HDFC ERGO General Insurance Company Limited HDFC ERGO Business Secure - Sookshma Udyam - Proposal Form {Please answer all questions in BLOCK eters) [Note you not id sutclent epace in any of the below columne please use addtional sheets forgiving full deta 1 aNameatthetnsued = [| | | | | Correspondence aedress [T[[[ 1 ore scr COTTE rrr CEEELEL TTP) tovsmote EEE EEL) em L emcee DLL prone wo.[ TT TTT TTT TTT) mobie [TT TT TT TT TTT) Email b. Adress poo! document & number «Occupation [Salaried []Professional [ ]Self Employed [ ]Student | |Housewite[ Retired Other Pease spect aNaueoteacesr | j Busines ofthe Insured echcome (Anna) (]oasim []2s-staxn []5-r6 xn []2030 lakh [_]201aKn and above {Income proof [ ] 4. Risk Occupancy [ ] hh Risk Location Addresses ‘ofall major locations 1 Name, Adcress ofthe Financial Insttutions oF ‘any bank/ person any inane ierestsnveved| Pale up capital of the fem 2 Peredetinsurance ‘From 1 “TEE Aadnar Number Permanent Aecount number (PAN No} 3 aSourceofBusiness — [] Agent [_]Broker] | Direct b.lntemediary Name [ ] elntermediany code [ ] @.Contactno. [ ] Rik Da a] 90 of Construction [Picea [Jrctene 1 Does any acaton proposed fr Reuse Fat Barer OCEIRAREV? yes, what stores nse and approximate valve out of ota St ‘Ae ofthe Bulcings Ts the balding par of ndutial Ares or Commercial Compler? [r] hevstisres [-]eonmerca Compe [~] Stanaione ‘What ate the suvounding eccupandes and thev dstance fiom the raety?| [Any ether eccupancy in same Bulng belonging to Insured or others “Approximate distance fiom the nearest water body (River, Lake, Canal, Sea, nala ete} \ihat ate the Fire Protection Systems a the Faelty? (Exinguishers, Hydrans, Sprinkler, Mose Reelete} How frie the nearest Puble Fre Brigade and what the response time? 1: | What are the seeuity evangements? Detalls shout business covered atthe insured location 2 | Detaleof insured property Please wekin the space below Oftees, Shops, Hotels ee vel] Nel] Indust / Manutecturing wake Yel] Ne LE] =| Storage octige eel Manufacturing rake ve ET ne CI Tonks /Gae holders outside Inévsial Manufacturing ke Yel] NL] Unies located outside Industrial Manufacturing risks ves] No [|_| Boundary wal eT] Ne] HE Suen arg chucngate wanas tost00 cuere Si rs cst apart cerer 0.30 oor ane desnes bac gn Ss erg Brand thes) tanse 400 78 re Cheat rete gua Ree eck chin ae ge Saye orbs t= ann Rete ra aay ao ott ae UN ASE ERED Ba ee9] Barementsioage vel] No [] Myer vane sores si® i Others (please speci ve) No] 3 fused as warehouse / gedovn ot located In a manufacturing uni please give the st of goods stored, 4 used as an Industrial Manufacturing unit give products manufactured atthe lection proposed (tale block plan showing various facies ove enclosed winerever applicable) 5 | fused as an neustia! Manufacturing unt, please state whether the factory working oF stent | Fe Protecion vies nstates ease ik he corecianswerin te box below, [Cronabtetxtngushers | [_] smat pore hese eee [tater Punpsitie engines | [] Hyerant sytem [EZ sonener system [Hl race water Soray system |Z Foam system [Lemar sytem [Tess Floocing System —_| [| others please specty below | rrePioectonoplonesisintece ves[_] no] 2 | constiuevon deta 2. Please state mari used Pease tekthe correct answer inthe Box 1 Wat tena] Pucca [] Floor tena] Pucca F] i Root utero] Pucca F] ‘Note: Kutch: uldingls having walls and/or raofof wooden planks/hatched leaves and/or arass/hay of any knd/bamboo/plastcclth/asphat/canvas/arpouin andthe like re treatedosKucha Construction, cea: Bulings other than Kutch are eatedas Pucca constructions b| Number of Floars | Age ofthe Bulling Less than Syeare 5 —10 years 1020 years ‘Above 20 years '9, | Distance between the risk tobe covered and nearest Fire Brigade {a Whether You have insured the same property with any ether Insurance ‘Company wth the same type of coverage (Give deta) I | Whether msurance was decined by any other Company (Give details) 12 Premium / Clam deta forthe past 36 months excluding the Premium ‘xping pai perioe z z z z z ‘Sum insured and Other detlis of Insured Property {Indicate Sum Insured onthe fllowing basis: + For ulsing, Plant and Mochinery, Future, Fiatureand tings andother contents: Reinstatement Value; + Forraw materia: Landed Cost: + Forstockin process Inputeost; 1 Forfinshedstock