UNITED INDIA INSURANCE COMPANY LIMITED
LIQUID PETROLEUM GAS DEALERS COMBINED POLICY
PROPOSAL FORM

IMPORTANT INFORMATION
PLEASE COMPLETE CLEARLY IN BLOCK LETTERS. SUM INSURED TO BE GIVEN IN INDIAN RUPEES ONLY.
1. Proposer’s Details
Proposer’s Full Name:
Name of Financing Bank:
Full Business (Shop ) Address:
Godown Address :
Pin code:
Telephone No:
Mobile No:
E-mail address:
Date on which insurance is to commence: From
To
Cover Required Whether
required Section Description of Property Insured Sum Insured in INR
I.
Fire & Allied
Perils
1- Shop Cum Godown
a) Building (Of Class A Construction only)
b) Contents within Shop-cum-godown (Excluding Money & Valuables)
i) Stock in Trade
ii) Furniture, Fixtures & Fittings
This
section is
mandatory
II- Shop & Godown Separately located:
A: GODOWN EXCLUSIVELY
a) Building (Of Class A Construction only)
b) Contents within Godown (Excluding Money & Valuables)
i) Stock in Trade
ii) Furniture, Fixtures & Fittings
Total:
B: SHOP
a) Building (Of Class A Construction only)
b) Contents within Shop (Excluding Money & Valuables)
i) Stock in Trade
ii) Furniture, Fixtures & Fittings
II.
Burglary & House
Breaking
Contents (Excluding Money & Valuables)
1. In the Shop-cum-godown
2. (a) In Godown
(b) In Shop
The Sum Insured of contents under Section II should be
equal to Sum Insured under Section I for Contents
Yes / No
III.
Gas Cylinders in
Transit
Cover is only in respect of cylinders carried outside the premises duly authorized
by the insured:
a. Liability for Any One Accident/event- Rs. 25,000/-
b. Liability for Any One Year- Rs. 50,000/-
Yes / No
AOA-25,000/- AOY-
50,000/-
IV.
Money Insurance
1. Money whilst in transit in custody of Delivery Boys-
AOA- Rs. 5,000/-, AOY- Rs. 15,000/-
2. Money whilst in transit in custody of Authorised Employees/Insured
to/from Bank- AOA- 50,000/-, AOY- 1,50,000/-
3. Money in Safe/Steel Cupboard/Cash Box- 75,000/-
4. Money elsewhere in premises (other than in safe)- Rs. 10,000/-
Yes / No 1. AOA- 5,000/-,
AOY- 15,000/-
2. AOA- 50,000/-,
AOY-
1,50,000/-
3. 75,000/-
4. 10,000/-
V.
Fidelity
Guarantee
Any One or all losses during policy period- Rs.20,000/-
Please provide details :
Sl. No Designation Salary per month
1.
2.
Yes / No Rs.20,000/-
VI.
Pedal Cycle
Please provide details:
Model, Make Frame Number Value Yes / No
VII.
Public Liability
Limit of Liability for Any One Accident- Rs. 5,00,000/-
Limit of Liability for Any One Year - Rs. 10,00,000/-
This Section is
Mandatory
AOA-5,00,000/-
AOY-10,00,000/-
VIII.
Workmen’s
Compensation
Insurance
Please provide details of :
a) Total Number of Employees
b) Estimated Annual Wages for all categories of Employees.
Liability shall be as per WC Act.
This Section is
Mandatory
IX.
Personal
Accident to
Employees
Sum Insured shall be Rs.50,000/- per person.
Please mention Table of Benefits required along with
details of employees to be covered such as Name, Age,
Details of existing disability if any and details of
Nominees for Assignment of Benefits
Yes / No
Rs. 50,000/- per
employee
X.
Personal
Accident to
Customers
PA (Table I & II) benefits to Customers at Customer’s premises,
Sum Insured restricted to Rs. 50,000/- per customer
Yes / No
Rs. 50,000/- per
customer
XI.
Plate Glass
Accidental Breakage of Plate Glass restricted to Maximum of Rs.5,000/-
please provide details of all Fixed Plate Glass. Yes / No Rs. 5,000/-
XII.
Neon Sign/Glow
Sign
Please provide full description of the sign, Year of
Manufacture, Manufactured by & Price
Maximum SI restricted to Rs. 10,000/-
Yes / No Rs.10,000/-
XIII.
Business
Interruption
Business Interruption due to loss caused by Insured Peril under Section I. SI
equivalent to Section I Contents.
Yes/ No
XIV.
Electronic
Equipment
Electronic Equipment used in the shop- including Computers, Printers, Fax
Machines, etc- please provide details with Model, Make,
Manufacturer’s Identification Number.
Yes / No
Extension 1 Extension to Section I- Terrorism Extension, SI to be equal to Sec I SI. Yes / No
Extension 2 : Yes / No
Extension 3: Yes / No
Extension 4 : Yes / No
TOTAL SUM INSURED
General Questions
How many years have you been in the current trade/ business? Years
Brief description of Shop-cum-Godown or Shop & Godown seperately.
INSURANCE HISTORY
Have you taken any LPG Traders Insurance in the last 3 years Yes / No
a) If YES, state name of previous Insurer(s), Policy Number(s) and Expiry
Date
b) Has any such previous Insurer declined a proposal, refused to renew a policy
or imposed special terms or conditions for any of the risks against which
you wish to insure?
Yes / No
If YES please provide details
LOSS/CLAIMS HISTORY
In respect of any of the risks against which you wish to insure have you
a) Incurred any loss, destruction or damage whether insured or not including any
Liability Claims?
Yes / No
Signature(s)
Date
SECTIONS I, VII & VIII ARE COMPULSORY. IN OTHER SECTIONS, 15% SECTIONAL DISCOUNT IS
AVAILABLE IF 4 TO 6 SECTIONS ARE OPTED AND 20% SECTIONAL DISCOUNT IS AVAILABLE IF
MORE THAN 6 SECTIONS ARE OPTED.
SECTION 41 OF THE INSURANCE ACT 1938
PROHIBITION OF REBATES
2. 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 commission payable or any rebate of the premium shown on the policy nor shall any person taking out or continuing a
policy accept any rebate except such rebate as may be allowed in accordance with the prospectus or tables of the Insurer.
3. Any person making default in complying with the provisions of this Section shall be punishable with fine, which may extend
to Rs.500/-.