UNITED INDIA INSURANCE COMPANY LIMITED
24, WHITES ROAD, CHENNAI – 600 014

PROPOSAL FORM FOR WORKMEN MEDICARE POLICY

1. Name of the Proposer
2. Proposer's Business Address
3. Proposer's Trade or Occupation
Particulars of Work :
SCHEDULE
ALL PERSONS EMPLOYED MUST BE INCLUDED
Description of Employees
1
Estimated Number of Employees
2
Workmen drawing monthly wages up to
Rs.4000/-
Clerical Staff
Commercial Travellers
Employees engaged with woodworking
machinery including machinists and machinists
labourers
Others (specify)
Workers drawing monthly wages over
Rs.4000/-
Clerical Staff
Commercial Travellers
Employees engaged with woodworking
machinery including machinists and machinist’s
labourers
Others (specify)
1. Does the above Schedule include?
a) All persons in your service?
b) All your sub Contractors?
2. Are your premises a Factory within the meaning of the
Factory Act?
3. Are you at present insured or have you ever proposed for an
Insurance in respect of your liability to your Employees?
If yes, please give the name/s of the Company or
Companies, Policy Nos. & Period.
4. Has any proposal for an insurance in respect of your liability (a) Declined
to your employees or renewal thereof ever been declined or (b) Withdrawn
withdrawn or changed rates, etc. ?(Give Full Details) (c) Changed Terms
5. State the total wages paid and particulars of accidents to your Employees, during
the past three years, in the table below :
Year No. of
workers
Fatal Permanent
Disablement
Temporary
Disablement
Number Cost Number Cost Number Cost
Rs. Rs. Rs.
Rs. Rs. Rs.
Rs. Rs. Rs.
6. Sum Insured Opted for per person* (please tick): 50,000 100,000 150,000
*Please note that all workers covered under the policy will have the same sum insured.
I/We hereby declare that all the above Statements is and particulars which I/We have read over
and checked are true, that I/We have not Suppressed misrepresented or misstated any material
fact, that I/We have fairly estimated my/our total wages and salaries expenditure, and I/We
agree that this declaration shall be the basis of the contract between me/us and the United India
Insurance Company Limited.
Signature of Proposer ________________
Note 1.The liability of the company does not commence until the proposal has been accepted
by the Company and full premium paid.
2. If space is found insufficient, please attach separate sheets for details.
3. Insurance is the subject matter of solicitation.
PROHIBITION OF REBATE -- Section 41 of the Insurance Act 1938
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 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 rebates as may be
allowed in accordance with the published prospectuses or tables of the Insurer.
Any person making default in complying with the provisions of this section shall be
punishable with fine which may extend to Five Hundred Rupees.
FOR OFFICE USE -
MARKETING / DEVELOPMENT OFFICER'S REPORT
The Proposer is known to me/my agent / Broker for___years and I recommend acceptance of
this proposal.
Name and Code No. Signature of Dev. Officer/A/AO-D
ACCEPTED BY DATE & TIME RATE REMARKS
CODES - OFFICE /DEV. OFFICER / AGENT /BROKERCOLLECTION
/ SCROLL NO POLICY NO.
.