Manufacturing costo the finshed stockor the Contract Price" of goods sold avin elvered, as applicable “contract Price isn respect only of goods sold but not delivered for which You are responsible and with regard to when underthe conditions ofthe sale, the sale contracts eancelee3y eason9y any Damage insured uncer this Paley ether whollartethe extentofte Damage. The Companys adity shalbe based ‘onthe ContraesPriee). HE Suen ar cnucngate nas foat00 cutee Sperone Wanagerem Castner lipase cote 1 attlor Caner bus bate Wage! lh 5s ar Brand [es mamas © 409 Gre Fe Cinoke ‘ets eras clue a1" 29 Cone coaa io tou C2048 Vet aly Secon on araheugo co pay caps cena sce Ree eck chin ae ge Saye orbs t= ann Rete ra aay ao ott ae UN ASE ERED Ba ee[3] Description | Butcing ncuding]| Plant & | FUT Trew atevas | Stoekin Fnshed Stock] Gther Contents | Total ofBtock | pith, Basement | Machinery |Fistres,Ftings Process (Presse Speci) ‘and other auipment z z e Inbuit Covers 1] Foster cover for stocks at various eeatons) vel] Nel] Location Postaladcress | Sum hewred a) wit anced) 1) Maximum value a any one locaton: Wi wnetner stocks storedin open-Yes [_] No [ ] 15 Tempore Repair Clause z 16 | On Account Of Payment cause z 17| Customers Gooes/Consigned Goods Ané Care! Custody & Control Clause | € 18 Floater Declaration Clause z 19, Declaration Policy For Stock ves.) Nel] Iryes, gve details below: Stocks which fituate in vale o be covered on (monthly) eclaraton bast: ‘Amaunt 30] Be You wane ot or ceeton folowing pens? (0) Earthquake ye] ne str ve ne FE] 23. Optional Covers (avaliable on payment of adelional premium) ai] Accidental Damage ve] nel] 11| Dynamo cue ves] nel] | Less Minimization yee] Nel] | Esra Expenses Yes.) Nol] Yes, _% ofmaterl damage cam amount “Please provide inthe multiples of 5% subjeet 1.9 maximum af 25% + Our Maximum Hail is ited to € 25 lacs «| tovturary bererment vel] wel] is, Lint of Linum sured = & 1)| Less errent and adsonal emense of Rentfor Aternatve expenses | Yer[] No[_] Wes, Prove ent amount per month-® ____ Indemnity Period nents up 36 mon 3a] Contract works vel) wel] Wes, Sum sured -& (ax pt 10% otal sum insured) W escatton vel] wel] wes, ‘increase pe annum fh mulipes of 5% upto haat aoc] 1) Brand and abel Coase ves] Ne[] Wes, Lino Labity/Sum insures -@ ___Upto_of Finished Goods Sum insured (ne up Z5N oT shed goods Suminsured 1) | Leakage Ane Overtowing vel] vel] IFYes, Lit of LiabltySum Insuree —& HE Suen ar cnucngate nas foat00 cutee Sperone Wanagerem Castner lipase cote 1 attlor Caner bus bate Wage! lh 5s ar Brand [es mamas © 409 Gre Fe Cinoke ‘ets eras clue a1" 29 Cone coaa io tou C2048 Vet aly Secon on araheugo co pay caps cena sce Ree eck chin ae ge Saye orbs t= ann Rete ra aay ao ott ae UN ASE ERED Ba ee1a] Contamination And Comingng Cause vel] Nol] is, Lint of LiabitySum sures —& 1 | Beteeraten OrStocksin Cole Storage Premises Due Te Aeseortal | Yes] Nol] Power Fare Consecuori te Damage At The Prams Of Power Sten Due Te An sure Pel Wes.Suminsuredofsiock= mi) Detereraton ofStecks in Cole Storage Premises Due To Change | Yes] Nol] TermperstureAisng Ou OF Loss Gr Damage To The Cala Storage Machinery es} inte Insure Premises Bue To Operation Of Wes, Suminsuredofstock: Inssreo Pet 1}| Impact Damage Due To Insuree’s Own RailRoad Vehicles, Fork Lits, Yes] nol] Cranes, Stoke's And The Like nd Aes Oropped There From Wes Lin LaitySum insure —@ «)| Meten Meta Spilage-ropery Damage ve L] Nol] ies, Lino LabtySum nsree 2) | Crane Hing Charges Yel] Wel] Wes, Lif LabitySum Insured © «| Omission To nsre Addins Or Etensions vel] Nol] Wes Lin LabiySum nsree—& 3 | BresawaterDamage Cause vesL] Nol] ies, mi Lsbty/Sum nsree 3i] Tevorsm cover Yes] ol] I Yes, Lin ofLabltySum Insure © 1 [a_i yoursremises guarded by WtchmenSecuily Guards 24 hows? Yel] he |] bs the premises insted wih CCTV? Burlay alan? ves[] he [| Are alley ents fhe premises secred with en gis andtocking system, | ves] We [-] 2 Ave stock and sales book maraied by you? EE] 3) a Wave ay premises aecpied by Yu beer RuBeeedo thet or bur? SET Ws, ave fll partcalrs tating when and how acess was obiined and he tent ofthe bss. 3 | Be you requ poly on 100% sum heared bai or fr ss ni on fistfoss nt, bL menson ine to he fllsum sree? | OperatngHous ofyeurBuaiene 2. Wilthe premised at anytime el unoccupied? b_Hfsehowmany and dung whattime? 