The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001

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 or accounting precautions without the insurers prior consent.
c) Caused by an employee after discovery of his previous fraud or dishonesty.
d) Such as stock taking shortages, trading losses not caused by fraud or dishonesty.

BASIS OF INSURANCE
Named employees can be selected and guaranteed for specified amount. 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 OFFERRED. 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 Paid Up Capital (if applicable) :

2. Details of Employees to be guaranteed.
Names Duties Since when in service Place of Employment Total remuneration Amount to be guaranteed Any other security taken

3. Is there a system to obtain references from previous Employers? If not, specify practice
followed.

4. Stated the estimate of maximum amount held by any employee at any one time and for how long?

a) Money: Amount______________ b) Stock: Amount______________
Period _______________ 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 authorized by a senior employee and
compared with supporting documents ?

8. How often the cash book is balanced, the entries 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 authorizing dispatch of goods and ensuring that dispatch 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 employees during last 5
years and steps taken to prevent recurrence.

16. Has any company in respect of any infidelity 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 The New India Assurance Company Ltd., whose policy for this insurance is acceptable to me/us. I/we undertake to exercise all ordinary and reasonable precautions as if it were 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 applications
3. To obtain full indemnity, insure for adequate guarantee for each employee.
4. Insurance is the subject matter of solicitation.

MARKETING OFFICER’S/BROKER’S/CORPORATE AGENT’S REPORT

The proposer is known to me us / my agent for __________ year, and I/We recommend acceptance of this proposal.
Place:
Date:

Signature of Officer/Broker/Corporate Agent
Name and Code No.

PROHIBITION OF REBATE
Section 41 of the Insurance Act, 1938
1. “No person shall allow, or offer to allow, either directly or indirectly as inducement to any persons 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 show 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 table of the insurer.
2. Any person making default in complying with the provisions of the section shall be publishable with fine which may extend to five hundred rupees.