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

PROPOSAL FOR WORKMEN’S COMPENSATION INSURANCE

This policy provides indemnity under the Workmen’s Compensation Act, 1923 and subsequent amendments of the said Act, prior to
the date of the issue of the Policy, Fatal Accidents Act, 1855 and at Common Law.
No Insurance is in force until the premium or a deposit premium has been paid and no acknowledgement for any premium or deposit
premium is valid unless upon the Company’s printed form.
If the space below is insufficient for any answer, please continue on separate sheet and attach hereto.
Proposer’s Name in Full………………………………………………………………………………………………………………….
Proposer’s Business Address……………………………………………………………………………………………………………..
Proposer’s trade or occupation……………………………………………………………………………………………………………
Particulars of work………………………………………………………………………………………………………………………..
SCHEDULE
ALL PERSONS EMPLOYED MUST BE INCLUDED
ESTIMATED ANNUAL WAGES For Office use only
SALARIES AND OTHER EARNINGS
Description of Employees
Estimated
Number of Cash Living or other TOTAL Insurance
Employees allowances required PREMIUM
( if any) State Table Rate
A or B of per
prospectus Mill
(1) (2) (3) (4) (5) (6) Rs. P.
Clerical Staff
Commecial Travellers
Employees engaged with wood
working machinery including
machinists and machinists
labourers
Other Employees
What was the total amount of wages, salaries and other earnings paid by you during the past twelve month? Rs…………………..
Do you wish to insure your liability under the Workmen’s Compensation Act, 1923 and subsequent
Amendments of the Act prior to the date of the issue of the policy to the workmen of sub-contractors? YES/NO
If yes please state :-
Names of Contractors
Full details of work
subject (specify exact nature
nature of work)
If the contract is
for labour only
state total amount
of contract or
wages paid
If the contract is for
labour and materials
state estimated
amount of contract
If the contract is for
labour material &
equipment state
estimated amount
of contract
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Rs………………..
Rs……………….
Rs……………….
Rs…………………..
Rs………………….
Rs………………….
Rs…………………
Rs…………………
Rs………………..
1. Do you wish your policy to be extended to provide for payment of medical and similar expenses as detailed
Overleaf ? If so please state limit per case required. YES/NO
____________________________________________________________________________________________________________
2. Does the above schedule include - (a) All persons in your service YES/NO
(b) All your sub-contractors YES/NO
____________________________________________________________________________________________________________
3. Are your premises a Factory within the meaning of the factory Acts ? YES/NO
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4. (a) Have you any circular saws or other machinery driven by steam, gas, water, electricity or other mechanical power? YES/NO
(b) Are your machinery, plant and ways properly fenced and guarded and otherwise in good order and condition ? YES/NO
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5. (a) Is your Boiler registered under the Indian Boiler Act, 1923 ? YES/NO
(b) If not, under what condition is it exempted from such registration ? YES/NO
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6. State what acids, gases, chemicals or explosive will be used and what extent
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7. Are you at present insured or have you ever proposed for an insurance in respect of your liability
to your employees ? If so please give the name of the Company or Companies YES/NO
____________________________________________________________________________________________________________
8. Has any proposal for an insurance in respect of your liability to your employees or renewal a) Declined……………YES/NO
thereof ever been declined or withdrawn ?
b) Withdrawn ………….YES/NO
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10. State the total wages paid and particulars of accidents to your employees during the past three years :-
Year
Total wages
Fatal
No. Cost
Permanent Disablement
No. Cost
Temporary disablement
No. Cost
19
19
19
Rs…………………..
Rs…………………..
Rs…………………..
……. Rs……………
……. Rs…………..
……. Rs…………..
……… Rs……………
…….. Rs……………
…….. Rs……………
……. Rs…………….
……. Rs…………….
……. Rs…………….
I/We, the undersigned desire to effect an insurance in terms of the policy to be issued by the company against my/our
Statutory and common Law liability. I/We agree to render, at the end of each period of Insurance, a statement in the form required by
the Company of all wages actually paid and to pay premium on any wages paid in access of the amount estimated above. I/We hereby
declare that all the above statements and particulars which I/We read over the 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 contract between me/us and the Company.
Date…………………… Signature of the Proposer
____________________________________________________________________________________________________________
Proposal Introduced by………………………………….. Proposal Completed by……………………………………………………
Signature & Name of the Inspector/Agent Signature and Name in full
WORKMEN’S COMPENSATION
INSURANCE
Policies are granted indemnifying Employers under
any of the following tables :-
Table A Indemnity against legal liability for accidents to employees under
the Workmen’s Compensation Act, 1923 and subsequent
amendments of the said Act prior to the date of issue of the Policy,
the Fatal Accidents Act, 1855, and at Common Law.
Table B Indemnity against legal liability under the Fatal Accidents Act,
1855, and at Common Law only.
PREMIUMS are based upon the merits of each proposal, but rates
for any particulars trade will be quoted on application. The proposal form
should be completed, and the wages for different classes of Workmen should
be estimated separately.
MEDICAL EXPENSES
The Table A policy may be extended on the following scales to
provide for the payment of medical, surgical and hospital expenses (including
cost of transport to hospital) incurred :-
Limit Rs. 80/- per case 12 ½ % additional premium
“ “ 120/- “ “ 15% “ “
“ “ 160/- “ “ 17 ½% “ “
“ “ 400/- “ “ 20% “ “
“ “ 800/- “ “ 25% “ “
“ “ 1600/- “ “ 35% “ “
“ “ 2400/- “ “ 45% “ “
THE INSURED is relieved of a great deal of detail work in the
matter of rendering returns of accidents to the authorities as this is undertaken
without charge by us by special arrangement with the Commissioners for
Workmen’s Compensation.
PROHIBITION OF REBATES
Your attention is particularly drawn to section 41 of the Insurance
Act, 1938 which reads as follows :-
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, 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.
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.