HDFC ERGO General Insurance Company Limited

Business Suraksha Classik - Sookshma Udyam - Proposal Form

Please answer all questions in BLOCK letters

Note: if you not find sufficient space in any of the below columns please use additional sheets for giving full details.

GENERAL INFORMATION

1 a. Name of the Insured

Correspondence address of the Insured
Phone No
Email ID
b. Nature of trade or Business of the Insured
c. Risk Occupancy
d. Risk Location Addresses of all major locations
e. Name, Address of the Financial Institution/s or any bank/person
(if any financial interest is involved)
f. Paid up capital of the firm
2 Period of Insurance From ………..................................….. To …………..............................
3 a. Source of Business Agent/ Broker/ Direct
b. Intermediary Name
c. Intermediary Code
d. Contact No.
4. Claims Details for past three years Claims paid + Outstanding (Rs) + No of claims in an year + Loss
Mitigation Factors in case of any major claim

SECTION I: FIRE & ALLIED PERILS

1. Risk Details
a. Type of Construction
b. Does any location proposed for insurance has basement occupancy?
If yes, what is stored inside and approximate value out of total SI?
c. Age of the Buildings
d. Is the building part of Industrial Area or Commercial Complex? Industrial Area/ Commercial Complex/ Stand-alone
e. What are the surrounding occupancies and their distance from the facility?
f. Any other occupancy in same building belonging to Insured or others
g. Approximate distance from the nearest water body
(River, Lake, Canal, Sea, nala etc.)
h. What are the Fire Protection Systems at the Facility?
(Extinguishers, Hydrants, Sprinkler, Hose Reel etc.)
i. How far is the nearest Public Fire Brigade and what is the response time?
j. What are the security arrangements?

Industrial Area/ Commercial Complex/ Stand-alone

2. Details of insured property Please tick in the space below :

a. Offices, Shops, Hotels etc. Yes / No

b. Industrial / Manufacturing risks Yes / No

c. Storage outside Industrial/ Manufacturing risks Yes / No

d. Tanks / Gas holders outside Industrial/ Manufacturing risks. Yes / No

e. Utilities located outside Industrial/Manufacturing risks. Yes / No

f. Boundary wall Yes / No

g. Basement storage Yes / No If, yes value stored SI: `

h. Others (please specify) Yes / No

3. If used as warehouse / godown (not located in a manufacturing unit), please

give the list of goods stored.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai –
400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. For Claim/Policy related queries call us at +91 22
6234 6234/+91 120 6234 6234 or Visit Help Section on www.hdfcergo.com for policy copy/tax certificate/make changes/register & track claim or simply text Hi on whats’app number 8169 500 500 for instant policy servicing. Trade
1
Logo displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: Business Suraksha Classik - Sookshma Udyam Suraksha - IRDAN125RP0001V03200607.
 4. If used as an Industrial Manufacturing unit give products manufactured
at the location proposed (detailed block plan showing various facilities to
be enclosed wherever applicable.)
5. If used as an Industrial Manufacturing unit, please state whether the
factory is working or silent?
6. Fire Protection devices installed Please tick the correct answer in the box below:
Portable Extinguishers
Small bore hose reels
Trailer Pumps/Fire engines
Hydrant System
Sprinkler System
Fixed Water Spray System
Foam System
Fire Alarm System
Gas Flooding System
Others, please specify below:

7. Indicate whether AMC (Annual Maintenance contract) for the Fire Yes / No
Protection Appliances is in force
8. Construction details
a. Please state material used Please tick the correct answer in the box.
i. Walls Kutcha / Pucca

ii. Floor Kutcha / Pucca

iii. Roof Kutcha / Pucca

Note:
Kutcha: Building(s) having walls and/or roofs of wooden planks/thatched
leaves and/or grass/hay of any kind/bamboo/plastic cloth/asphalt/ canvas/
tarpaulin and the like are treated as Kutcha Construction.
Pucca: Buildings other than Kutcha are treated as Pucca constructions
b. Age of the Building
c. Number of Floors
Less than 5 years
5 – 10 years
10 – 20 years
Above 20 years

