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

1. a) Name of Proposer (in full)
b) Address
c) Occupation
a)
b)
c)
2. Address at which the television set is installed
3. a) Was the Television set installed by a qualified
technician?
b) Date of installation
a)
b)
4. Has any insurer previously granted a cover in
respect of the risk proposed for insurance? If so,
pleased state
a) Name of the insurance co.
b) The period of insurance
a)
b)
5. a) Has the Proposer ever suffered any loss or
incurred any legal liability in connection with
any Television set? If so give particulars.
b) Has the Proposer made any claim in respect of
any such loss or legal liability? If so, please
give below details
a)
b)
Date of
Occurrence
Details of loss Name of
Insurer
Amount
recovered Rs.
Amount to be recovered Rs.
6. Has any Insurer
a) declined a proposal from the proposer, or
b) cancelled or declined to renew any policy or
c) demanded an increased rate, or
d) required any special terms to insure or grant
any renewal?
a)
b)
c)
d)
7. Period of insurance From To
8. If the set is portable, does the Proposer require
insurance when the set is taken away from the
Premises?
SCHEDULE OF TELEVISION SET TO BE INSURED
Description of Set
(Name of Maker)
and Type
Additiona
l
Apparatus
Date
Purchased and
Price Paid
Estimated
Present Value
(including
Accessories)
Television Serial Number
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.