UNITED INDIA INSURANCE COMPANY LIMITED
Head Office: 24, WHITES ROAD, CHENNAI - 600014

PROPOSAL FOR STANDARD FIRE & SPECIAL PERILS POLICY

Acceptance of this proposal is subject to the rates & regulations of Our Company’s Tariff. The
property is not covered until the risk is accepted and premium paid.
DETAILS ABOUT PROPOSER
1. Name of Proposer
2. Address of Proposer
3. Pincode
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
Institutions)
6. Location to be covered - (Full
Postal Address with Pincode)
7. Period of Insurance
From To
8.Would you like to delete these perils
from the basic cover? a. Flood, Cyclone, group of
perils
Yes / No
b. Riot, Strike, Malicious
and Terrorism Damage
Yes / No
9. Would you like to cover the
following along with your
buildings?
Plinth & Foundation
Yes / No
Sl.No Add-On Cover Specify Yes/ No Value on which premium
has to be charged
10.1 Architects, Surveyors and Consulting
Engineers Fees ( in excess of 3%
claim amount)
(To Specify sum insured)
10.2 Removal of Debris (in excess of 1%
claim amount)
(To Specify sum insured
(SI) upto maximum 10% of
SI )
10.3 Deterioration of Stocks in Cold
Storage premises due to accidental
power failure consequent to
damage at the premises of Power
Station due to an insured peril (Sum insured of stocks)
10.4 Deterioration of stocks in cold
storage premises due to change in
temperature arising out of loss or
damage to the cold storage
machinery(ies) in the Insured’s
premises due to operation of
insured peril. (Sum insured of stocks)
10.5 Forest Fire
(To Specify sum insured)
10.6 Impact Damage due to Insured’s
own Rail/Road Vehicles, Fork lifts,
Cranes, Stackers and the like and
articles dropped therefrom.
(Policy Sum insured)
10.7
Spontaneous Combustion
(To List Commodities)
1. -------------
2. ------------ (Sum insured of each
commodity)
10.8
Omission to Insure additions,
alteration or
extensions (5% of sum insured of
Building Machinery and Accessories
(BMA))
10.9 Earthquake (Fire and Shock)
(Policy sum Insured)
10.10 Spoilage Material
Damage Cover
(Value of stocks in specified
blocks )
M/A value in specified
blocks.
10.11 Leakage And Contamination
Cover
Where the tanks are within the
Insured’s own premises
Where the tanks are located
elsewhere
Leakage
Cover
only
Leakage &
Contaminatio
n
( To Specify sum
insured)
10.12
Temporary Removal of Stocks
Clause
(Policy sum insured)
10.13
Loss Of Rent clause
(To Specify sum
insured)
10.14 Insurance Of Additional Expenses
of Rent For An Alternative
Accommodation
(To Specify sum insured)
10.15
Start up Expenses
(To Specify sum insured)
10.16
House Breaking
(To Specify sum insured)
10.17
Electrical apparatus
(To Specify sum insured
of all electrical
apparatus)
10.18 Spontaneous Combustion
(including Non -fire damage)
(To Specify sum insured)
10.19 Insurance of jetties, Docks and
other Properties erected in water
& damage
by water borne bodies (To Specify sum insured)
10.20 Boiler explosion damage
(To Specify sum insured)
10.21 Start up / Shut down Expense
(To Specify sum insured)
10.22 Accidental Damage
(Policy Sum Inusred)
11. Whether you have insured the same
property with any other Insurance
Company with identical coverage. (Give
details)
12. Whether Insurance cover was declined
by any other Company or imposed any
Special Conditions (Give details)
13.Premium / Incurred Claim details for the
past three preceding policy periods
Premium Incurred Claims
Year
Year
Year
DETAILS ABOUT PROPOSER’S BUSINESS COVERED AT THE LOCATION
14.The Insured property is
Dwellings, Offices, Shops, Hotels etc
Yes / No
Industrial / Manufacturing Risks Yes / No
Storages outside Industrial Manufacturing 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 stocks stored
include any stocks appearing in the list given below. If yes,
whether the value of such stocks exceed 5% of total value of
stocks
Yes / No
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
Deg.C (Closed Cup test), 12.Paints with inflammable base having flash point below 32
Deg.C (Closed Cup test) - other than in sealed tins or drums, 13.Varnishes having a Flash
point below 32 Deg.C (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 an Industrial Manufacturing unit, state
the details of 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 Extinguishing Appliances installed
Please Tick in the box below
Portable Extinguishers
Trailer Pumps
Fire Engine
Hydrant System
Sprinkler System
Fixed Water Spray System
20. The basis proposed for insurance (Building / Machinery / Furniture Fixtures &
Fittings)
Market Value basis
Yes /No
Reinstatement Value Basis Yes /No
21.Construction Details
a Please state material used i. Walls
ii. Floor
iii. Roof
b Height of the Building ________ Meters _________Floors
c Age of Building Less than 5 Years ‚5 - 10 Years ‚
10 – 20 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
Of Block Amount in Rs
Age
Yrs
Heig
ht
Mts
Constr
uction
Building
including
plinth
Machinery
&
Accessories
F&F,
office
and
other
equipm
ents
Stocks and
Stocks in
process**
Other
Property
to be
insured
specifically
Total
Total
Note
** Indicates those stocks which are covered on normal basis and do not fall under Serial No.23 A, B, C
and D below
23.Special Coverage for Stocks only
Please Tick in the box below and give the amount to be insured against each
A. On Floater Basis
Stocks at various locations (Process blocks, warehouses / godowns and /or in open
etc.,) can be covered on floater basis under single Sum Insured.
Locations (Postal Address with Pincode)
Amount Rs.
B. On Declaration Basis
Stocks which fluctuate in value can be covered on (monthly) declaration basis.
Locations (Postal Address with Pincode)
Amount Rs.
Note:
1.Minimum Sum Insured per policy should be Rs.1 Crore, and policy will not be issued
on short period basis
2.Stocks in process & stocks stored at Railway sidings cannot be covered
C. On Floater Declaration Basis
Stocks which fluctuate in value as well as stored at various locations under single Sum
Insured can be covered on (monthly) floater declaration basis.
Locations (Postal Address with Pincode)
Amount Rs.
Note:
1.Minimum Sum Insured should be Rs. 2 Crores
2.Stocks in process & stocks stored at Railway sidings cannot be covered
D. Stocks stored in open (located outside the factory compound)
Details of stocks stored in the open
Locations (Postal Address with Pincode)
Amount Rs.
E. Tank Farm and Gas holders (located outside the factory compound)
Details of stocks stored
Locations (Postal Address with Pincode)
Amount Rs.
Declaration by Insured
I/ We hereby declare that the statements made by me / us in this Proposal Form are true
to the best of my / our knowledge and belief and I / We hereby agree that this declaration
shall form the basis of the contract between me / us and the “THE UNITED INDIA
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 would be conveyed to
the company immediately.
Date
Place
Signature of
Proposer