9. Distance between the risk to be covered and nearest Fire Brigade

10. Whether You have insured the same property with any other Insurance
Company with the same type of coverage (Give details)
11. Whether Insurance was declined by any other Company (Give details)
12. Premium / Claim details for the past 36 months excluding the expiring
Year Premium Claim
policy period
` `
` `
` `
` `
TOTAL ` `

Sum Insured and Other details of Insured Property

(Indicate Sum Insured on the following basis:
• For Building, Plant and Machinery, Furniture, Fixture and Fittings and other contents: Reinstatement Value;
• For raw material: Landed Cost;
• For stock in process: Input cost;
• For finished stock: Manufacturing cost of the finished stock or the Contract Price* of goods sold but not delivered, as applicable.
*Contract Price is in respect only of goods sold but not delivered, for which You are responsible and with regard to which under the conditions of the sale,
the sale contract is cancelled by reason of any Damage insured under this Policy either wholly or to the extent of the Damage. The Company’s liability shall
be based on the Contract Price).

13. Description Building including Plant & Furniture & Fixtures, Raw Stock in Finished Other Contents Total
of Block plinth, Basement and Machinery Fittings & other Material Process Stock (Please Specify)
additional structures equipment
`
`
`

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai –
400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. For Claim/Policy related queries call us at +91 22
2 6234 6234/+91 120 6234 6234 or Visit Help Section on www.hdfcergo.com for policy copy/tax certificate/make changes/register & track claim or simply text Hi on whats’app number 8169 500 500 for instant policy servicing. Trade
Logo displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: Business Suraksha Classik - Sookshma Udyam Suraksha - IRDAN125RP0001V03200607.
Details for in-built cover for Floater
14. Floater Cover (for stocks at various locations) Please tick in the space below :
Location (Postal address with pincode) Sum Insured (In `)

i) Maximum value at any one location: ` ....……......................….

ii) Whether stocks stored in open: Yes / No

Standard Add-on
Do You want to opt for Declaration Policy? - Yes/No (strike off what is not applicable). If Yes, give details below:

15. Stocks which fluctuate in value to be covered on (monthly) declaration basis:

Amount (`):

SECTION II: BURGLARY & HOUSEKEEPING

1. a. Is your premises guarded by Watchmen/Security Guards 24 hours? Yes / No

b. Is the premises installed with CCTV/ Burglary alarm? Yes / No

c. Are all entry / exits of the premises secured with iron grills and locking system. Yes / No

2. Are stock and sales book maintained by you? Yes / No

3. a. Have any premises occupied by you been subjected to theft or burglary? Yes / No

b. If so, give full particulars stating when and how access was obtained and the extent of the
loss.
4. Do you require a policy on 100% sum insured basis or a first loss limit? If on first loss limit,
pl. mention the % to the full sum insured?
5. Operating Hours of your Business
a. Will the premised at any time be left unoccupied?
b. If so, how many and during what time?
6. Add-on Covers: If any of the below mentioned add-on covers are required.
• Floater Cover
• Riot & Strike Damage Clause
• Theft Extension
• Cost of Debris removal
• Cost of restoring documents
• Expense for Loss minimisation
• Employee personal property cover
• Replacement of locks including repair to Insured premises
• Omission to Insure
• Theft by use of Duplicate Keys
• Reinstatement Value policies
• Terrorism cover Inclusion
7. Sum Insured Details
Sr. no. Description of property to be insured Sum Insured (`)
a. Plant & Machinery
b. Stocks & Stocks in Process
c. Furniture, Fixture & Fittings
d. Other Contents

SECTION III – PLATE GLASS & SANITARY FITTINGS

1. What Type of glass/ sanitary fittings are proposed for insurance?

(Exterior building glass, fixed glass on door/ window/ table tops etc)
2. Does this proposal include all the insurable glass at the premises?
(if selection is made, then please Furnish details)
3. Do you desire to insure lettering or painting Yes / No