3 | Add-on Covers any afthe below mentioned aden covers re eaued later Cover 2 hit size Damage couse thet Extension 2 costerbebis renova 2 costofrestrng documens 2 expense fortes inimisaton 1 Employee persenalpraery cover 2 aptacement flocs inching repo sree premisas 2 omission te nsure 1 Taetbyuse of Duplicate Keys {1 Reinsttemen Value police 7 Sum nswed Botte SINo | Desersion of papery tobe nares Sum hawed = Plant & Machinery ® ‘Socks & Stocks m Process < Faire, Far &Ftings 4 ther Contents HE Suen ar cnucngate nas foat00 cutee Sperone Wanagerem Castner lipase cote 1 attlor Caner bus bate Wage! lh 5s ar Brand [es mamas © 409 Gre Fe Cinoke ‘ets eras clue a1" 29 Cone coaa io tou C2048 Vet aly Secon on araheugo co pay caps cena sce Ree eck chin ae ge Saye orbs t= ann Rete ra aay ao ott ae UN ASE ERED Ba eeSE 1 | What Type of glass! sanitary fitings are proposed for insurance? Exterior building lass, feed glass on door window’ table tops ete) 2 | Does ts proposalinclude all the mnsurabe glass atthe premises? selection is mace, then please Furish eta) 3. Bo you desire to nsure leteing er painting vel] Nel] 7 | Be you dete to sre Damage to woodwork afshowcase o Window Fames ve P]) L) 3 | Teron coverIndsion ef] Ly | Please fish vale ofthe glass wit dimension and offamework and any Sed enbossed, emamental or parted lass 5 No] Descrinon Dimension valve fe) 7_| sanitary Ftings x | Please specy the locations ofthe premses, where he neon sign glow tian nomang seed or evected 2 | Doss tis proposal nce athe msuabie neon signs atthe penises 3 | fete premises where the neon ins are ereced owe or eased by you | Does the poposalncude athe insuableneon signs athe premises | Pes tmsh he eeseratonin he folowing frnat IN| Descintonofneon sgn glow sgnihoardng Vales = | Tevorsm cover duson vel] Nel] 1 Hasyour machinery sustained any damage rom breakdown oraher cause curing astvee years | ves] no L] 2 | Are epuar penodcalinepectns ofthe machinery caed out 15, by whom and at what ntervat ves] eC] 3 | Schedule of machinery tobe neued- 3) Each machinery should be entered separately wth necessary specication 1) The sum insured must be calculated on the present day new replacement value ofthe machiney tebe insures Including provision fr packing, Freight and ase value of erection casts customs euty, ete 9 aiferefullarateetion undar the potey ©) Please declare only nstaled machines net potable ones {@ Separate value or Teundalions masonry and bricawark or Oi WansTormers and olherelecweal {equipments are tobe specifi if covers required fr them, SINe) Quant Deserptions ype, model, capacity of Make’sName | Year ofMake | Suminsured ®) machines! sires, HO/ KAY Vals, Ams, Ram | ane county af origin 1 2 4 | Aadd.on Caves: any of the Below mentioned add-on covers are required + Escalation Clause + Express Freight + Ar Freight + Owners Surrounding Property +The Pay Liabitty + Adational Customs Duty + Modifestion cos¥ncompatbity exaenses + UnRepated camages + Waiver ofimprovementBetterment clause for replacement of selected machinery {+ Expense for loss minimization + Capital adetion + Claim Preparation Costs + Un repairable Equipment Clause 1 Serial Losses HE Suen ar cnucngate nas foat00 cutee Sperone Wanagerem Castner lipase cote 1 attlor Caner bus bate Wage! lh 5s ar Brand [es mamas © 409 Gre Fe Cinoke ‘ets eras clue a1" 29 Cone coaa io tou C2048 Vet aly Secon on araheugo co pay caps cena sce Ree eck chin ae ge Saye orbs t= ann Rete ra aay ao ott ae UN ASE ERED Ba eeEVES [he equpmentmantainedn accordance wth manufacues instructions? vet] eC] 2 | Have operators been tained by manuacure? ve LL 2 | there any Annual Maintenance Contract AMG) in force ve Le [2 | Prase provide te deta ofthe aims any made by you forthe ns te years. yes please prove deans [ves |] no |] 5 [ Seneaue of machinery to be insured SiN | Gvantiy Desernons often YexrofMake | Vahie | SeralNe 2 3 Sub Toa) Re eave note ht he vale of eleconle equipment should be replacement value by new one of ame Kind hehe of igh, customer dityand other charges andcostoferection 6 | Adé-on Coves: any ofthe belowmentoned ad-on covers arerequied + EndorsementForExetision of Damage CausedBy Fre And Allee Pers + Mecical Equipment Using XRays Tubes + Escalon Clause + ExpressFreight + AirFreight + Owners