NATIONAL INSURANCE CO. LTD.
(Subsidiary of General Insurance Corporation of India)
Regd. Office : 3, Middleton Street, Calcutta – 700 071

CODE
DEV. OFFICER / AGENT
ADDRESS OF ISSUING OFFIUCE
For OFFICE USE ONLY

Accepted By_______________________________________
Date & time. ______________________________________
Rate __________________________________ ___________
Remarks ______________________________ ____________
Policy No _____________________________ ____________
Collection/Scroll No _________________________________
________________________________________________________________________________________________
PROPOSAL FORM FOR FIDELITY GUARANTEE
INSURANCE (EMPLOYER)
SCOPE OF COVER
This Insurance Policy provides indemnity to Employers against any direct financial loss, including loss of goods,
caused by fraud or dishonesty of employees.
EXCLUSIONS
This Insurance Policy does not cover any loss :
(a) Discovered more than 12 months after the termination either of the guarantee or of the service of the employee
concerned.
(b) When there has been any change in the agreed system of check of accounting precautions without the Insurer’s
prior consent.
(c) Caused by an employee after discovery of his previous fraud or dishonest.
(d) Such as stock taking shortages, trading losses, not caused by fraud or dishonest.
Basis of Insurance
Named employees can be selected and guaranteed for specified amounts. Employees can be guaranteed for a total
amount overall or for separate amounts in respect of different categories.
THE FOREGOING IS ONLY A BROAD INDICATION OF THE COVER OFFERED, FOR DETAILS PLEASE
REFER TO ANY OFFICE OF THE COMPANY.
NOTE : PLEASE ANSWER EVERY QUESTION AND FULLY
1. (a ) Name and Address of the Employer ________________________________________
(b ) Description of Business ________________________________________
(c ) Since when established ________________________________________
2. Details of Employees to be guaranteed
Names
Duties
Since
when in
Service
Place of
Employment
Total
remuneration
Rs.
Amount
to be
guaranteed
Rs.
Any other
security
taken
3. Is there a system to obtain references from previous
Employers ? If not, specify practice followed.
4. State the estimate of maximum amount held by any
employee at any one time and for how long ?
(a) Money : Amount_______________________ (b) Stock : Amount ______________________________
Period _______________________ (b) Period ______________________________
5. Has there been any occasion to question honesty or
conduct of any person proposed for guarantee ? _______________________________________
6. (a) How often are the employees required to
account for money ? _______________________________________
(b) What independent system is there to check that
all sums received by employees are accounted
for ? _______________________________________
7. (a ) Do employees pay out money or draw cash from
Employer’s account ? _______________________________________
(b ) System of operation of Bank Account and
precautions taken. _______________________________________
(c ) Whether such payments/withdrawals are
authorised by a senior employee and compared
with supporting documents ? _______________________________________
8. How often the cash book is balanced, the entried
Checked with vouchers and Bank’s Pass Book
And with counterfoils of receipt books ? _______________________________________
9. How often are the Proposer’s books balanced ? _______________________________________
10. (a) System followed for purchase of goods and
recording deliveries. _______________________________________
(b) System followed for authorising despatch of
goods and ensuring that despatch is recorded
and charged to the customer. _______________________________________
11. How often and by whom stock verification is done ? _______________________________________
12. System for collecting outstanding accounts. _______________________________________
13. How often will statements of account be furnished
by the Proposer direct to Customers ? _______________________________________
14. What is the extent and frequency of audit ? _______________________________________
15. Details of losses suffered on account of infidelity of
any employee during last 5 years and steps taken to
prevent recurrence ? _______________________________________
16. Has any Company in respect of any Fidelity
Guarantee Insurance ? _______________________________________
(a ) Declined your proposal ? _______________________________________
(b ) Cancelled or refused to renew policy ? _______________________________________
(c ) Accepted your proposal on special terms
and conditions. _______________________________________
I/We do hereby declare that the above statements and answers are true and that I/We have not withheld any information
Whatsoever regarding this proposal. I/We agree that this Proposal and Declaration shall be the basis of the contract
between me/us and NATIONAL INSURANCE CO. LTD. whose policy for this insurance is acceptable to me/us. I/We
undertaken to exercise all ordinary and reasonable precautions as if risk was uninsured.
Place :
Date : Proposer’s Signature
________________________________________________________________________________________________
Note : 1. The liability of the Company does not commence until the proposal has been accepted and premium paid.
2. Premium will be quoted on application.
3. To obtain full indemnity, insure for adequate guarantee for each employee.
DEVELOPMENT OFFICER’S REPORT
The Proposer is known to me/my Agent for ___________ years, and I recommend acceptance of this Proposal.
Place : Signature :
Date : Code/Name :
______________________________________________________________________________________________
PROHIBITION OF REBATE
Section 41 of the Insurance Act, 1938 :
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 the 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 Insurer.
Any person making default in complying with the provisions of this section shall be punishable with fine which may
extend uoto five hundred rupees.