NATIONAL INSURANCE COMPANY LIMITED
(Subsidiary of General Insurance Corporation of India)
Regd. Office :: 3, Middleton Street, Calcutta – 700 071

PROPOSAL FORM FOR PUBLIC LIABILITY INSURANCE
Non-industrial risks

FOR EXHIBITIONS/FAIRS FETES/CIRCUSES/FILMSTUDIOS (INDOOR AND OUTDOOR) PANDAL / TOURNAMENTS /ZOOS/PERMANENT AMUSEMENT PARKS

LIABILITY OF THE COMPANY DOES NOT COMMENCE UNTIL THE PROPOSAL HAS BEEN ACCEPTED AND THE PREMIUM PAID. THE TERRITORIAL LIMIT AS APPLICABLE TO THIS POLICY IS ANYWHERE IN INDIA.

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ALL QUESTIONS SHOULD BE ANSWERED WITH RESECT TO EACH UNIT/ESTABLISHMENT.

1. NAME OF THE PROPOSER (IN FULL)
2. ADDRESS OF THE PROPOSER
3. ADDRESS OF EACH OF THE PREMISES AND/OR CHAIN OF ESTABLISHMENTS TO BE INSURED :
1.
2.
3.
4.
5.
4. FULL DESCRIPTION OF EACH OF THE PREMISES :
a) TYPE OF CONSTRUCTION
b) AGE OF THE BUILDING
c) NO. OF FLOORS AND HEIGHT OF THE BUILDING WHICH FLOOR IS OCCUPIED BY YOU ?
d) DETAILS OF OTHER OCCUPANTS.
e) DETAILS OF THE LIFTS, ELEVATORS, ESCALATORS ETC., PLEASE SPECIFY MAKE AND
CAPACITY.
f) ACTIVITIES BEING CARRIED ON IN THE PREMISES.
5. a) ARE THE PREMISES / EQUIPMENTS / MACHINERIES INSOUND CONDITION OF REPAIR.
b) DETAILS OF SUPPOUNDING AREAS / PROPERTY.
6. HAVE YOU COMPLIED WITH ALL STATUTORY RULES / REGULATIONS PERTAINING TO THE PREMISES
AND YOUR BUSINESS ACTIVITIES :
a) DOES THE PREMISES HAVE BOUNDARY / FENCING
b) SECURITY / SAFETY ARRANGEMENTS
c) DETAILS OF SYSTEMS PROVIDED FOR PREVENTION OF FIRE, EXPLOSION ETC
d) DETAILS OF EMERGENCY PLAN IF ANY :
7. DO YOU HANDLE OR USE OR STORE GASES / HAZARDOUS / TOXIC / RADIOACTIVE MATERIALS AND/OR
EQUIPMENTS IN THE PREMISES. IF YES, PLEASE GIVE DETAILS OF MAX. CAPACITY STORED / USED /
HANDLED AT A TIME.
8. PLEASE GIVE THE CLAIMS HISTORY FOR THE LAST THREE YEARS IN THE FOLLOWING FORMAT :
YEAR 19 19 19
NO. OF CLAIMS __ __ __
TOTAL AMOUNT PAID Rs. Rs. Rs.
BODILY INJURY
PROPERTY DAMAGE
COST OF DEFENCE ACTIONS
TOTAL AMOUNT OF PENDING CLAIMS
BODILY INJURY
PROPERTY DAMAGE
COST OF DEFENCE ACTION
9. HAS YOUR PROPOSAL OR RENEWAL BEEN DECLINED OF PREMIUM BEEN INCREASED OR SPECIAL
TERMS HAS BEEN IMPOED BY ANY INSURER IN THE PAST ?
10. PLEASE INDICATE THE LIMIT OF INDEMINITY REQUIRED
a) ANY ONE ACCIDENT
b) ANY ONE YEAR
11. POLICY PERIOD REQUIRED - FROM ..............................
TO ...................................
12. OUTDOOR / PANDALS / TOURNAMENTS / ZOOS / PERMANENT AMUSEMENT PARKS
13. WHAT IS THE MAXIMUM SEATING CAPACITY / AREA OCCUPIED
14. WHAT ARE THE OTHER FACILITIES / GAMES PROVIDED ?
PLEASE PECITY WHETHER THEY ARE OPERATED AND CONTROLLED BY YOU :
a)
b)
c)
d)
I/WE DESIRE TO EFFECT AN INSURANCE IN TERMS OF THE PUBLIC LIABILITY POLICY OF THE COMPANY
AGAINST THE LIMITS OF INDEMNITY SPECIFIED ABOVE. I/WE HEREBY DECLARE THAT ALL STATUTORY
PROVISIONS RELATING TO MY/OUR BUSINESS PROPOSED FOR INSURANCE ARE COMPLIED WITH. I/WE FURTHER
DECLARE THAT THE ABOVE STATEMENTS AND PARTICULARS ARE TRUE AND I/WE HAVE NOT OMITTED,
SUPPERESSED, 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.
SIGNATURE OF THE PROPOSER
PLACE :
DATE :
SECTION 41 OF 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 OF 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 NOT SHALL
ANY PERSON TAKING OUT OR CONTINUING A POLICY ACCEPT ANY REBATE EXCEPT SUCH REBATE AS
AMY BE ALLOWED IN ACCORDANCE WITH PROPECTU OR TABLE, 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.
Skd./ public liability proposal