Surounding Property + ThyeParyLiabity + Additional Customs Duty + Software Endorsement + FlosterCiause + Omissiontolnsureadttions + Remavalot Debris + ProfessionalFee + CleanUp andDecontamination Cost + Modiieation cosvincompatiity expenses + Waiver ofimprovementBettermentclause forreplacementofselected machinery + UnRepated damages + Capitaladettion + Claim Preparation Casts + Terrorism Coverlnelusion | Is there ary Annval Maintenance Contract AMC) in foree Yer No 2 _| Terral Lim requires India or Worldwide 3 | Have you sutered any oss af or eamage to any equipments or had a breakdown or flue during the Tast three years and shows any sign of rep I's, give éetals thereat 4__| Senedute of machinery tobe insured SSINe | Quantity Descriptions of tems Year of Make Vaue) | Serat No. 1 2 5 _| Adé-on Coves: Wary ofthe below mentioned adden covers are required + Reinstatement value couse fr portale tems + Omission to eure actions or extensions + Inlernal Breaktown + Worldwide geographical tnt + Capital adeition + Un Repaired gamages + Unrepatable Equipment clause + Claim Preparation Costs + Expense 1 toss minimization + WaverofimprovementBetterment clause for replacement of selectee machinery + Exealtion Cause {Terrorism cover Incision HE Suen ar cnucngate nas foat00 cutee Sperone Wanagerem Castner lipase cote 1 attlor Caner bus bate Wage! lh 5s ar Brand [es mamas © 409 Gre Fe Cinoke ‘ets eras clue a1" 29 Cone coaa io tou C2048 Vet aly Secon on araheugo co pay caps cena sce Ree eck chin ae ge Saye orbs t= ann Rete ra aay ao ott ae UN ASE ERED Ba eeEES Description of Money tobe insured, ff ne Insurance Is requied for any tem insert NE} Rem No Money Esimated Annual amount of money in wane, Highest amountin rans ‘which wil be the Basis on which the provisional premium willbe chargee Re 1 Money in det transit tom te. IL Money n locked safe or strong room curing business — Ti; Money in andor counter during business hours = Ti Money in locked safe or strong room outside business hours . Money inthe personal custody ofthe sured or the authorized emplayesls | — a the insured whilst in eansit to the premises ar bank within a petiad not exceeding 4Bhours from the time of callection ‘v, Damage te Sate, Cath Box o Strong ream inthe premises ~ 1_| Howie the money eared? 2 | Winatie the eistance over wien the money ville cariec? (rn) 3 | Have you ever sustainee any loss of money whilst in tanstor whist on your premises? Iso give fl partivlars yes) nol] 4 | What means of wanspert do the persons canying the meney use Le ‘oun eatfpulie transport ete? 5 | Are the persons carving the money accompanied by an armed guards? IFnet state wnat protection any, provided (ot then 6 | State folowing particuis of safels angler strong ream in whieh ‘money willbe kept outside ausiness hours 2) Maker's Name, Weight Dimensions, enttieation Number ys fined tothe walls offoor? ‘@ By whom are the keys ofthe safe) angio strong roam hel? ‘@)_ Areal such Keys removed Fam the premises outside business Rous? ‘)_ Wilthe premised are guarded whibt they ae closed for business? Irs0, by whom? 7] Have you ever sustained any ls of money whist in tranat or whist on your premised? 30, ve full parteaars 8.| Acé-on Covers Ifany ofthe below mentioned adé-on covers are required, + Automate Reinstatement +Business! Working Hours extended + Claim Preparation Costs + Damage te ething! personal effects assault clause + Definition of Money + Inielty cover clause + Loss or Damage to Safes Strong rooms & Money Receptacles including damage to property and landlords fotures ane tings) + Money in overnight custody clause + Replacement of Keys & Locks, recoding of locking devices jinelding repair + Temporary Safe Rental{anetheinsurancethereet) + Thettbyuse ofDuplicateKey 2 Wotlwide vavel 2 TheftfromUnattenced Vehicle + AdjustmentorPremium + Terrorism inchsion 1 Rite ste Damage Clause Sees | Ferrera Unt required Thala or worlewide 2 [Limi oftncemnity a Anyone eerie pron z Anyone yea fr persons, x 5 | Tovoram cover neon vel) weld HE Suen ar cnucngate nas foat00 cutee Sperone Wanagerem Castner lipase cote 1 attlor Caner bus bate Wage! lh 5s ar Brand [es mamas © 409 Gre Fe Cinoke ‘ets eras clue a1" 29 Cone coaa io tou C2048 Vet aly Secon on araheugo co pay caps cena sce Ree eck chin ae ge Saye orbs t= ann Rete