UNITED INDIA INSURANCE COMPANY LIMITED
Head Office: 24, Whites Road, Chennai-600014
GUN INSURANCE PROPOSAL FORM

1. a. Name of the Proposer (in full) :
_____________________________________________
b. Address :
_____________________________________________
_____________________________________________
c. Profession or Occupation :
_____________________________________________
2. SCHEDULE OF GUNS TO BE INSURED :
Name of Maker Number of Gun Date of Make Value
5. Besides cover to gen and Public Liability Risks what other covers are required ? Please
strike out type of cover not required
o Workmen’s Compensation Liability
o Personal Accident
o Insured’s Properties and Contents
6. Has any proposal for insurance of
the risk been previously made or
has the risk been previously insured?
If so, state with what Insurers and
Whether such insurance or renewal
Thereof has been declined or an
Increased rate required.
7. What claims have been made against
the proposer in connection with shooting
accidents and what losses if any, in
respect of guns has the proposer
sustained during the past five years.
8. Has the proposer ever sustained bodily
injury by accident while shooting ? if,
so, please give details.
9. Particulars of Licence of the Proposer
To hold the gun and/or fire arm.
I / We hereby confirm that I / We are in good health and have no physical infirmity or disability.
I / We warrant that the answers to the above queries are true and complete and that no material
affecting the risk has been concealed by me, and agree that this proposal shall be the basis of the
Contract between me / us and The New India Assurance Co. Ltd. and I / agree to accept a policy
in the Company’s usual for this of insurance.
Place : ________________
Date : ________________
SIGNATURE
Note 1.The liability of the company does not commence until the proposal has been accepted by
the Company and full premium paid.
2. If space is found insufficient, please attach separate sheets for details.
3. Premium will be quoted on application.
4. Insurance is the subject matter of solicitation.
PROHIBITION OF REBATE -- Section 41 of the Insurance Act 1938
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 of risk relating to
lives or property in India, any rebate of the whole 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 rebates as may be allowed in accordance with the
published prospectuses or tables 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.
In case full cover personal accident is required the same may be considered by issuing a separate PA policy as per Company’s
rates and terms. .