UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE: NO 24 WHITES ROAD CHENNAI – 600 014

PROPOSAL FORM FOR PLATE GLASS INSURANCE
1.
a) Name of Proposer (in full)
b) Address
c) Business
a)
b)
2.
a) Address of premises in which Glass is fixed
b) Trade or Business carried on in the premises
a)
b)
3.
Are the premises at the corner of a street or in an exposed
position?
4.
Is any of the Glass now broken?
If so, describe its position and size.
5.
Is the Glass insured at present?
If so, for what amount(s) and with which Insurer (s)?
6.
What breakages have occurred during the last twelve months
and from what causes?
7.
Has the Proposer ever made any claim for breakage loss of or
damage to any Plate Glass? If so give below particulars.
Date of
Occurrence
Details of breakage
loss or damage
Name of
Insurer
Amount
Recovered Rs.
Amount to be recovered Rs.
8.
Has any Insurer in respect of any plate glass cover
ever
a) Declined a proposal from the Proposer, or
b) Cancelled or declined to renew any policy or
c) Demanded or increased rate, or
d) Required any special terms to insure or grant any
renewal?
a)
b)
c)
d)
9.
Period of insurance From To
I / We hereby declare that the above statements and answers are true and correct and that no material
fact has been with-held, mis-stated or mis-represented and that I / We agree that this proposal and
declaration shall be the basis of the contract between me / us and
------------------------------------------- whose standard policy for the insurance proposed is acceptable
to me/us.
Place :
Date : Signature of the Proposer
Note: The liability of the Company does not commence until the Proposal has been accepted by the
company and the premium paid.
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 of risk relating to lives or
property in India any rebate of the whole or part of the commission payable or any rebate of
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 provisions of this section shall be punishable
with fine which may extend to five hundred rupees.
PROPERTY TO BE INSURED
State
whether
Glass is
fixed in
shop front,
rear or side
or door
PARTICULARS AND DIMENSIONS
Sum to
be
insured
Rs.
No. of
Panes
Whether Plate or Sheet and
whether Plain, Silvered Embossed,
Curved, Stained, Lettered or
Ornamented or more than 1/4 in.
thick
Size of each
Pane in Cms. Square
Cms.
Each
Height Width Pane
Total ….
Note: In the event of a loss All Glass is considered plain and of ordinary glazing quality unless the
CONTRARY is specially named in the Policy. No Lettering, Embossing, Silvering or any Ornamental
work is considered insured unless named on the Policy and the additional premium paid thereon. No
insurance is granted in respect of glass not completely and securely fixed.