ra aay ao ott ae UN ASE ERED Ba eePa ES Ti Detals of Employees tobe guaranteed Named! Designation covet option) ‘SeNo, | Name Designation Place of Employment | Amountto be ‘Any other ‘guaranteed per person | security taken ®. Please aached separate sheet the spaces insucent ‘otal Annual Aggregate Limit of Guarantee x lh Detals of Employees tobe guaranteed Floating cover option) ‘SiMe, | Category af employees No ofemployees | Place of Employment Amount to be ‘ny other security tobe covered tobe covered guaranteed per person _| taken a Please attachee! separate sheet ithe space is insufisent ‘otal Annual Aggregate Limit of Guarantee z 2. | Isthere a system to obtain reference trom previous employees? I not, specify practice folowed 3. | State the estimate of maximum amount helé by any employee at any ene tine and for how long 2._Money:_ Amount Perioe b. Stocks: Amount Period 4 | a: How often are the employees required to account fr mney? 15, What Independent system is thereto check tha ll sums received by employees sre accounted fo? 5 | ®. Doemployees pay out money or éraw cash ram Employers account? System af operation of Bank aecount and precaution taken ‘© Whether such payments) withdrawals are authorized by a senior employee and compared with supporting documents? 6. | How often the eash back i balances, the entries checked with vouchers, Bank’ passbook ne with counterfils of receipt books 7. | How often are the Proposer's books balnncae? | a. System followed for purchase of goads and recording deliveries System followed fr authorized dispatch of goods and ensuring thal dispatch us recoreed and changed to the custome °9, | How often ane by whom stack vereation is done? 10. | System for coiecing outstanding accounts 11 | How oten wi statements f account be furnished by the Proposed direc te Customer? 12.| What the extent and frequency of audi? 18. | Details of asses sutfered on account of iniety of any employees duting lst 5 years and steps taken to prevent recurrence, 18 | Aceon Covers any ote below mentioned adeé-on covers are required + Extended cover for past employees + Accountants & asters + Aeration of systems + Automatic reinstatement ‘+ Claims preparation costs &auelt fees nelucing computer system certetion) + Costs of recovery fllowing subrogation tothe company fy the company) + Costs of recovery by the insured fr loss in excess ofthe sum insured + Costofectiying accounting & computer records & programmes + Credit deat card fraudulent use of) + Discretion in repartng to police (perio of grace ane successful ‘+ Subrogation water jeontractng parties} + Unidentifiable employees oss asa result of) 1 Contraction Roll Employee Cover HE Suen ar cnucngate nas foat00 cutee Sperone Wanagerem Castner lipase cote 1 attlor Caner bus bate Wage! lh 5s ar Brand [es mamas © 409 Gre Fe Cinoke ‘ets eras clue a1" 29 Cone coaa io tou C2048 Vet aly Secon on araheugo co pay caps cena sce Ree eck chin ae ge Saye orbs t= ann Rete ra aay ao ott ae UN ASE ERED Ba ee2. Projected Annual Revenue >, Numberofemployees Projected Annualsalares ©. Occupiedfograresinsameter ©. Typecteonstrction 1 Agoottne bulking '@. Noofitoors andheight ifthe building ndwhich flrs are aceupieday you 1h Detais af ether occupants L_Detais arts, elevators, escalators ete please specty make andeapacty. ‘ofmauumum capacty stored used handled atthetme. 2| Actwites bengeaniedaninthepremises 3 | Detalsetsurrounding areas! property 4 | Please ngiestethe imits ofindemntyrequired a. Anyoneaceident b. Aryoneyear | Do you handle or use or store gazes! hazardous! toxic! radio active material and! or equipments Inthe premises. I yess, please give cetals Es SoS Year of corporation of insures fmicompany 2 | Which Chartered Accountant Name and Aderess) aude nsueds accounts nd at what interval? | What ype of repair wrk can be avid oukwhhou etemal hai? | Please ncicteemeral reper] procurement aces evalabein nals Normal working hour fhe work To beineured ‘2 Hour per ay No.of she fe days of Week 6. | Number of employees in the works tobe nsec? Fy: [are tere any seasonal production or sales fuctatons mare than 20%, nthe works tobe sued? [ver [] No |] [hier a tok ofseimstederinsteepoaicu es ste ere fweeisotwpavs | | state Indemny Period dested (Months al sate tre ime deduce deste faye) it | Sum nswred 2 