National Insurance Company Limited
(A Subsidiary of General Insurance Corporation of India)
Regd. Office : 3, MIDDLETON STIREET, CALCUTTA – 700 071

PROPOSAL FORM FOR DIRECTORTS AND OFFICERS LIABILITY
INSURANCE AND COMPANY REIMBURSEMENT LIABILITY INSURANCE

This is a Propsal Form for a Policy relating only to claims made against the Insured Party during the currency of the
Policy. Please answer all questions fully (if there is insufficient space herein please use additional sheets and attach
them to this form. Please indicate question number)
SALIENT FEATURES OF THE INSURANCE COMPANY
Insured : Directors & Officers of the Company
Insured event : Indemnifies the Directors & Officers of the Company( and the Company where it is permitted to
indemnify the Directors or Officers legally or by its Articles of association) in respect of their legal liability to third
party claimants resulting from a Wrongful Act(defined in the Policy) committed during the course of managing the
business.
Coverage : (a) Covers Directors & Officers where they cannot be reimbursed.
(b) Covers Directors or Officers where their Company can reimburse them.
Legal Liability to third party may arise
in case of claims by :
(a) Employee/former employee
(b) Shareholders
© Competitors
(d) Company bodies
Policy : The Policy period is for 12 months and it is a claims made policy.
Policy extensions :
Policy may be extended to cover –
(a) Non-Executive Directors
(b) Spouse of Directors and Officers
c) The estates, heirs, legal representatives of the deceased insured.
d) Outside Directorship
(e) Subsidiaries, takeover and merger of the Company.
Defence Cost : Defence costs are also paid subject to the overall limit of indemnity.
Definition :
(i) Wrongful Act : Actual or alleged breach of duty, breach of trust, negligent error, omission, misstatement, breach
warranty of authority
(ii) Director : Member of the Board.
(iii) Officer : A person with authority to commit the Company i e Manager/Company Secretary.
Principle Exclusions :
(a) Dishonest, fraudulent, criminal or malicious act.
(b) Personal guarantee
© Libel and slander and damage to property.
(d) Pollution damage
Premium/Rate : to be decided on submission of completed proposal form.
For details of coverage please refer to the policy
Please state :
1. a. The name of the Company ___________________________________________________________
b. The Address of Head Office __________________________________________________________
_________________________________________________________________________________
c. Country of registration _____________________________________________________________
2. Please state for how long the Company has continiously carried on business _________________________
3. During the past five years has
a. The name of the Company been changed ? _____________________________________________
b. Any acquisition or merger taken place? ______________________________________________
c. Any Right Issue taken place ? ______________________________________________________
d. The capital structure of the Company changed ? ________________________________________
If so, please give full details ______________________________________________________
_______________________________________________________________________________
e. Has the Company any acquisitions or mergers pending or under construction?______________________
If So, please give full details _____________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
f. Please complete Appendix “A” of this form giving the full names of all persons who at the date of this
proposal are Directors and/or Officers of the Company and the capacities in which they respectively serve.
g. Do you require the Director and/or Officers of any Subsidiary Company to be included in the coverage?
Yes/ No _______________________________________
If yes, please complete Appendix B of this form giving the full information requested.
h. Please state :
a. The total number of Ordinary shareholders _______________________________________________
i. b. The total number of i) ordinary shares issued ____________________________________________
ii) Preference shares issued ___________________________________________________________
c. The total number of ordinary shares owned by Directors and Officers(both direct and beneficial) _______
____________________________________________________________________________________
d. The name of shareholder and percentage holding of all shareholding which exceed 5% of the total ______
____________________________________________________________________________________
j. If Directors and Officers Liability Insurance has been carried during the past three years, please state :
a. Insurer _____________________________________________________________________________
b. Expiry Date of the Policy _______________________________________________________________
c. Indemnity Limit ______________________________________________________________________
k. Is the company
Listed on any Stock Exchange in India?
Please specify name ____________________________________________________________________
Listed on any foreign stock exchange?
Please specify country and city ___________________________________________________________
Traded in any other way e.gt. U.S.M.?
Please specify _________________________________________________________________________
4. 1 Has any previous Policy for Directors and Officers Liability Insurance and reimbursement for Directors and
Officers Liability Insurance been (i) cancelled or, (ii) declined for renewal by any Insurer ? ________________
_________________________________________________________________________________________
4. II Has any penal action been taken by the Stock exchange any timer.(Please give details) ___________________
_________________________________________________________________________________________
5. If any insurance similar to that now proposed had been or were now in effect would any claim which has been
made or which is now pending against any past or present Director or Officer of the company or its subsidiaries
have fallen within the scope of such Insurance?
If so, please give full details __________________________________________________________________
__________________________________________________________________________________________
6. Is any Director or Officer aware, the enquiry, of any circumstance which might afford ground for a cliam?
If so, please give full details __________________________________________________________________
7. Amount of indemnity required for
i) Any One Claim in India Rs. _______________________________________________________________
North America/USA/CANADA ___________________________________________________________
Any Other Countries ___________________________________________________________________
ii) Any One Period in India Rs. _____________________________________________________________
North America/USA/CANADA ___________________________________________________________
Any Other Countries ____________________________________________________________________
8. If any cover is required in respect of claims made in USA and Canada or claims made elsewhere arising out
of the Company’s operation in USA or Canada Please complete Appendix ‘C’.
APPENDIX – A
Please complete for all persons who at the date of this proposal are Directors or Officers of the Company :
Name Position held
APPENDIX - B
Please complete for all Directors and Officers of Subsidiary companies to be included under the policy (other than
Directors and Officers of the company appears in appendix- A)
Name of Company Country of
Incorporation
Percentage
Ownership
Number of
Directors
Number of
Officers
Title/Position of each
Director and Officers
APPENDIX - C
A. Please give total gross assets of the Group in India ___________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
B. Please give total gross assets of the Group in other countries ___________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
C. Please list those subsidiaries in India and Other countries which are not wholly owned together with the Company’s
percentage interest in each _______________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
D. For each subsidiary-who owns the monority stock? __________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
E. Does the Company or any of its subsidiaries
i) Have any stock, share or debentures in India and other countries? ___________________________________
ii) If yes, on what date was the last offer/tender/issue made? _________________________________________
_______________________________________________________________________________________
iii) What the offer subject to USA Security Act of 1933 and/or the Securities Exchange Act of 1934 and/or any
amendment thereto and/or Indian Securities Act : ______________________________________________
______________________________________________________________________________________
iv) Have any debt or equity instruments or commercial paper in North America/in India or any other countries?
______________________________________________________________________________________
In the answer to (iv) is YES, what was the most recent effective date?______________________________
______________________________________________________________________________________
F. Please enclose a copy of the latest 20 F filing made to the USA regulatory authorities, If not applicable please
confirm ________________________________________________________________________________
G. Enclose Company’s last 3 Annual Report together with any subsequent interim reports.
DECLARATION
I declare that the statements and particulars in this proposal are true and no materials facts have been mis-stated or
suppressed. I agree that this proposal, together with any other information supplied shall form the basis of any contract
of Insurance effected thereon. I undertake to inform Insurers of any material alteration to those facts occurring before
completion of the contract of Insurance.
Signed _______________________________________________________________________________________
Chairman/Chief Executive _______________________________________________________________________
Company ___________________________________________________________________________________
Date _______________________________________________________________________________________
Office Seal