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

PROPOSAL FOR FIDELITY GUARANTEE POLICY FOR GOVERNEMENT SERVANTS

QUESTIONS TO BE ANSWERED BY THE EMPLOYEE
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1. Full Name and Address of the Applicant :
2. Age of the Applicant :
3. Martial Status and the number of persons :
dependent on the Applicant
4. (a) Amount of insurance required :
(b) Period for which cover is required :
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5. (a) In what capacity is the applicant working :
and in which Department
(b) Is the applicant required to handle cash :
and or stock as part of his / her duties?
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6. (a) Is the Applicant in Permanent Service? :
If not state the tenure of his / her service?
(b) Salary and other allowances the applicant :
draws in respect of this appointment
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7. (a) If the applicant is required to handle cash :
please state whether the books are
balanced daily
(b) Is the applicant permitted to retain cash :
overnight? If so, what is the maximum
amount so permitted to be retained any one
time? How the cash is secured during night?
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8. If the applicant is in-charge of stock please :
state the nature and value of the stock and
whether they are physically verified
periodically.
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9. Is the applicant authorised to issue receipts :
on behalf of the Employer? If so please state.
(a) Whether a printed serially numbered receipt
book with counterfoils is used.
(b) Whether his / her work is supervised by
any superior.
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10. State the designation and address of the officer :
to whom the Policy is required to be issued
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11. State the designation and address of the :
Applicant's immediate superior to whom
The Policy should be sent
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12. Has any insurer previously granted a cover in :
respect of the risk proposed for insurance>
If so please state?
a) Name of the Insurer?
b) The Period of Insurance
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13. Please give the names and addresses of 2 :
persons who are not related to the applicant 1.
but who are known to the applicant for atleast
3 years to whom the Company may refer if 2.
necessary
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14. Premium remitted by cheque / DD /Money Order: No. . . . . . . . . . . . .Date . . . . .
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I hereby declare that the foregoing answers are correct without any reservation whatsoever on my part.
Date: Signature of Employee . . . . . . . . . . . . . .
Counter Signature of Superior Officer . . . . . . . . . . . . . .
Designation . . . . . . . . . . . . . . . . . . .
INSURANCE ACT 1938
SECTION 41 - PROHIBITION OF REBATES
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 or risk relating to lives or
property in India any rebate of the whole or part of the premium shown on the policy nor shall any
person taking out or renewing 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 this Section shall be punishable
with fine which may extend to five hundred rupees.