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Proposal For Standard Fire & Special Perils Policy

This document is a proposal form for a standard fire and special perils insurance policy. It requests details about the proposer such as name, address, business details, and location of the property to be insured. It also requests information on the period of insurance, whether certain perils should be excluded from coverage, additional coverages required, details of the insured property and its construction, sum insured amounts for buildings and property, and a declaration by the insured.

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Visas Siva
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85 views

Proposal For Standard Fire & Special Perils Policy

This document is a proposal form for a standard fire and special perils insurance policy. It requests details about the proposer such as name, address, business details, and location of the property to be insured. It also requests information on the period of insurance, whether certain perils should be excluded from coverage, additional coverages required, details of the insured property and its construction, sum insured amounts for buildings and property, and a declaration by the insured.

Uploaded by

Visas Siva
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as RTF, PDF, TXT or read online on Scribd
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PROPOSAL FOR STANDARD FIRE & SPECIAL PERILS POLICY

Acceptance of this proposal is subject to the rates & regulations of Tariff Advisory Committees Tariff. The property is not covered until the risk is
accepted and premium paid.

Divisional Office Address & Code


Development Officers Name & Code
Agents Name & Code
DETAILS ABOUT PROPOSER
1. Name of Proposer
2. Address of Proposer including Phone,
Fax, E-mail & Pincode
3. Business of Proposer
4. Paid up Capital of the Firm
5.Policy to be Issued in favour of
(List out all the parties who have insurable
interest including the Financial Institutions)
6. Location to be covered - (Full Postal
Address with Pincode)
7. Period of Insurance
8.Would you like to delete these perils from the
basic cover?

9. Would you like to cover the following


along with your buildings?

From

To
Yes / No

a. Flood, Cyclone, group of


perils
b Riot, Strike, Malicious and
Terrorism Damage

Yes / No
Yes / No

Plinth & Foundation

10. Add-On Covers Required as under


Architects, Surveyors & Consulting Engineers Fees (in excess
of 3% of the claim amount)

Yes / No

Debris Removal (in excess of 1% of claim amount)


Yes / No
Deterioration of Stocks in cold storage premises due to failure of
Electrical Supply at terminal ends of Electric Service Feeders

Yes / No

Forest Fire
Yes / No
Impact damage due to insureds own vehicles
Yes / No

Spontaneous Combustion
Yes / No
Omission to Insure additions
Yes / No
Earthquake (Fire & Shock)
Yes / No
11. Whether you have insured the same property with
any other Insurance Company with identical coverage.
(Give details)
12. Whether Insurance cover was declined by any
other Company or imposed any Special Conditions
(Give details)
13.Premium / Incurred Claim details for the past three
preceding policy periods

Premium

Incurred Claims

DETAILS ABOUT PROPOSERS BUSINESS COVERED AT THE LOCATION


14.The Insured property is

Dwellings, Offices, Shops, Hotels etc

Yes / No

Industrial / Manufacturing Risks


Yes / No
Storages outside Industrial Manufacturing Risks
Yes / No
Tanks / Gas Holders outside Industrial Manufacturing Risks
Yes / No
Utilities located outside Industrial Manufacturing Risks
Yes / No
15.If used as Shop, please declare whether the stocks stored include any
stocks appearing in the list given below. If yes, whether the value of such
stocks exceed 5% of total value of stocks

Yes / No

1.Celluloid Goods, 2.Coir Loose, 3.Crackers & Fire Works, 4.Explosives of any kind, 5.Hay / Straw, 6.Hemp,
7.Jute Loose, 8.Matches, 9.Methylated Spirit, 10.Nitro-Cellulose Plastics, 11.Oils / Ether / Industrial Solvents
and other inflammable liquids flashing at and below 32 Deg.C (Closed Cup test), 12.Paints with inflammable
base having flash point below 32 Deg.C (Closed Cup test) - other than in sealed tins or drums, 13.Varnishes
having a Flash point below 32 Deg.C (Closed Cup test) - other than in sealed tins or drums,14.Disinfectant
liquids and liquid insecticides - other than in sealed tins or drums,15.Vegetable fibres of any kind including
Rayon Fibre.
16.If used as warehouse / godown (not located in a
manufacturing unit) please give the list of goods stored
17.If used as an Industrial Manufacturing unit, state the details
of products manufactured at the location proposed.