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai –
400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. For Claim/Policy related queries call us at +91 22
6234 6234/+91 120 6234 6234 or Visit Help Section on www.hdfcergo.com for policy copy/tax certificate/make changes/register & track claim or simply text Hi on whats’app number 8169 500 500 for instant policy servicing. Trade
3
Logo displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: Business Suraksha Classik - Sookshma Udyam Suraksha - IRDAN125RP0001V03200607.
 4. Do you desire to insure Damage to woodwork of showcase or Window- Yes / No
frames
5. Terrorism cover Inclusion Yes / No

6. Please furnish value of the glass with dimension and of framework and
any tinted embossed, ornamental, or painted glass

SECTION IV– NEON SIGNING/ GLOW SIGN/ HOARDING

1. Please specify the locations of the premises, where the neon sign/ glow sign/ hoarding is
fixed or erected
2. Does this proposal include all the insurable neon signs at the premises
3. Is the premises where the neon signs are erected owned or leased by you Yes / No

4. Does the proposal include all the insurable neon signs at the premises Yes / No

5. Pleas furnish the description in the following format Yes / No

Sr. No. Description of neon sign/glow sign/hoarding Values (`)

a.
b.
6. Terrorism cover Inclusion Yes / No

SECTION V– BREAKDOWN OF ELECTRICAL AND MECHANICAL APPLIANCES

1. Has your machinery sustained any damage from breakdown or other cause during last three years Yes / No

2. Are regular periodical inspections of the machinery carried out Yes / No

3. Schedule of machinery to be insured:

a) Each machinery should be entered separately with necessary specification.
b) The sum insured must be calculated on the present day new replacement value of the machinery to be insured including provision for packing,
freight and also value of erection costs, customs duty, etc to afford full protection under the policy
c) Please declare only installed machines not portable ones.
d) Separate value for foundations masonry and brickwork or Oil in transformers and other electrical equipments are to be specified if cover is
required for them.

Sr. Quantity Descriptions, type, model, capacity of machines/sr nos, Maker’s Name and Year of Make Sum Insured (`)
No. HO/ KVA/ Volts, Amps, Rpm country of origin
1.
2.

4. Add-on Coves: If any of the below mentioned add-on covers are required.
• Escalation Clause
• Express Freight
• Air Freight
• Owners Surrounding Property
• Third Party Liability
• Additional Customs Duty
• Modification cost/Incompatibility expenses
• Un Repaired damages
• Waiver of improvement/Betterment clause for replacement of selected machinery
• Expense for loss minimization
• Capital addition
• Claim Preparation Costs
• Un repairable Equipment Clause
• Serial Losses

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai –
400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. For Claim/Policy related queries call us at +91 22
4 6234 6234/+91 120 6234 6234 or Visit Help Section on www.hdfcergo.com for policy copy/tax certificate/make changes/register & track claim or simply text Hi on whats’app number 8169 500 500 for instant policy servicing. Trade
Logo displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: Business Suraksha Classik - Sookshma Udyam Suraksha - IRDAN125RP0001V03200607.
 SECTION VI – ELECTRONIC EQUIPMENTS

1. Is the equipment maintained in accordance with manufacturer’s instructions? Yes / No

2. Have operators been trained by manufacture? Yes / No

3. Is there any Annual Maintenance Contract (AMC) in force Yes / No

4. Please provide the details of the claims (if any) made by you for the last three years. If, yes please provide details Yes / No

5. Schedule of machinery to be insured:

Sr. Quantity Descriptions of Items Year of Make Value (`) Serial No.
No.
1.
2.
3.

Sub Total (a) ..................................................................

Rs. ............................................................................................................................................................
Please note that the value of electronic equipment should be replacement value by new one of same kind inclusive of freight, customer duty and other
charges and cost of erection.

6. Add-on Coves: If any of the below mentioned add-on covers are required.
• Endorsement For Exclusion of Damage Caused By Fire And Allied Perils
• Medical Equipment Using X-Rays Tubes
• Escalation Clause
• Express Freight
• Air Freight
• Owners Surrounding Property
• Third Party Liability
• Additional Customs Duty
• Software Endorsement
• Floater Clause
• Omission to Insure additions
• Removal of Debris
• Professional Fee
• Clean Up and Decontamination Cost
• Modification cost/Incompatibility expenses
• Waiver of improvement/Betterment clause for replacement of selected machinery
• Un Repaired damages
• Capital addition
• Claim Preparation Costs
• Terrorism Cover Inclusion

1. Is there any Annual Maintenance Contract (AMC) in force Yes / No

2. Territorial Limit required India or Worldwid

3. Have you suffered any loss of or damage to any equipments or had a breakdown or failure during the last three
years and shows any sign of repair. If so, give details thereof
4. Schedule of machinery to be insured

Sr. Quantity Descriptions of Items Year of Make Value (`) Serial No.
No.
1.
2.
3.

