Make and Year of Frame No. Value
Name Including
Manufacturer Manufacture accessories
____ ______ _________ _____
____ ______ _________ _____
____ ______ _________ _____
V
PLATE
GLASS
Description of Plate Glass and its value
S. No. Description Dimension Value
_____ __________ ______ _________
_____ __________ ______ _________
_____ __________ ______ __________
VI
Neon &
Glow Sign
Inc. theft
of whole
sign
Description Year of manufacture Price Paid Mfg. By
………….. …………………… ………… ……….
…………. ……………………. …………. ……….
………… ……………………. …………. ……….
(2% of the SI under Section-I or Rs. 10,000/- whichever
is less)
VII Carrying trade Samples and/or personal effects of
BAGGAGE
INSURANCE
Insured/Partner
a) baggage in connection with trade carried by the
Insured/Partner/Employee
b) Personal baggage of Insured/partner/employee
(2% of the SI under Section-I or Rs. 10,000/- whichever
is less)
VIII
PERSONAL
ACCIDENT
(Age Group Between 16-55)
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: 1) For table of benefit see attached information sheet
2) For assignment of benefit in case of death please see Policy
IX
FIDELITY
GUARANTE
E
(excluding Salesmen and Commission Agents)
Name Designation Salary(PM) Amount of Guarantee
1. ……. ………….. ………….. …………………….
2. ……. ………….. ………….. ……………………..
X
PUBLIC
LIABILITY
a) Public Liability
(5% of the sum insured under Section-I or Rs. 25,000/-
whichever is less)
b) W.C. Liability (for domestic servants/Driver)
Name of Nature of Monthly As per WC Act As per Tariff
Employee work
Note:
1. The sum insured stated against each section shall Total Premium Rs .
be the maximum limit of Liability/Indemnity under Less:discount for covering
.the policy during the policy period. More than 4 Section…%
2. The liability of the Company does not commence
until the Proposal has been accepted by the NET PREMIUM Rs.
the Company and the full premium paid
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 contract 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.
I/We further declare that all reasonable steps to safeguard the property against loss or damage will be taken
and shall maintain records and books of accounts reasonably required. I/we also hereby declare that I/we
have not insured the building and or contents/stock in trade of the shop for which I/we have filled in this
proposal for more than Rs. 5 lac in aggregate with all the Insurance companies in India.
Place
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 Company.
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