UNITED INDIA INSURANCE COMPANY LIMITED
PROPOSAL FOR ELECTRONIC EQUIPMENT INSURANCE POLICY

1. Name and address of proposer ___________________________________
Type of business
Location of equipment to be
insured (address of building/
storey)
Structure of building Steel skeleton Brickwork Concrete Wood
2. Has any of the equipment to be
insured previously been covered
by other insurance companies?
Yes No
If so, which items of the
specification and by which
companies?
a) State when the Insurance is to
commence?
Note-Period of Insurance to
expire at the same date next
year.
Date __________
3. Is all the equipment to be
insured new? Yes No
If not, which items of the
specification are second handS? __________________________________________
____
What equipment can still be
obtained ex works?
(State items of the specification)
4. Condition of equipment -
Is the equipment maintained in
accordance with the
manufacturer's instructions?
Yes No
5. Quality of staff -
Have operators been trained with
manufacturer? Yes No
6. Is there a risk of flood and
inundation? Yes No
If so, specify By bodies of
water
By torrential
rainfall
By sewer
backflow
Or by others
7. Are dangerous materials used in
the vicinity? Yes No
If so, specify Acids Prepared
or sensitized
papers
Dyes Test
solutions
Developers Explosives Isotopes Others
8. Valid Maintenance Contract in
force? Yes No
If yes, Copy to be enclosed
9. Air conditioning Plant Prescribed Recommended by
manufacturers not necessary
We hereby declare that the statements made by us in this Proposal IS to the best of our knowledge and
belief, complete and true, and we hereby agree that this proposal forms the basis and is part of any
policy issued in connection with the above risk(s). It is agreed that the Insurers are liable in accordance
with the terms of the policy only and that the Insured will not lodge any other claims of whatever nature.
The Insurers undertake to deal with this information in strict confidence.
Executed at ______________ ___________this day of 20 ________
Signature
ELECTRONIC DATA PROCESSING (EDP)
UINTED INDIA INSURANCE COMPANY LIMITED
Additional questionnaire for the Insurance of Electronic
Data Processing (EDP systems)
1. Name and address of Proposer
___________________________________
Type of business
2. EDP System -
a) If the system is rented state
monthly rent Rs. _______
b) Date of start of operation _______________
c) Operational hours per day in
shifts ______________
d) Name and address of
manufacturer and/or lessor. _________________
e) What are the provisions of
your lease contract
regarding your liability in the
case of damage to the EDP
system?
Please furnish copy of lease
contract if available.
3. Housing of the EDP System -
a) Central Unit - Basement Ground Floor Floor
b) Peripheral Unit - Basement Ground Floor Floor
c) Total value of plant located - In basement
Rs. _______
On ground
floor Rs.
_____
On floor On floor
Rs. ______ Rs.
______
d) Is Installation in accord- ance
with the manuf- acturer’s
recommendations
Yes No
If not, specify deviations from instructions
e) Manner in which the EDP
system has been installed On vibration absorbers On rollers
By rigid anchoring Without anchoring
4. Air-conditioning Plant - Prescribed Recommend by the
manufacturer
Used for EDP system only
a) Maintenance - by the manufacturer by ___________
b) Loss prevention -
c) Does the air conditioning plant
automatically shut off by limit
switches, if the normal control
facility fails?
Yes, in the case of
excessive -
Temperature
Moisture
No
d) Is the air-conditioning plant
also equipped with an
independent signaling
device in the case of
disturbance or failure?
Are adequate loss prevention
measures initiated immediately, even
if the above protective devices are
actuated outside operational hours.
Yes
Optical
Acoustic signal
Presence of
corrosive gases
Excessive temp.
Moisture
Yes
No
No
5. External Data Media –
Note - Please answer the following
questions only, if insurance is
desired.
Mark those data media, which are stored in the
same hazard zone as the EDP system with an ‘A’ in
the column ‘Location of the specification’ Mark data
media stored in another hazard zone with a ‘B’
a) Storage - On wooden
shelves
In steel
cabinets
In fire-proof
cabinets
Together with
EDP system
b) Air-conditioning if not, how is air conditioning effected?
Risk aggravating circumstances
as in the storage rooms -
steam &
water lines
vibrations acid atmosphere
6. What deductible do you wish to
opt
-
7. A) Exclusion of Fire & Allied
Perils as per Standard Fire &
Special Perils Policy.
Yes No
We hereby declare that the statements made by us in this Questionnaire and Proposal are to the best of
our knowledge and belief, complete and true, and we hereby agree that this Questionnaire and proposal
forms the basis and is part of any policy issued in connection with the above risk(s). It is agreed that the
Insurers are liable in accordance with the terms of the policy only and that the Insured will not lodge any
other claims of whatever nature. The Insurers undertake to deal with this information in strict confidence.
Executed at ______________ ___________this day of 20 ____
Signature
INCREASED COST OF WORKING –
UNITED INDIA INSURANCE COMPANY LIMITED
Additional Questionnaire for the Insurance of Increased
Cost of Working as a result of failure of EDP systems
1. Name and address of Proposer
________________________________________
____
Type of business ______________________________
2. EDP system to be insured -
a) Operational hours on average
per day per month
b) Is it possible in the event of
failure to utilize other EDP
system so as to obviate using
an outside system?
Yes No
c) Are there any special
agreement regarding
continued payment of the rent
and other costs if the EDP
system fails?
Yes No
If so, please specify.
3. Outside EDP system available for
use -
a) Name and address of - Owner Lessee
b) Is the use of the outside EDP
systems subject to any special
conditions (waiting periods,
conversion measures, etc.)?
Yes No
If so, please specify _________________________________
c) Has the system already been
used? Yes No
If so, how often? ________________________________________
_
d) Causes
Max. duration _____
Max. cost incurred ___
4. Sums to be insured -
a) Rent of substitute Equipments Rs. ______ per hour
b) Indemnity period per
occurrence _______ Weeks
c) Limit per occurrence (a x b) Rs. _________
d) Aggregate indemnity limit
during the period of insurance Rs. _________
e) Personnel Expenses Rs. _______
f) Transportation of material Rs. ______
5. Conditions desired -
a) Period of indemnity per
occurrence (minimum) _________ Weeks
b) Time Excess
4 days
(96 hrs)
7 days
(168 hrs)
14 days
(336 hrs)
28 days
(672 hrs)
We hereby declare that the statements made by us in this Questionnaire and Proposal are to the best of
our knowledge and belief, complete and true, and we hereby agree that this questionnaire and proposal
forms the basis and is part of any policy issued in connection with the above risk(s). It is agreed that the
Insurers are liable in accordance with the terms of the policy only and that the Insured will not lodge any
other claims of whatever nature. The Insurers undertake to deal with this information in strict confidence.
Executed at ______________ ___________this day of 20 ________
Signature