5. Add-on Coves: If any of the below mentioned add-on covers are required.
• Reinstatement value clause for portable items
• Omission to Insure additions or extensions
• Internal Breakdown
• Worldwide geographical limit
• Capital addition
• Un Repaired damages
• Un repairable Equipment Clause
• Claim Preparation Costs
• Expense for loss minimization
• Waiver of improvement/Betterment clause for replacement of selected machinery
• Escalation Clause
• Terrorism cover Inclusion

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai –
400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. For Claim/Policy related queries call us at +91 22
6234 6234/+91 120 6234 6234 or Visit Help Section on www.hdfcergo.com for policy copy/tax certificate/make changes/register & track claim or simply text Hi on whats’app number 8169 500 500 for instant policy servicing. Trade
5
Logo displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: Business Suraksha Classik - Sookshma Udyam Suraksha - IRDAN125RP0001V03200607.
 SECTION VIII – MONEY
Description of Money to be insured, (If no Insurance is required for any item insert “NIL”)
Iii. Money in till and/or counter during business hours.
Item No. Money Estimated Annual amounrt of money in transit, which will be the basis on which the Highest amount in transit
provisional premium will be charged Rs.
i. Money in direct transit from ...................................... to ......................................
ii. Money in locked safe or strong room during business hrs _______________
iii. Money in till and/or counter during business hours. _______________
iv. Money in locked safe or strong room outside business hours _______________
v. Money in the personal custody of the insured or the authorized employee/s of the insured whilst in transit to the premises or bank within a period not
exceeding 48 hours from the time of collection _______________
vi. Damage to Safe, Cash Box or Strong room in the premises ______________________________

1. How is the money carried?

2. What is the distance over which the money will be carried? (Km)
3. Have you ever sustained any loss of money whilst in transit or whilst on your premises? If so give full particulars Yes / No

4. What means of transport do the persons carrying the money use i.e. own car/public transport etc.?
5. Are the persons carrying the money accompanied by an armed guard/s? If not state what protection if any, is provided
or them.
6. State following particulars of safe/s and/or strong room in which money will be kept outside business hours
a) Maker’s Name, Weight Dimensions, Identification Number
b) Is it fixed to the walls of floor?
c) By whom are the keys of the safe(s) and/or strong room held?
d) Are all such keys removed from the premises outside business hours?
e) Will the premised are guarded whilst they are closed for business? If so, by whom?
7. Have you ever sustained any loss of money whilst in transit or whilst on your premised? If so, give full particulars
8. Add-on Covers: If any of the below mentioned add-on covers are required.
• Automatic Reinstatement
• Business/ Working Hours extended
• Claim Preparation Costs
• Damage to clothing/ personal effects (assault) clause
• Definition of Money
• Infidelity cover clause
• Loss or Damage to Safes, Strong rooms & Money Receptacles (including damage to property and landlords fixtures
and fittings)
• Money in overnight custody clause
• Replacement of Keys & Locks, recoding of locking devices (including repair)
• Temporary Safe Rental (and the insurance thereof)
• Theft by use of Duplicate Key
• Worldwide travel
• Theft from Unattended Vehicle
• Adjustment of Premium
• Terrorism Inclusion
• Riot & Strike Damage Clause

SECTION IX – BAGGAGE

1. Territorial Limit required India or worldwide

2. Limit of Indemnity
a. Any one event per person Rs.
b. Any one year for all persons Rs.
3. Terrorism cover Inclusion Yes / No

SECTION X – INFIDELITY/ DISHONESTY OF EMPLOYEES

1 (I) Details of Employees to be guaranteed (Named/ Designation cover option)