OnNet Prot Re. of shite fe Oniereased Cont of Working ha] inex of Business Actvty TunoveriOupuaTarupaRevencel Dierence Basis Fa [Detas of Previous nierupion '& Period of eruption Nature ofinteruption with causes ‘eos Gross raft Turnaver during the interruption HE Suen ar cnucngate nas foat00 cutee Sperone Wanagerem Castner lipase cote 1 attlor Caner bus bate Wage! lh 5s ar Brand (wes, manos {Db One Por CumaPoty ves querer eas at 3029 ei oat na Shas G708 war velo seta on wumnaetgn com fr ply copyancoétrmace Ree eck chin ae ge Saye orbs t= ann Rete ra aay ao ott ae UN ASE ERED Ba eeSEI Employee Details Deserption Estimated Number | Fulldetais of werk | Cash fannvay) |Livng/other | TotalEstimated | insurance required of Employs of Employs subject Speety aowaness any | Annual Earnings | Slate Table Aor 8 exact, nature of work) fannvat) ofprespectus Clerical Start ‘Commercial Travellers ‘ny other employ {plprovice extegory ane detals as provided in frsttwo extegertes 2| The tral amount of wages salanies and ether eamings paid by me during the past twelve ments was & 2.) Does the above schedule include ves] Nol] {@) Allpersonsin your service? 1B) Allyoursubcontvactors? | IFNot, then kinaly conf which categories of employees are not covered? '5| De you provide spect training to your employees on how to perform thei respective job? Ye] Nol] Does all employees are acquited with standard safety procedures? ‘re your premises a Factory within the meaning afte Factoies Act? ‘Does the insured instruct allworkers in praper iting techniques? Are they provides with materalz-handling ads ane encouraged to obtain hela where moving extremely heavy objects? Ee 1. Please provide cetals of your existing Insurance polis} any Poly No.7 | Insurer Name Peed of naurance Sum Insured] Clima lodged during ‘pptcation No, the preceding years From, re 2 Has any Company decined insurance to any ofyour locaton? vel] Nol] 2. Has any Company decned lo renew surance orerease the premium or imposed special condtonsonenewa —Yes[_]_No[_] In ease the response is "Yes" to any ofthe questions mentioned above, please provide the details EA Premium Details: Amount Rs. Premium Payment Options -[_]cash [cheque [00 []cara [1] Netbanking [] Payment Wallet Referenca/cheque Neel) ate [) Bank Name | Amount: Rs| ] Source of Funds 1 Satery: Ll Business: Ll others Menton’: ST eyed Cheque willbe isued inthe name ofthe Proposer only In caze of payment mace through crett card there fune ammount would! be reversed in Crect Card account director through cheque. Please provide the following bank deta and a copy ofa Cancelled Cheque you opt fr cirect redtinte your bank account: (Cancelled Cheque should be of the same bank accountin which therefundneeds tobe credteddirety). ‘Cheque No "Name as in Bank Account Bank Name Bank Account No Branch Name IFSC Code Cheque Date ICR Co ‘Cheque Amount fort NNole The Proposer agiees and underiakes fo intimate in wing to HDFC ERGO about any change in bank seeount dela ECS i seectec, please submt the stancing instruction form avallable at eur branches. HE Suen ar cnucngate nas foat00 cutee Sperone Wanagerem Castner lipase cote 1 attlor Caner bus bate Wage! lh 5s ar Brand [es mamas © 409 Gre Fe Cinoke ‘ets eras clue a1" 29 Cone coaa io tou C2048 Vet aly Secon on araheugo co pay caps cena sce Ree eck chin ae ge Saye orbs t= ann Rete ra aay ao ott ae UN ASE ERED Ba eeNationality Non Indian IfNon-Inclan, please speciy Countye feist owner Yes] wo] Name of the Benetiay Waboveis Yes, re you Political Exposed Person orrelatedtoPoltical Exposed Person: Yes| | No|__lepaopateteeI'Yes, ve etal Organization Icorporation: — CIcavenments» C1 Seciety: — 1Pvate organizations: [] intematonal Organization Wee: ( Parnership: §— C] ust others 1 Gosreen ana Make a diferenceiby choosing this option, anty soft copy of Paley shallbedelveredto your registered mal The soft copy is vals fot oegng aims or any other service needs ifyou require physical copy of your poli In future, please vst “Hela” secton on yaw héfeerge.com or contactour customer the undersignes, declare andacknowledge: = Wie hereby declare that he nvormation givens, tothe best ef our knowledge and belt, correct andlthat we are net aware ofan eicumstances hat we havenotsclosedte youwhien mightiniuence your assessment of andwilingness