UNITED INDIA INSURANCE CO. LTD. Regd. & Head Office : "UNITED HOUSE" 24, Whites Road, CHENNAI - 600014 Bharat Sookshma Udyam Suraksha PROPOSAL FORM Important : This proposal is for covering an enterprise whose total value of insurable assets ata location does not exceeds ® 5 Crore, against Fire and Allied Perils, 2, Read the Prospectus/Key Features Document/Policy Wordings before filing up this proposal form to understand the Meaning of the terms used herein bett 3.__The property proposed for insurance is nat covered until the proposal is accepted and premium is paid Divisional Office No.2: ‘Agents Name 19, Dharampeth Extension, Sarkar Nagar Square, Nagpur - 10. (Code No. Ph. 0712-2248287, 2248975 A. __Detalls about Proposer and Policy Period : Name of Proposer SSS ‘Address of Proposer 3. Telephone No (Landline). 5. Email 4. Mobile No, 6. Contact person details if not an individual a. Name b. Designation 7. Policy to be Issued in favour of (list out allthe parties whohave insurable interest) including the financial institutions Tee 8. Period of Insurance From To B. Business and Location of Busines 9. Business of proposer 10. Location of risk / business to be covered - full postal address with Pin Code Si ‘Age No. Address with Pin Code Occupancy | of unit | Floor *Floor. Ground Floor (GF)/ Mezzanine Floor (MF)/ Higher Foor (H)..c Details about business covered at the insured location Ti. | Details of insured property Please tick in the space below ‘a._| Ottices, shops, hotels ete Yes C1 /No LJ '._| Industrial “manufacturing risks Yes] /No C) ._| Storage outside industrial manufacturing risks Yes CJ /No CJ 3. | Tanks / gas holders outside industrial / manufacturing risks. Yes CJ /No C) e._| Uiiities located outside industrial manufacturing risks. Yes CJ /No CJ 1._| Boundary wall Yes Co) /No CJ 9. | Basement storage Yes.) /No (J IH, yes value stored SI: As, h._[ Others please specity) 72. | Ifused as warehouse / godown (notlocatedina manufacturing unit) please give the list of goods stored. 13, | ifusedas an Industrial Manufacturing unit give products ‘manufactured atthe location proposed (detailed block plan showing various facilities to be enclosed wherever applicable) 14. | itused as an industrial Manufacturing Uni, please state whether the factory is working or silent? 15. | Fire Protection devices installed Please Tick the correct answer in the box below. Portable Extinguishers 1 Small bore hose reels CJ Trailer Pumps /Fire engines TS Hydrant System TZ Sprinkier System (1 Fixed Water Spray System [© Foam system TS Fire Alarm System [1 Gas Flooding System others, please specity below. 76, | Indicated whether AMG (Annual Maintenance contract) Yes. (-] 7 No CI for the Fire Protection Appliances isin force : 17. | Construction Details 2._| Please state material used Please tick the correct answer in the box. i. | Walls Kutcha [_]_/ Pucca (_] ii, | Floor Kutcha [=] / Pucca CI) i. | Root Kutcha CL] / Pucca []Building(s) having wall and/or oof of wooden planksithatched leaves and/or grass/hay of any kind/oamboo! plastic cloth/asphalt/ canvas/tarpaulin and the like are treated as Kutcha Construction, Pucca : Buildings other than Kutcha are treated as Pucca constructions. b._| Number of Floors c. | Age ofthe Building Less than 5 years 5- fOyears| 10-20 years ‘Above 20 years 76. | Distance between the risk to be covered and nearest Fire Brigade 19. | Whether you have insured the same property with any other Insurance Company with the same type of coverage. (Give details) 20. | Whether insurance was declined by any other Company (Give details) 21. | Premium / Claim details for the past 36 months ‘Year Premium Claim ‘excluding the expiring policy period, z x z z z t z t Toran |t x D. Sum Insured and Other detalis of Insured Property (Indicate Sum Insured on the following bas + For Building, Plant and Machinery, Furniture, Fixture and Fittings and other contents: Reinstatement Value. + For raw material: Landed Cost; : 3k in process : Input Cos 1 Fortnisnedstock: Manufacturing cost othe fished stock orth Contract Price of goods sold but nt delivered, ‘as applicable, regard to 4 Ice Is in respect only of goods sold but not delivered, for which you are responsible and with regard cinch under the conatons ofthe sale the sale, contacts eancaled by reason of any Bemage insured under his Policy either wholly or to the extent of the Damage. The Company's liability shall be based on the Contract Price) i Finished] Other Total ti Buildir Plant & |Fumiture&| Raw ‘Stock in 22 | Desepton Teekay | Pee cmon: | moma | Ercess | Sao | cones plinth, Fittings ang| (Please [Basement and other specify) additional equipment structures z z zE. Details for in-built cover for Floater 23. Floater Cover (for stocks at various locations) Location (Postal Address with Pin Code) Sum insured (in @) ')__Maximum value at any one location : 2 il) Whether stocks stored in open: Yes [—] /No[—] Standard Add-on Do you want to opt for Declaration Policy? : Yes / No (strike off whats not applicable) ites, give details below 24. | Stocks which fluctuate in value to be covered on (monthly) declaration basis :Amount (®) Premium Details Mode of Payment 25. | Payment Details ‘Amount z Inwords, H. Declaration by Insured | nereby declare that the value insurable assets's less than & 5 Crore (Rupees Five Crore) and the statements made by me/ Us in this Proposal Form are true to the best of my /our knowledge and belief and |/ We hereby agree that this declaration shall form the basis of the contract between me/Us and the United India Insurance Company Ltd. It any additions or alterations are carried out inthe risk proposed after the submission of this proposal form then the same should be conveyed to the insurers immediately Date: + Place: ‘Signature of the Proposer TA IN 4: 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 a policy ‘accept any rebate, except such rebate as may be allowed in accordance with the published prospectus 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 TEN LAKHS RUPEES.