Sr. Name Designation Place of Employment Amount to be Any other security
No. guaranteed per person taken
a.
b.
Please attached separate sheet if the space is insufficient
Total Annual Aggregate Limit of Guarantee Rs.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai –
400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. For Claim/Policy related queries call us at +91 22
6 6234 6234/+91 120 6234 6234 or Visit Help Section on www.hdfcergo.com for policy copy/tax certificate/make changes/register & track claim or simply text Hi on whats’app number 8169 500 500 for instant policy servicing. Trade
Logo displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: Business Suraksha Classik - Sookshma Udyam Suraksha - IRDAN125RP0001V03200607.
 1 (I) Details of Employees to be guaranteed (Floating cover option)
Sr. Category of employees to be covered No. of employees to Place of Employment Amount to be Any other security
No. be covered guaranteed per person taken
a.
b.
Please attached separate sheet if the space is insufficient
Total Annual Aggregate Limit of Guarantee Rs.

2. Is there a system to obtain reference from previous employees?

If not, specify practice followed
3. State the estimate of maximum amount held by any employee at any one time and for how long
a. Money: Amount ……………. Period ………………..
b. Stocks: Amount ……………. Period ………………..
4. a. How often are the employees required to account for money?
b. What Independent system is there to check that all sums received by employees are
accounted for?
5. a. Do employees pay out money or draw cash from Employer’s account?
b. System of operation of Bank account and precaution taken
c. Whether such payments/withdrawals are authorized by a senior employee and
compared with supporting documents?
6. How often the cash back is balanced, the entries checked with vouchers, Bank’s passbook
and with counterfoils of receipt books
7. How often are the Proposer’s books balanced?
8. a. System followed for purchase of goods and recording deliveries
b. System followed for authorized dispatch of goods and ensuring that dispatch us
recorded and changed to the customer
9. How often and by whom stock verification is done?
10. System for collecting outstanding accounts
11. How often will statements of account be furnished by the Proposed direct to Customer?
12. What is the extent and frequency of audit?
13. Details of losses suffered on account of infidelity of any employees during last 5 years and
steps taken to prevent recurrence.
14. Add-on Covers: If any of the below mentioned add-on covers are required.
• Extended cover for past employees
• Accountants & auditors
• Alteration of systems
• Automatic reinstatement
• Claims preparation costs & audit fees (including computer system certification)
• Costs of recovery following subrogation to the company (by the company)
• Costs of recovery (by the insured for loss in excess of the sum insured
• Cost of rectifying accounting & computer records & programmes
• Credit/ debit card (fraudulent use of)
• Discretion in reporting to police (period of grace and successful recovery)
• Subrogation waiver (contracting parties)
• Unidentifiable employees (loss as a result of)
• Contractual/Off Roll Employee Cover

SECTION XI – PUBLIC LIABILITY

1 Year of incorporation of insured’s firm/company

2 Which Chartered Accountant (Name and Address) audits insured’s accounts and at what
interval?
3 What type of repair work can be carried out without external help?
4 Please indicate external repair/ procurement facilities available in India
5. Normal working hours of the works to be insured
a. Hours per day
b. No. of shifts
c. Days of Week
6. Number of employees in the works to be insured?
7. Are there any seasonal production or sales fluctuations more than 20%, in the works to be Yes / No
insured?
8. Is there a stock of semi finished or finished products? If Yes, state the no. of weeks of supply Yes / No
this stock can cover
9. State Indemnity Period desired (Months)
10. State the time deductible desired (Days)

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai –
400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. For Claim/Policy related queries call us at +91 22
6234 6234/+91 120 6234 6234 or Visit Help Section on www.hdfcergo.com for policy copy/tax certificate/make changes/register & track claim or simply text Hi on whats’app number 8169 500 500 for instant policy servicing. Trade
7
Logo displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: Business Suraksha Classik - Sookshma Udyam Suraksha - IRDAN125RP0001V03200607.
 11. Sum Insured
a. On Net Profit
b. No. of shifts
c. On Increased Cost of Working
12. Index of Business Activity Turnover/Output/Thruput/Revenue/Difference Basis
13. Details of Previous Interruption
a. Period of Interruption
b. Nature of interruption with causes
c. Loss in Gross Profit /Turnover during the Interruption

SECTION XIII – WORKMAN COMPENSATION

1. Employee Details
Description of Estimated Full details of Cash Living/ other Total Estimated Insurance
Employees Number of work subject (annual) allowances if any Annual Earnings required State
Employees (Specify exact, (annual) Table A or B of
nature of work) prospectus
Clerical Staff
Commercial Travellers
Any other employee (pl provide
category and details as provided
in first two categories)
2. T he total amount of wages salaries and other earnings paid by me during the past twelve months was Rs.