to accept thersk = Wtehereby agree that youlssue a poticyto us, his arapesalshalform the basis of ane beineorparstedin, sven ley = Wie agree that ths éeclarationanlthe answers given above shale the bass ofthe convact between melus andthe Compary and shallbe éeemed to be incorporated such contract Andthatfanyuntue statementbe contained therein the saié contrat shallbe absolutely ulland vol. = WWleuncertake to exercise allreaconable and orcinary pecauton‘orthe safety ae casted and iWe agiee to accept the policy inthe form esuedby the Company subjecttathe terms exceptions and coneitions areseibed therein encorsed onthe poly. = "We hereby understand, declare, consent and authorize HDFC ERGO General Insurance Company Lt, that nancial Information, as provided tothe Company maybe utlized or processing the claim madi under the Policy = We hereby also understand, decare and consent thatthe Compary shall have right te retain ané dlsseminate the same to any service provider for providing services relatecto insurance = Wie nereay contm that allpemiums nave been be pald ‘tom Bonafide sources and no premiums have beeniwill be paid out of proceeds of crime relateeto any of the offence Isted in Prevention of Money Laundering Aet, 2002. | understand thatthe Company has the ght te calif documents to establshsoureesoffunds = Thereby authorize the Company to notiy me through email, SMS, or ay other leetronie mode any information pertaining to my proposal, poly acumen, claim servicing ete Name: Signa: oas: SEE EEE) Note:The lapilly ofthe Company does nat commence unilthe acceptance of the proposal has been formally intimated by the Insured ane fl premium has been eaizeeby tne Company We areuncer ne obigationte accept ary propesaltor insurance. The Pronoser agrees thatthe receipt othe Proposal Farm by HOFC ERGO General nsurance Company Limited alongwith the premium payment does not antamount to the aeeeptence af the Proposal fr insurance by HOFC ERGO General Insurance Company Limited and does not result ina conclued contract of surance. The acceptance ofthe Proposalfor insurance shall at the Companys sole and absolute eiscreton ang upen full realzation of the premium payment In the event of acceptance of the Proposal for Insurance by HDFC ERGO General Insurance Company Lmitec, uch acceptance shalloe specially intmatecto he Proposer by HOFC ERGO General Insurance Company Linted along withthe date from whven the insurance Cove: shallbecome evfecive. HDFC ERGO Generallnsurance Conipany Limited shallnat be Habe foray cli in respect ofan event giving set a claim covered unde the Poly of surance thats occur prot to pai issuance Is Nat covered unde ths polleyYeur propesel orm ‘willbe considered after HOFCERGO General insurance Company Limited receives premium payment Fraud Warning: This poley shall be voidable at the option ef the Company in the event of mis-epresentation, mis-ceserstion or nor-dsclosure of any material particulars by the Proposer Any person win, knowingly and wth intent rau the Insurance Company ot any ether person, les aprepesalfor insuranes containing any fase infomation, ar conceals o the purpose of misleading, Information concerning any fact material hereto, commits a fraudulent insurance ae, which willrendethe poi voidable atthe sole eiseretion ofthe Insuranee Company and resuktinadenialetinsurancebenetts ‘Ant-Money Laundering: The Company belleves in adherence to Ant Maney Laundering (AML) gudelinesitules as I ales in ensuring thet financial nsttution Iie ours 976 Not used as venice for money laundering, The poteynelge/ nominee are hus Bound to provide such information as may be requited By the Company or ensuring the adherence ofAML guidelinesirles Sharing of Information Clause:The information sought ftom the Insured Is stietly forthe purpese of pole issuance and poy servicing. This Information| sought andthe details 9f pay are kept canfcential ancl notae shared vith any exernalpariyinany ereumslances whatsoever However ininsances when such information’ details is sought by any governmental ocies / regulatory authorities or when the Company is erected lo share such information in accoréance with any law regulations or crection ftom any such governmental bodies / regulatory authors, the Company wil be bound to abe to such rections Data