18. If used as an Industrial Manufacturing unit, please state


whether the factory is working or silent?
19.Fire Extinguishing Appliances installed
Please Tick in the box below
Portable Extinguishers
Trailer Pumps
Fire Engine
Hydrant System
Sprinkler System
Fixed Water Spray System
20. The basis proposed for insurance (Building / Machinery / Furniture Fixtures & Fittings)
Market Value basis

Yes /No
Reinstatement Value Basis

Yes /No

21.Construction Details
a

Please state material used

Height of the Building

Age of Building

i. Walls
ii. Floor
iii. Roof
________ Meters
Less than 5 Years
10 20 Years

_________Floors
5 - 10 Years
Above 20 Years

Note:
Buildings having walls and/ or roofs of wooden planks/thatched leaves and/or grass/hay of any
kind/bamboo/plastic cloth/asphalt cloth/canvas/tarpaulin and the like are treated as Kutcha
construction.
22.Building wise values (Please include the Kutcha buildings also in this list and give individual values
against such buildings)
Description
Amount in Rs
Of Block
Age HeightConstructio Building
Yrs
Mts
n
including Machinery
plinth Accessories

&

F&F, office
and other
equipments

Stocks and Other Property


Stocks in
to be insured
process**
specifically

Total

Total
Note
** Indicates those stocks which are covered on normal basis and do not fall under Serial No.23 A, B, C and D
below
23.Special Coverage for Stocks only
Please Tick in the box below and give the amount to be insured against each

A. ON FLOATER BASIS
Stocks at various locations (Process blocks, warehouses / godowns and /or in open etc.,) can be
covered on floater basis under single Sum Insured.
Locations (Postal Address with Pincode)
Amount Rs.

B. ON DECLARATION BASIS
Stocks which fluctuate in value can be covered on (monthly) declaration basis.
Locations (Postal Address with Pincode)
Amount Rs.

Note:
1.Minimum Sum Insured per policy should be Rs.1 Crore, and policy not to be issued on short period basis
2.Stocks in process & stocks stored at Railway sidings cannot be covered
C. On Floater Declaration Basis
Stocks which fluctuate in value as well as stored at various locations under single Sum Insured can be
covered on (monthly) floater declaration basis.
Locations (Postal Address with Pincode)
Amount Rs.

Note:
1.Minimum Sum Insured should be Rs. 2 Crores
2.Stocks in process & stocks stored at Railway sidings cannot be covered

D. STOCKS STORED IN OPEN (LOCATED OUTSIDE THE FACTORY COMPOUND)


Details of stocks stored in the open
Locations (Postal Address with Pincode)
Amount Rs.

E. TANK FARM AND GAS HOLDERS (LOCATED OUTSIDE THE FACTORY COMPOUND)
Details of stocks stored
Locations (Postal Address with Pincode)
Amount Rs.

25. Add-On Covers

Clause
Code

Risk
Code

Rate
Code

Rate

Amount to be
Insured/Percentage
wherever applicable

Architects, Surveyors &


Consulting Engineers Fees
Debris Removal
Spontaneous Combustion
Omission to Insure additions (%)

DECLARATION BY INSURED

I/ We hereby declare that the statements made by me / us in this Proposal 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 THE NEW INDIA ASSURANCE COMPANT LIMITED.
If any additions or alterations are carried out in the risk proposed after the submission of this proposal
form then the same would be conveyed to the insurers immediately.
Date

Place

Recommendations of
Development Officer / Agent

Signature of Proposer

PROHIBITION OF REBATES (SECTION 41 OF THE INSURANCE ACT)


1. No person shall allow or offer to allow either directly or indirectly as inducement to any person to take
out 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 any rebates as of the premium shown on the
policy, nor shall any person taking out or renewing or continuing a Policy accept any rebate except such
rebate as may be allowed in accordance with the published prospectuses or tables of the Insure.
Provided that acceptance by an insurance agent of commission in connection with a policy of life
insurance taken out by himself on his own life shall not be acceptance of are take of premium within the
meaning of this section if at the time of such acceptance the insurance agent satisfies the prescribed
conditions establishing that he is `Bonafide insurance agent employed by the Insurer.

2. Any person making default in complying with the provision of this section shall be punishable with

fine which may extend to five hundred rupees only.

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