UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE: NO 24 WHITES ROAD CHENNAI – 600 014

DIRECTORS AND OFFICERS LIABILITY INSURANCE
PROPOSAL FORM

1. Please read carefully and answer all questions. If a question is not
applicable, so state. If space is insufficient to answer any question fully,
attach a separate sheet.
2. The original Proposal Form must be submitted.
IMPORTANT NOTICE:
1. This is a proposal form for a claims made policy. That is to say a policy
relating only claims made against the Directors and / or Officers of the
Company shown in answer to question 1 and of its subsidiary companies
(hereinafter referred to as the Proposers) during the currency of the
said policy. ANY CLAIM ADVISED TO UNDERWRITERS AFTER THE
EXPIRY DATE OF THE POLICY PERIOD WILL NOT BE COVERED. The
limit of liability available shall be reduced and may be exhausted by
payments made by United India Insurance Company Ltd (hereinafter
referred to as United India) under the policy. The limit of liability is
inclusive of and not in addition to costs and expenses.
It is the duty of the Proposers to disclose all material facts to United
India. A 'Material fact' is one which may influence United India's
judgement in their consideration of the proposal form. If the proposal
form is a renewal, it is likely that any change in facts previously advised to
United India will be material and such changes should therefore be
disclosed.
Failure to disclose could prejudice the rights of the Proposers to recover
in the event of a claim or allow United India to void this policy.
Appropriate enquiries should be made to ensure that the statements set
forth herein are true and complete and that no material fact has been
omitted. Any Change in the answers given and any material change in the
risk arising before inception of any policy must be advised to United India
and should therefore be notified immediately.
2. In the event that there is any material change in the answers given to the
question contained in this proposal form prior to the inception of the
policy, the Proposers must notify United India and, at the sole discretion
of the United India, any outstanding quotations may be modified or
withdrawn.
3. Signing the proposal form does not bind the Proposers or United India to
enter into a binding contract of insurance.
4. Any request for cover or any aspect of cover, by or on behalf of the
Proposers does not compel United India to offer terms and conditions to
accede to such request.
5. The particulars and statements contained in the proposal form and dany
other information submitted are the basis for the proposed policy and will
be considered as being incorporated into a constituting a part of the
proposed policy.
PROPOSAL FORM
A.
1. Name of the Company
Registered Address:
Country of incorporation
2. The Company has continuously been in business since.
3. Full description of business activities
B.
1. Is the Company
Listed on the Stock Exchange: Yes No
If yes, please state which stock exchange and date listing obtained.
If no, please advise what type of entity is the company.
2. The Company has continually paid cash dividends on its.
ii) Common Stock since
iii) Preferred stock since
3. Complete the following in respect of all classes of shares issued by the
Company.
i) Class of shares:
ii) Number of shares outstanding
iii) Number of shares owned by Directors ( Directly and / or
beneficially)
iv)Number of shares owned by Officers who are not Directors
( Directly and / or beneficially);
4. Total number of Subsidiary Companies at the date of completing this
Proposal Form.
Tick this box if cover is requested for these Subsidiary
companies
5. Does any person or entity own 10% or more any class of shares issued by
the Company.
Yes No
If yes give details:
C. Complete the following for each of the three most recent fiscal years
(The figures presented should be taken from the Group Consolidated
Reports and Accounts)
Section a) should be completed if the Company is a financial institution
otherwise complete Section b) Delete as applicable consult your broker or
agent if advice is required.
a. Current Year Previous Year Earlier Year
Total consolidated Assets
Total Loans
Total Deposits
Net worth
Reserve for Loan Losses
Non performing loans
Net write offs
Total investment securities
Net Income for Fiscal year
Interest Income
Interest Expense
Cumulative Retained Earnings
Total Capital Adequacy Ratio
Tier 1 Capital Adequacy Ratio
Tier 2 Capital Adequacy Ratio
Return on Assets
Return on Equity
Please advise latest independent ratings (giving the dates thereof and name
of rating agency).
b.
Total consolidated Assets
Current Assets
b.
Current Liabilities
Net worth
Stocks and /or Inventory
Net Income for fiscal year
Net Income per Share
Dividends Per Share
Sales / Revenues
At any time over the last five years have there been breaches of any debts
convenants or loan agreements?
Yes No
D.
1. Give details of any current Directors' and Officers' Insurance
i Insurer:
ii Limit
iii Period
iv Retention
v Premium
2. Has the Company, in the past two years or under consideration at the
present time any acquisitions, tenders offers, mergers or offering of
shares or other securities?