Protection Requirement (Below Declaration should be mentioned in Insured Declaration}:"IWe hereby uncerstane, declare, consentane authorize the Company that alldetals ofthe policy and financial information, as provided othe Company may be lize fr processing the clsim made under the Policy LWe heteby alsounderstand, declare and consentthatine Company shallhave ightte retain and disseminate the same a any service provicer er providing services related toinsurance ‘Anti: Rebating Waring: As per Section 41 othe Insurance Act 1838.25 amends. the practice of ebatingis prohibited as follows: No person shallalow or offer tallow, ether erect or ndirecy as an nducementto any person to take out or renew or continue an insurance policy nrespectto any kind of rskrelaing to les rpropertyin nla, any rebate ofthe wnele or part othe commssion payable o any eae of te premium shovin an the palie, ner shall any person taking outer renewing or continuing a policy accept any rebate, except such rebate as may be llowee in accordance withthe publshed prospectus oF tables of the Insurer Violation of Sections ofthe Insurance Act 938, as amended, shalloe punishablewtha fine whieh may extend to E10 Lakhs Insuranceis the subject matter ofthe solletation Date Signature ofthe Proposer: (ies, mura!" 400 06 ror CiumPoey vets qures cates oa 29 2234 eosaca) 120 Saas E224 Ver velpSecconon va netergacom or pay capyrarcencxornace MB Sen teen geen nang ohne Soi seRCO bro snd enon SH HENS EReS BaasITERMEDIARY'S DECLARATION D (FullName)in my capacity as an insurance Acvisor! Specified Person ofthe Corporate AgentiAatnorzed enployee of the Brokerielalonship Officer do hereby cectare that | have explained athe contents of this Proposal Form, Including the nature ofthe questions contained inths PropesalFermto the Propeser including statemert), information and respensets submited ay hmvhet inthis Proposal Frmte questions contained herein oF any deals sought here in wil frmthe basis the Contact of surance Between the Company andthe Proposer ths Proposals aeceptedby the Compary for ssunee ofthe Peiey have rther exaeined tha any untrue statemenisjnfermavonespense\s) isfare contained inthis Proposal Form inclucing addendums. affdavis, statements submissions, furnished! tobe furished, the Company shal have the ight, tovarythe benefits which may be payable ancfurtner more if inere na been a nomclclorute of any matetalfact. the poly issvedteMsther vor pursuantto this Propasalmay betreatedby te Company 2snullane vol andl premiums paid under the ley may be ‘orfetedt the Company. LUcense No. (intermediary Place Date Signature of intermediary: ToT ‘ChannelPartner Code: Branch Location: Signature of Channel Partner CEE Received fromMe:/Ms./ Mes. Reference/Cheque No: Dated Drawn on Bank for 2 sum of € towards payment of bremiumen behalf of HOFCERGO Generalinsurance Companyta Date Signature &sea Nettherthe submissionto us ofa completed propesalforinsurance ner any paymentfor any palcy sought obliges uso agreeto issue apalicy which decisions land always shal a In our sole and absolite dscretion. we accept» proposal for insurance i'shalbe subjectto the poly ters and conctions ang we shall nave notably tomake any payment premium s natreceivedby us infullanein tine, Fs natreaized. we de not accea! he aropesal, We wlinformyou ane ‘fund any paymentreceived ram you witheutinterest thinnest 30 days INSURANCE ACT 1938 SECTION 4%. Prohibition of Rebates No person shallalow or offerte allow ether rector inerecth, as an netcement to any person to take ovtor new or continue an insurance nrespectof any kind ofriskrelatng to Ives or property in India ary seat ofthe whole or part ofthe commission payable or any rebate ofthe premium shown on te palcy, nor shall any person taking out or renewing a policy accept any rebate, except such rebate 3s may be allowee in accordance withthe published Prospectus ortableseftheinsures ANY PERSON MAKING DEFAULT IN COMPLYING WITH THE PROVISIONS OF THIS SECTION SHALL BE PUNISHABLE WITH FINE WHICH MAY EXTEND TO TEN LAKHS RUPEES {Wes rb" 400 OE For GiumiPolty vets ques cates asa 27 e23¢eoaaral oo ia €294 or Vat ely sacton on wnvahatcrge com fot paly copyon cect nase “aeestegter este ace ago saved ame betrgsteH=C Bunt and e1CO treater mt ased by be Copan caer coos UN HLS EROS Bushes seco