The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001

MONEY INSURANCE PROPOSAL FORM

DEV. OFFICER AGENT

CODE _________ ___________
ADDRESS OF ISSUING OFFICE

COVERS: This Insurance Policy provides cover against loss of money in transit, by the Insured or Insured's authorised employee(s) occasioned by robbery, theft or any other fortuitous cause. This Insurance Policy also covers loss by burglary or housebreaking whilst money is retained at Insured's premises, in safe(s) of strong room.

EXCLUSIONS: This Insurance Policy does not cover loss or damage due to Flood, Cyclone, Earthquake and other Convulsions of Nature, War and Warlike Operations, Civil Commotion, Riot and Strikes & Terrorists Activities, Shortage due to error or omission, by use of keys to safe(s) or strong room, unless such keys are obtained by force or threat, whilst being carried under contract of affreightment, theft from unattended vehicle and Consequential loss.

DEFINITION: Money shall mean and include Cash, Bank Draft, Currency Notes, Cheques, Postal Orders & money order and Current Postage Stamps.

NOTE: THE FOREGOING IS ONLY A BROAD INDICATION OF THE COVER OFFERED. FOR DETAILS PLEASE REFER TO ANY OFFICE OF THE COMPANY. Ensure that the sum fixed as limit of the Company's liability in respect of any one loss is adequate to get full protection. This type of Insurance is also available in Shopkeepers Policy.

NOTE: PLEASE ANSWER EVERY QUESTIONS AND FULLY

1. Name of the proposer (in full)(In block letters):

2. Business Address:

3. Business of Trade:

4. Description of Money to be Insured,
(if no Insurance is required for any item, Insert "NIL”).

Section No. Money Estimated Annual amount Highest amount in
of money in transit, which transit at any one time which
will be the basis on which the will be limit of the company's
provisional premium will be liability for any one loss.
charged.
Rs. Rs.

I. A. Money for payment of wages, salaries & other earnings or for
Petty cash, in direct transit from the Bank, to the Insured's
premises, from the time the money is received at the bank by
the Insured or authorised employees of the Insured, until
delivered at the Premises or other place of disbursement, and
whilst there until paid out, provided that outside business hours,
money shall be secured in locked safe(s) or locked strong
room on the Premises, Cheques drawn by the insured to
provide for such Money are also covered whilst in transit, from
the Premises to the Bank

B. Money (other than described in Item A above) in transit, from/
to Insured's Premises/Bank/P.O. Any other specified Premises

C. Money other than described in Items A & B) collected by and
in the personal custody of the Insured or the authorised
employees of the Insured, Whilst in transit to the Premises or
Bank, within a period not exceeding 48 hours, from the time of
collection

ESTIMATEDTOTAL ANNUAL AMOUNT OF MONEY INTRANSIT

II. Money (other than described in Section I A above) whilst on the
Premises during the business hours or whilst secured in locked
safe(s) or strong room, on the Insured's Premises, outside
business hours, against the risks of Burglary, Housebreaking,
Dacoity Robbery and Hold UP.

MAXIMUM AMOUNT OF MONEY HELD AT ANY ONETIME:

5. a. What is the maximum distance over which the money will be
conveyed ?
b. Addresses of premises between which money will be carried.

6. Are employees authorised to handle/carry money covered under
Fidelity Guarantee Policy ? If Yes, give details.

7. How is the money carried? (i.e whether in bags, trunks etc.)

8. What means of transport do the persons carrying the money use
i.e. own car/public transport etc ?

9. Are the persons carrying the money accompanied by an armed
guards? If not, state what protection if any, is provided for them.

10. Do you need to cover against Riot & Strike and terrorist activities
on payment of additional premium?

11. a. State following particulars of safe/s and/or strong room in which
money will be kept outside business hours.

Maker's Name Weight Dimensions identification Number

b. Addresses of premises where safe is kept.
c. Is it fixed to the walls or floor?
d. By whom are the keys of the safe(s) and/or strong room held?
e. Are all such keys removed from the premises outside business
hours ?
f. Will the premises guarded whilst they are closed for business?
If so, by whom?

12. Have you ever sustained any loss of money whilst in transit or
whilst on your premises? If so, give full particulars.

13. Has any Company in respect of money Insurance
a. Declined your proposal?
b. Cancelled or refused to renew your policy
c. Accepted your proposal on special terms & conditions’

14. Has the risk been previously Insured? If so,
a. The name of the Insurance Company.
b. Policy No.
c. Period
d. Rate charged
e. Any special terms and conditions Imposed

15. Period of Insurance From _______________ To ____________________

I/We hereby declare and warrant that the above statements are true and complete. I/We agree that this proposal and the declarations shall be the basis of the contract between me/us and the company and I/We agree to accept a Policy, subject to the conditions prescribed by the Company and to render at the end of each period of Insurance a statement in the form required by the Company of all money conveyed and to pay premium on the amount in excess of the amount estimated above.

Date _________ Proposal's Signature____________________

_________________________________________________________________________

DEVELOPMENT OFFICER'S REPORT

The Proposer in known to me/my Agent for ____years and I recommend acceptance of this proposal.

Date Signature of DEV.OFFICER.

Place Name & Code No.

PROHIBITION OF REBATES

Section 41 of 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 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 renewing or continuing a Policy accept rebate except such rebate as may be allowed in accordance with the published prospectus 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.