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

PROPOSAL GENERAL BUSINESS AND PRODUCTS LIABILITY INSURANCE

AGENCY: ____________________________________________________________________
SECTION 1 – DESCRIPTION OF TRADE
1. Proposer’s name in full
________________________________________________________________________
2. Tel. No. _______________ Telex No. _____________________ Fax No. ____________
3. Postal Address ___________________________________________________________
4. Country of Operations _____________________________________________________
5. Business Description ______________________________________________________
6. Describe process and activities ______________________________________________
7. Date established __________________________________________________________
If new, give details of experience ____________________________________________
8. Provide an estimated breakdown of annual wages in respect of manual work away from own
premises (other than collection and delivery)
Type Description of Activity Estimate
Country of Operations
Other
Offshore
Sub-Contracted to Firms
Sub-Contracted to Self
Employed
9. Do you vet the insurance arrangements of subcontractors? Yes No
10. Will you, or your employees, handle or come into contact with any industrial dust of known
harmful nature (e.g. asbestos, silica, cotton), radioactive materials, or any other substance harmful
to health? Yes No
11. Is there an occupational deafness hazard associated with your trade? Yes No
If “YES” to 10 and 11 give details and state safety procedures and length of exposure in years past.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
SECTION 2 – GENERAL QUESTIONS
The following questions must be answered in all cases
1. Have you been prosecuted during the last 5 years under any safety legislation?
Yes No
2. Have you or any of your directors or partners ever been charged with a criminal offence other than
a motoring offence? Yes No
3. Has any Insurer ever declined to insure you or refused to renew any of your insurances?
Yes No
If “YES” to any of the above, please provide full details (including identity of Insurers if
responding to Q3)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4. Give details of any separate business in which you or any of your directors or partners are
or have been involved the last 5 years.
Name of Business Trade From To
5. Give name (s) of present liability insurer (s) and expiry date (s)
________________________________________________________________________
________________________________________________________________________
6. Do you require : Indemnity Limits
(a) Employers Liability Yes No ___________________
(b) Public Liability Yes No ___________________
(c) Products Liability Yes No ___________________
Date from which cover is to commence: ______________________________________
SECTION 3 – PRODUCTS AND SERVICES
Details Estimate
(Annual Turnover)
A. BROAD OUTLINE
Please provide a general
description of products supplied
or manufactured and total of
Turnover figure
B. ANALYSIS OF PRODUCTS
1. Indicate details of products
you do not manufacture
2. Indicate details
of products
which you
alter, adapt or
change in some
way
3. Give details of
imported
products
including
source of origin
4. Give details of
any products
used :
(a) In Aircraft
(b) In Marine craft
(c) Offshore
Details Estimate
(Annual Turnover)
C. U.S.A OR CANADA
1. Give details of any
products supplied
directly or to your
knowledge indirectly to
the U.S.A. or Canada
2. If products have been
supplied in previous
years to U.S.A. or
Canada indicate
Turnover applicable to
each of last 3 years “IN
ADDITION” to usual
information.
D. SERVICES / TREATMENT
If you provide any services or
treatment other than products
provide details
E. GENERAL QUESTIONS RELATING TO YOUR LIABILITY AS A PRODUCER
1. Do you retain rights of recovery against manufacturers ?
2. Do any of your products require an accompanying hazard warning ?
3. Do you design or prepare specifications for the products you supply ?
Give below details relevant to the above questions (including qualifications of design team ) :
4. Provide details of your quality control system including any “early warning” mechanism built
into your complaints procedure
5. Please indicate period of time, in years, that you retain stock records of :
Customers :
Suppliers :
F. Please quantify sales turnover product wise for the last 3 years as under:
(a) Domestic
(b) USA/Canada
(c) OECD countries (Countries belonging to the Organisation for Economic Co-operation and
Development viz. Austria, Belgium, Denmark, Finland, France, Germany, Great Britain,
Greece, Iceland, Ireland, Italy, Japan, Luxemberg, Netherlands, New Zealand, Norway,
Portugal, Spain, Sweden, Switzerland, Turkey Yugoslavia)
(d) Other countries including non-OECD countries.
SECTION 4 – WAGES / TURNOVER / CLAIMS
1. Please complete showing the projected situation for the next 12 months
Description of all employees
(Wages but not fees of working directors to be
included)
No Wages/Salaries
Clerical Staff
Supervisory / Manual
All other employees (specify below any extra
hazardous activities) :
2. Total Turnover :
Past Financial Year ____________________
Current Financial year ____________________
Estimate Coming Financial year ____________________
3. Please complete the undernoted section which relates to your claims record over the last 5
years (arising out of the business and where you may be legally liable) – DO NOT
INCLUDE MOTOR INSURANCE CLAIMS
EMPLOYER’S LIABILITY
Death, disease, illness or injury to employee including casual employees
Year
(last 5 years)
Salaries or Wages Paid Claims No O/S Claims No
PUBLIC AND PRODUCTS LIABILITY
Death, disease, illness or injury to other parties and loss or damage to their
property and attendant financial loss
Year
(last 5 years)
Excess Turnover Property
Damage
No O/S Claims No
DECLARATION (in respect of all sections)
I/ We declare that to the best of my/our knowledge and belief the above statements are true and complete
and will form part of the contract between me/us and the Insurance Company.
Signature ____________________ Position in Your Company _______________________
Date ________________________________