Yes No
If yes please give details
3. Are there any qualifications, comments or observations made within the
report and accounts and / or auditors report.
Yes No
If applicable, please provide a translation into English.
4. Are there any contingent liabilities / extra oridinary terms / litigation
shown within the report and accounts?
Yes No
If applicable, please provide a translation into English.
Has the Company, at any time over the last three years changed its
external auditors or external legal advisors?
Yes No
If yes, give detail, reason for change.
Questions in this section are only to be completed if cover is requested
for United States of America or Canada jurisdiction.
E.
1. Please give the total consolidated assets of the Company and the
subsidiary companies in the United States of America or Canada.
Please give the approximate number of employees in the United States of
America or Canada.
Please tick the appropriate box:
0-25 25-50 50-75
75-100 100-200 200+
2. Please list those subsidiary Companies in United States of America or
Canada that are not wholly owned:
For each subsidiary company set forth in E 3 state who owns the minority
stock together with the percentage ownership?
3. Does the company or any of its Subsidiary Companies:
a) Have any stock, shares or debentures in the United States if
America and / or Canada?
Yes No
b) i) If the answer to E5 a is 'YES' on what date was the last offer
tender issued made?
ii)Was the offer subject to The United States Securities Act 1993
and / or the Securities Exchange Act of 1934 and / or any
amendments thereto?
c) Have any debt or equity instruments or commercial paper in The
United States of America and / or Canada?
Yes No
If the answer to E5 c is 'YES' give details together with the most
recent effective date.
4. Please enclose a copy of the latest 20-F filing made to the
regulatory authorities. If not applicable please tick.
F.
1. Is the company aware of any claims which, if insurance had been in force
similar to that now proposed would have fallen within the scope of such
Insurance, have been made or are now pending against any person (s)
proposed for insurance in the capacity of either director or officer? (if
answer is 'none', so state)
2. Is any person proposed for this insurance cognisant of any circumstances
which he/she has reason to suppose might afford grounds for any future
claim such as would fall within the scope of the proposed insurance/ (if
answer is 'none', so state).
3. Has any insurance similar to that now proposed been declined, canceled or
renewal thereof refused/ (if answer is 'none', so state)
4. Has the Company and / or any of its subsidiary companies been involved in,
or have nay knowledge of, any anti-trust, price -fixing, tax, copyright,
patent litigation, or governmental, regulatory or administrative
proceedings or civil and criminal action? ) if the answer is 'none', so
state).
5. Limit of Indemnity required.
Is any fact, circumstance or situation indicating the probability of a claim
against which indemnification would be afforded by the proposed
insurance known by any person (s) or entity (ies) applying for this
insurance other that that which is disclosed in this Proposal form? It is
alleged by all concerned that if any person(s) or entity(ies) to be insured
under the policy has any knowledge of any such fact, circumstances or
situation any claim subsequently emanating therefrom shall be excluded
from coverage under the proposed insurance. (if the answer is 'none'
state).
6. Please state why you wish to designate to receive any and all notices from
Underwriters or their authorised representative(s) concerning this
insurance.
7. The undersigned declares that:
i. He/she is authorised to complete this Proposal Form on behalf of
al proposer and
ii. The 'IMPORTANT NOTICE' on page 2 of this Proposal Form is
understood and accepted by all proposers and
iii. Underwriters are hereby authorised to make any investigation
and enquiry in connection with this Proposal Form and the proposed
insurance as is deemed necessary and
iv . To the best of his/her knowledge and belief and after enquiry
the statements in this Proposal Form are true.
Warranty Statement:
It is warranted that the particulars and statements contained in the
Proposal Form from the proposed policy and any materials submitted
herewith (which shall be retained on file by underwriters and be deemed
attached hereto, as if physically attached hereto ) are the basis for the
proposed policy and are to be considered as incorporated into and
constituting a part of the proposed policy.
Signed -----------------------------------------------
Capacity --------------------------------------------
Company --------------------------------------------
Date --------------------------------------------
Insurance Act 1938
Section 41 of the Indian Insurance Act, 1938, reads as follows 41 (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 premium
shown on the policy, nor shall any person taking out or renewing or continuing
a policy accept any rebate, except such rebate as may be allowed in
accordance with the published prospectuses or tables of the Company.
Any person making default in complying with the Provisions of this section
shall be punishable with fine which may extend to five hundred rupees.