UNITED INDIA INSURANCE COMPANY LIMITED
PROPOSAL FOR MACHINERY INSURANCE
(The liability of the Company does not commence until this proposal has been
accepted by the Company and premium paid)
(Information given herein will be treated in strict confidence)

i) PUT A TICK MARK WHEREVER APPLICABLE
a) Proposer's Name _____________________________________
__
b) Proposer's Trade or
Business _____________________________________
__
c) Proposer's Postal Address _____________________________________
_
d) Address where plant to be
insured is located. _____________________________________
____
e) Nearest Railway station
and distance
1. Do the items listed represent the
whole of the plant
Yes No
2. a) Are you at present Insured Yes No
b) If so, with whom? b)
__________________________________
3. Has any Company -
a) declined to insure any of the
machinery now proposed ?
Yes No
b) required an increased premium
or imposed special conditions? Yes No
c) requested for repairs or made
other special stipulations for risk
improvement?
Yes No
4. a) Are you aware of any defects/
damages existing in the
machinery?
Yes No
b) If so, give details thereof b)
___________________________________
5. a) Has your machinery sustained
any damage from breakdown or
other cause during last 3 years?
Yes No
b) If so, give details of damage(s)
and repairing cost.
b)
__________________________________
6. a) Are regular periodical inspections
of the machinery carried out? Yes No
b) If so, by whom and at what
intervals?
b)
___________________________________
7. On payment of additional
premium do you wish to cover the
following?
If yes, provide limits of indemnity
a) Escalation Amount/percentage Rs. _______ No
Or %age ________
b) Express Freight (excluding Air
Freight), Overtime and Holiday
rates of Wages. Rs. _______
No
c) Air Freight Rs. _______ No
d) Owners surrounding property Rs. _______ No
e) Third Party Liability e) _____________ No
- AOA Rs. _______ No
- AOY Rs. _______ No
f) Additional Customs Duty Rs. _______ No
8. Period of Insurance From To
SCHEDULE OF MACHINERY TO BE INSURED –
a) Each Machinery should be entered separately with necessary specification as
mentioned in Schedule Column No.3
b) The Sum Insured must be calculated on the present day new replacement
value of the Machinery to be insured including provision for packing, freight
and also value of erection costs, customs duty, etc., to afford full protection
under this Policy.
c) If any of the Machinery is a `stand by' this fact should be mentioned.
d) All portable Machinery must be so designated. All items in the open must be
so described separately.
e) Separate value for foundations masonry and brickwork or Oil in transformers
and other electrical equipments are to be specified if cover is required.
S.
No. Quantity
Description, type, Model,
Capacity of Machines/Sr.
Nos/HP/kVA Volts, Amps, RPM
Maker’s Name
and Country of
origin.
Year
of
Make
Sum
Insured
(1) (2) (3) (4) (5) (6)
I/We, the undersigned hereby declare that the above statements and particulars
are true and complete and I/We declare and agree that this declaration and the
answers given above shall be held to be promissory and shall be the basis of the
contract between me/us and the Company.
Place __________________
Date ___________ Proposer’s Signature _____________