NATIONAL INSURANCE CO. LTD.
(Subsidiary of General Insurance Corporation of India)
Regd. Office : 3, MIDDLETON STREET, CALCUTTA – 700 071

PROPOSAL FOR KISAN AGRICULTURAL PUMPSET INSURANCE

1.
a) Name of Proposer ……………………………………………………………………………………
b) Postal Address ……………………………………………………………………………………….
c) Situation of the Pumpset …………………………………………………………………………….
2. Nature of Business Agriculturist
3. Name of the Firm supplying and servicing the
Pumpset.
4. DESCRIPTION OF PUMPSET :
P U M P D R I V I N G U N I T
Electrical Motor Diesel engine
Make ……………………………
Section ……..Delivery………….
Serial No………………………..
Year of Make …………………...
Type : centrifugal / Submersible
Make …………………………..
HP ……………RPM…………..
Serial No. ………………………
Year of Make …………………..
AMPS ………/ Voltage………..
Type : Squirrel Cage / Slip Ring
Make …………………………..
HP ………….RPM ……………
Serial No……………………….
Year of Make ………………….
No.of Cylinders ……………….
Stroke ………….Bore …………
5. Sum Insured Rupees
6. State the date when the Insurance
Is to commence. Date ………………..Month ……………Year..……………..
Period of Insurance will be from Noon on the same date and month next year.
DECLARATION
I/We hereby declare and warrant that the above statements are true and complete and that I / We agree that
this declaration and the answers given above shall be the basis of the contract between me / us and the
Company , and shall be deemed to be incorporated in such contract and that if any untrue statement be
contained therein the said contract shall be absolutely null and void. I / We agree to accept the policy in the
form issued by the Company subject to the terms , exceptions and conditions prescribed therein or endorsed
on the policy.
Place………………………
Dated ……………………….. Signature ……………………………
The liability of the Company does not commence until this proposal has been accepted by the Company
and the premium paid.
N.B. : If above space is insufficient for answer, please continue on a separate sheet and attach hereto.
PROHIBITION OF REBATES
Section 41 Insurance Act, 1938.
1) No person shall allow or offer to allow, either directly or indirectly as an inducement to the 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 commission payable or any rebate of the
premium shown in the policy not 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 provisions of this section shall be punishable
with fine which may extend to five hundred rupees.