NATIONAL INSURANCE COMPANY LIMITED
(Subsidiary of General Insurance Corporation Of India)
Regd. Office : 3, Middleton Street,

JEWELLER’S BLOCK INSURANCE PROPOSAL FORM

Cover Note No. :
Please reply fully to All the following Questions
If the answer to any question is none state “NONE”
1.
(a) Name of the Proposer (in full)
(b) Address to which all communications should
be sent
(c) State address of all premises to shich the
Policy is to apply (if more than one please
attach a statement) the floor(s) on which your
premises are situated in each location.
(d) Since when established
(a)
(b)
( c)
(d)
2. Nature of your Business Wholesale % Retail %
Manufacturing % Pawn %
Broking
% %
% %
3.
(a) Give the Safe Maker’s name, cost when
purchased (state whether new or second-hand
and whether marked “Thief resisting or
“Burglar Proof”).
(b) Will the premises be occupied at night by the
Proposer ?
(c) Will there be a watchman on insured
premise(s)
If yes specify :- (Answer for all premises)
I. Whether he/they is/are your employees
and is/are employed for all the 24 hours of the
day
II. Whether he/they is/are common
Watchman for the whole building / locality or
only a night watchman to guard the insured
premise(s) Or the building or the locality.
(d) Is a burglar alarm system installed or any other
special means of protection adopted ? If so,
state what protection.
(e) Is an inside grill fitted to your Gold and Gems
Showroom Window or is any other protection
in stalled against loss by window smashing ? If
so state what protection .
(f) Are your display windows, protected by Roller
Shutter outside business hours ?
(g) How are the windows protected ?
(h) How are Skylights, If any, protected?
(a)
(b)
(c)
(I)
(ii)
(d)
(e)
(f)
(g)
(h)
4. State the approximate maximum value of any
one article of jewellery or gem stock which
will be displayed in the windows (A pad or
tray containing a number of rings or other
articles to be counted as one article). (give
separate answer for each location)
Note :- Window Display at Night is not
covered.
5. STOCK :
(a) What was
I. The average daily total value of your
stock during the past 12 months ?
II. Cash and Currency Notes during the
past 12 months ?
(b) Will the whole of your stock when on your
premises be kept in safe locker at night and at
all times when the premises are closed ? If not,
state value and class of stock which will be left
outside safes locker ?
Note : This policy does not cover Stocks kept
out of the safe after Business Hours and at
night.
6. VALUATION BASIS :
Are the figures under Question & complied on
the basis of Market value for your own Stock ?
If not, give details :
N.B. Unless otherwise mutually agreed claims
in respect of your own stock will be paid on
the basis of Market value.
7. LOSSES :
(a) Have you ever sustained a loss or losses ?
(b) If so, give statement covering past five years
with particulars.
(c) Were you insured and if so, give the name of
the Insurance Company and whether they paid
the cliam in full or a part thereof ?
(Please state how much)
(a)
(I)
(II)
(b)
(a)
(b)
(c)
8. Anywhere in India Amount Sum to be Insured (only total to be
Insured may be given )
Rs. Rs.
1
SECTION – I
1. Property Insured on the premises.
(a) Property Insured in display windows/show
cases.
(b) Property Insured in locked safe on premises.
(c) Others (specify)
2. Cash and currency Notes
3. Property insured in Bank Lockers.
2
SECTION II (Outdoor Risk)
Property (excluding cash and currency notes)
whilst
(a) In the custody of the Insured, his partners or
his employees, Directors, duly Constituted
Attornies and Sorters of diamond
(b) In the custody of brokers, agents, cutters,
jewellery manufacturers.
3
SECTION III
(a) Regd. Insured Parcel Post
(b) Air Freight (value declared to the Airline)
(c) Angadia
4
SECTION IV
Furniture , Fixtures, Fittings at premises not
used as residence and sales at residences
9. Does the sum to be insured on Trade and
Office Furnitures and Fittings, Machinery
Plant and all other contents (except your stock
and goods in trust) represent the full value
thereof. If not state the approximate present
value.
10. REFERENCES
Unless proposing for renewal , give two
references from your trade
11. OTHER INSURANCE :
(a) Has any insurer ever cancelled or refused to
issue or to continue any insurance for you ?
(b) Have you been previously insured ?
If so, state with whom, risks covered, and for
what amount ?
Signing this Form does not bind the proposer to complete the Insurance , but it is agreed that this Form
shall be the basis of Contract should Policy be issued.
I / We have read the above and agree that to the best of my / our knowledge and belief it represents true and
complete statement.
I / We agree that if this insurance is completed the protection and / or safeguards mentioned above shall not
be withdrawn or varied to the detriment of the Interest of the Underwriters without their consent.
Date ……………………
Signature of Proposer
PROHIBITION OF REBATES
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 or risk relating to lives or property
in India , any rebate or 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.
2. Any person making default in complying with the provision of this section shall be punishable with
fine which may extend to five hundred rupees.