National Insurance Company Limited
(Subsidiary of General Insurance Corporation of India)
Regd. Office : 3 MIDDLETON STREET, CALCUTTA – 700 071

PROPOSAL FOR STANDARD FIRE & SPECIAL PERILS POLICY

Acceptance of this Proposal is subject to the rates & regulations of Tariff Advisory Committee’s All India Fire Tariff
(The Property proposed for Insurance is not covered until the proposal is accepted and premium paid)

Divisional office address & code
Development Officer’s Name & Code
Agent’s Name & Code
DETAILS ABOUT PROPOSER
1. Name of Proposer
2. Address of Proposer including their
Phone, Fax no. and e-mail address
3. Business of Proposer
4. Paid up Capital of the firm
5. Policy to be issued in favour of (list out all the parties
who have insurable interest) including the financial
institution.
6. Location of risk to be covered – full postal address
with pincode.
7. Period of Insurance From _____________ to _____________
8. Would you like to delete any of following covers
from the basic cover?
a. Flood, Cyclone, group of perils Yes/No
b. Riot, Strike & Malicious damage, Terrorism Yes/No
9. Would you like to cover Plinth & Foundation along
with your buildings
Yes/No
10.
a) Add-on Covers Required.
b) Architects, Consulting & Engineer’s Fees
( in excess of 3% claim amount)
C) Debris Removal
(in excess of 1% claim amount)
d) Deterioration of Stocks in cold storage premises
due to power failure due to an insured peril
e) Forest Fire
f) vehicle Impact damage due to insured’s own
g) Spontaneous Combustion
h) Omission to Insure additions
i) Earthquake
Yes/No
11. Whether you have insured the same property with
any other Insurance Company with the same type of
coverage.(Give details)
12. Whether Insurance was declined by any other
Company or Imposed any Special Conditions (Give
details)
13. Premium /Claim details for the past 3 policy
periods.
Premium Claims
DETAILS ABOUT BUSINESS COVERED AT THE INSURED LOCATION
14. The Insured property is
Residence, Office, Shops, Hotels etc Yes/No
Industrial /Manufacturing risks Yes/No
Storages outside industrial risks Yes / No
Tanks/Gas Holders outside Industrial
Manufacturing risks
Yes/No
Utilities located outside Industrial
Manufacturing risks
Yes/No
15. If used as Shop please declare whether the goods
handled are as per the following list. If yes, whether
the stock value will exceed 5% of shop value
1. Celluloid goods, 2. Coir Loose, 3. Crackers & Fire Works, 4. Explosives of any kind, 5. Hay/Straw 6. Hemp
7. Jute Loose, 8. Matches, 9. Methylated Spirit, 10. Nitro-Cellulose Plastics, 11. Oils/Ether/Industrial Solvents and
other inflammable liquids flashing at and below 32 Degree Centigrade (Closed Cup test), 12. Paints with
inflammable base having flash point below 32 Degree Centigrade(Close Cup test) – Other than in sealed tins or
drums, 13. Varnishes having a Flash point below 32 Degree Centigrade (Closed Cup test) – Other than in sealed tins
or drums, 14. Disinfectant liquids and liquid insecticides – Other than in sealed tins or drums, 15. Vegetable fibres of
any kind including Rayon Fibre.
16. If used as warehouse/godown (not located in a
manufacturing unit) please give the list of goods stored.
17. If used as industrial manufacturing unit give
products manufactured at the location proposed
18. If used as an Industrial Manufacturing unit, please
state whether the factory is working or silent?
19. Fire Protection devices installed Please Tick in the box below
Portable-Extinguishers
Trailer Pumpd
Fire Engine
Hydrant System
Sprinkler System
Fixed Water Spray System
20. The basis proposed for insurance (Bldg / machinery /
FFF )
Market Value basis Yes/No
Reinstatement ValueBasis Yes/No
21. a) Construction Details Please state material used
i) Walls __________________
ii) Floor _________________
iii ) Roofs _________ -
__________Meters
Less than 5 years 10-20 years
5 – 10 years above 20 years
Note :
Buildings having walls and/or roofs of wooden planks/thatched leaves and/or grass/hay of any kind/bamboo/plastic
cloth/asphalt cloth/canvas/tarpaulin and the like are treated as “Kutcha” construction.
22. Building wise values(Please include the kutcha buildings also in this list and give individual values against such
Buildings
Description Amount in Rs.
of Block Building
Including
plinth
M & A F & F and
other
equipments
SSP** Property
to be
insured
separately
Total AGE
(YRS)
HT
(MTS)
CONSTRUCTION
TOTAL
Note :
** Indicates those stocks which are covered on normal basis and do not fall under Serial No.25 A,B,C and D below.
23. Special Coverages for Stocks only
PleaseTick in the box below and give the amount to be insured against each.
A. On Floater Basis
Stocks at various locations (warehouses/godowns and/or oppppen etc.,) can be covered on floater basis for a single
Sum Insured.
Tick Amount Rs.
Floater Basis
B. On Declaration Basis
Stocks which fluctuate in value can be covered on (monthly) declaration basis.
Tick Amount Rs.
Declaration Basis
Note :
1. Minimum Sum Insured is Rs.1 Crore, and policy not issued on short period basis.
2. Stocks in process & stocks stored at Railway slidings are not covered.
C. On Floater Declaration Basis
Stocks which fluctuate in value as well as stored in various locations can be covered on (monthly) floater declaration
basis.
Tick Amount Rs.
Floater Declaration Basis
1. Minimum Sum Insured is Rs.2 Crore
2. Stocks in process& stocks stored at Railway siding are not covered.
D. Stocks stored in open
Locations Amount Rs.
1. Stocks in open
(located outside the factory compound)
24. Total Sum Insured (as per relevant serial number shown against each)
Clause/
Peril
code
Risk
Code
Rate
Code
Rate Sum
Insured
Premium Risk
Code
Rate
Code
(Plinth & Foundation)
Architects & Engineer’s Fees
Debris Removal
Deterioration of Stocks in cold
storage premises on account of
power failure due to insured
peril.
Forest Fire
Impact damage due to Insured’s
own vehicle.
Spontaneous Combustion
Omission to Insure additions
alteration extension
Earthquake
Building wise values
(Stocks Floater Basis)
(Stocks Declaration Basis)
(Stocks Floater declaration)
(Stocks in open-outside factory
compound)
Grand Total
Declaration by Insured
I/We hereby declare that the statements made by me/us in this Proposal Form are true to the best of knowledge and
belief and I/we hereby agree that this declaration shall form the basis of the contract between me/us and the
“NATIONAL INSURANCE COMPANY LIMITED”.
If any additions or alterations are carried out in the risk proposed after the submission of this proposal form then the
same should be conveyed to the insurers immediately.
Date
Place :
Recommendations of
Development
Officer/Agent
Signature of Proposer
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 risks 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 any rebate except such rebate as may be
allowed in accordance with the prospectus or tables of the Insurers.
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.