Declaration to be Submitted with Fire Proposal Form

Name of
Proposer:
Risk
Location
Address:
Fresh /
Renewal
(Policy
Number)
APPLICABLE FIRE SAILENT FEATURES FOR DISCOUT AND LOADING
Please declare as YES or NO for the below mentioned features as per availability at Risk Location.
SR No. Feature Applicable Pls.
Declare
as YES/
NO
1. Are Fire Hydrant/Sprinkler/ Water spray system/ Fire alarm/ Smoke detectors
operational in Premises/ Risk Locations?
2. Whether Electrical Installations are Well maintained with standard equipment and
installations?
3. Whether there exists Provision of storm water drainage system and whether the
buildings with plinth level at least 1.5ft above ground?
4. Whether there exists High standard of Security (no. of security guards ____) for 24 * 7
and are CCTVs installed?
5. Claim history for past 3 years 1.
2.
3.
6. Whether Basement in the building used for operations/ storage/ plant machinery
installed therein?
7. Whether the Insured premises located within 1 km distance of a water body like
Seashore, Lake, Rivers, Canal?
8. Whether the Risk located in thickly populated area with no access to fire brigade
vehicle?
9. Age of the building beyond 30 years/strength & condition of the building below average

Declaration by Insured:
I/We hereby declare and warrant that the above statements are true and complete and the
Declarations made by me/Us in this Declaration 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 New India Assurance Co. Ltd.
If any additions or alterations are carried out in the risk proposed after the submission of this
proposal form then the same should be conveyed to the insurers immediately.

Date:________________ Proposer Signature: __________________