UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE: NO 24 WHITES ROAD CHENNAI – 600 014
PROPOSAL FORM FOR PRODUCT LIABILITY INSURANCE

Liability of the Company does not commence until the proposalhas been accepted and the Premium Paid
1. Name of the proposer (in full)
Names of the Subsidiaries &
Associate Cos: (in full)
2. Registered Address of the Proposer Registered Address of the
Subsidiaries & Associate Cos.
2A
.
Please state whether cover required for subsidiary & associate
companies
3. Business address of the proposer
4. Location from where distribution is effected
5. How long have you been in the business?
6. Do you manufacture the complete product?
If not what components / parts are purchased by you?
7. Can the date of manufacture of each product be identified by the
factory number stamped on it?
8. Do you have any assets and / or representation and / or any domiciled
operation and / or activities and / or association (Financial, Technical
or otherwise) in U.S.A / Canada and other foreign countries? If so,
please furnish details of association.
9. Are you affiliated in any manner with any of yours suppliers and
distributors?
10. Please give full description of the following for the last three years:
a) Year
b) Goods manufactured and estimated turnover
c) Goods sold or supplied and estimated turnover
d) Goods repaired, serviced, tested and processed and estimated:
(Please attach leaflets, brochures and / or any other literature)
19--- 19 ---- 19 ----
11. Please furnish details of products to be considered for insurance
which are manufactured and / or designed
a) Name of the product:
b) Principal component:
c) Annual Units produced:
d) Annual turnover:
e) How long has it been in the market?
f) Expected life of use:
g) Intended use:
h) Intended customer/ultimate user
i) Warranties as to use:
j) Technical know-how / collaboration:
12. Do you have Research & Development Dept?
13. Please specify any products which are inflammable / explosive,
dangerous, radioactive, harmful to health, poisonous by themselves
or any combination with others. If so, please give full details and
state what precautions are taken.
14. Please state whether goods sold or supplied subject to disclaimer
notice and if so, please give full text, particulars or such disclaimer
notice
15. Please furnish particulars of new products to be market during the
next 12 months.
16. Please furnish details and list of products discontinued recalled or
withdrawn during the last five years.
17. Please elaborate complaints incident accident reporting system in
your organisation.
18. Please give details of checks or examinations or controls including
batch control and testing carried out or effected to discover possible
defects or errors in products.
19. Do your products comply with standards like ISI or any other
Standards?
20. Have your products ever been subject to any enquiry or investigation
by any Government agency, concerning the efficiency / adequacy or
labeling, hazardous contents or safety? If so please give full details.
21. What is the failure rate of each product after hand over?
22. Do you issue guarantees / and / or warranties to purchasers? If so, for
what period do you guarantee and / or warrant your product?
23. Particulars regarding directions for use
a) Is it by printing on container or product?
b) Is it by separate leaflet or brochure?
c) Is the hazard warning clearly shown?
24. Please furnish claims history for the last three years in the following
format:
a) Year
b) No. of claims:
c) Total amount paid:
Bodily injury: Rs.
Property Damage: Rs.
Cost of defence action Rs.
Total amt. Of pending claims: Rs.
Bodily injury Rs.
Property Damage Rs.
Cost of defence action Rs.
19 --- 19 --- 19 ----
25. Are you aware of any incidents conditions, defects circumstances or
suspected defects which may result in claim?
26. Have your personal or renewal been declined or premium increased
special terms imposed by any Insurer? If so, please give particulars:
27. Please indicate the limit of indemnity required for domestic sales.
i. any one accident: Rs.
ii. Aggregate during the policy period Rs.
28. Please indicate the Voluntary Excess for each claim (in addition to
Compulsory Excess) you are willing to bear.
U.S.A
Canada
All other
countries
including
India
29. Please quantify sales turnover product wise for the last 3 years as
under:
a) Domestic:
b) USA/ Canada:
c) OECD countries (as listed below)
d) Other countries including non OECD countries.
Organisation for Economic Co-operation and development (OECD)
countries: Australia, Belgium, Denmark, Finland, France, Germany
(FRG), Great Britain, Greece, Iceland, Ireland, Italy, Japan,
Luxembourg, Netherlands, Newzeland, Norway, Portugal, Spain,
Sweden, Switzerland, Turkey and Yugoslavia.
30. How long have you been exporting to the following countries and do
you require cover for exports to these countries?
a) USA and Canada?
b) OECD countries:
c) Other countries including non-OECD countries
(Cover for exports will be granted only if domestic turnover is
covered)
31. Do you require “Limited Vendor’s Endorsements”?
(Please enclose a copy of the contract with the Vendors and give the
names to each product of export to such countries)
32. Do you comply with USA / Canadian State / Federal Laws/ Standards
applicable to each product of export to such countries?
33. Please give details of any power of attorney to Assets in USA /
Canada.
34. Policy period: From 12.00 midnight
of----
To 12.00 midnight of
-------
I/ We desire to effect an Insurance in terms of the Product Insurance Policy of the
----------------------------- against the limits of indemnity specified above and I/We hereby declare that
statutory provisions relating to my/our business proposed for Insurance are complied with. I / We
further declare that all the above statements and particulars are true, and I / We have not omitted,
suppressed, misrepresented or misstated any material fact and I / We agree that this declaration shall be
the basis of the contract between me/us and the Company and be incorporated therein.
Place :
Date : Signature of Proposer
SECTION 41 OF THE INSURANCE ACT 1938
PROHIBITION OF REBATES
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 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.