3. Does the above, schedule include:

(a) All persons in your service?
(b) All your subcontractors?
4. If Not, then kindly confirm which categories of employees are not covered?
5. Do you provide specific training to your employees on how to perform their respective job? Yes / No

Does al l employees are acquitted with standard safety procedures?

Are your premises a Factory within the meaning of the Factories Act?
Does the insured instruct all workers in proper lifting techniques? Are they provided with
materials-handling aids and encouraged to obtain help where moving extremely heavy objects?
Signing this form does not bind the Proposer to complete the insurance, but it is agreed that this form shall be the basis of the contract should a policy be issued.
I / We have disclosed all the facts, which could influence the acceptance of this Proposal or the terms to be approved, & the above facts, documents;
statements shall be the basis of the contract between me/us and HDFC ERGO General Insurance Company Limited. The Proposer agrees that the receipt
of the Proposal Form by HDFC ERGO General Insurance Company Limited along with the premium payment does not tantamount to the acceptance of the
Proposal for insurance by HDFC ERGO General Insurance Company Limited and does not result in a concluded contract of insurance. The acceptance of
the Proposal for insurance shall be at the Company’s sole and absolute discretion. In the event of acceptance of the Proposal for insurance by HDFC ERGO
General Insurance Company Limited, such acceptance shall be specifically intimated to the Proposer by HDFC ERGO General Insurance Company Limited
along with the date from which the insurance Cover shall become effective. HDFC ERGO General Insurance Company Limited shall not be liable for any
claim in respect of an event giving rise to a claim covered under the Policy of Insurance that has occurred prior to policy issuance (Your proposal form will
be considered after HDFC ERGO General Insurance Company Limited receives premium payment.)
Fraud Warning: This policy shall be voidable at the option of the Company in the event of mis-representation, mis-description or non-disclosure of any
material particulars by the Proposer. Any person who, knowingly and with intent to defraud the insurance company or any other person, files a proposal for
insurance containing any false information, or conceals for the purpose of misleading, Information concerning any fact material thereto, commits a fraudulent
insurance act, which will render the policy voidable at the sole discretion of the insurance company and result in a denial of insurance benefits. Insurance
is the subject matter of the solicitation
I / We agree that if this insurance is completed the protections and/or safeguards mentioned above shall not be withdrawn or varied to the detriment of the
intrests of the Company without their consent and additional premiums if any will be remitted.
I, hereby grant consent to Agent/Broker/Corporate Agent or any other licensed intermediary to share my KYC (Know your Customer) and customer due
diligence information with HDFC ERGO General Insurance Company Limited for the purpose of my insurance proposal.

Signature and Name of the Proposer

PAYMENT DETAILS

Amount (Rs.) ________________ Rupees _____________________________________

MODE OF PAYMENTS

Bank Account No. _______________________________________ Bank Name: ________________________________________________________

Branch Name & Address : ___________________________________________________________________________________________________
Instrument No. ___________________________ Instrument Date : ______________________________________________
Note: The liability of the Company does not commence until the acceptance of the proposal has been formally intimated by the Company and full premium
has been realised by the Company.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai –
400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. For Claim/Policy related queries call us at +91 22
8 6234 6234/+91 120 6234 6234 or Visit Help Section on www.hdfcergo.com for policy copy/tax certificate/make changes/register & track claim or simply text Hi on whats’app number 8169 500 500 for instant policy servicing. Trade
Logo displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: Business Suraksha Classik - Sookshma Udyam Suraksha - IRDAN125RP0001V03200607.