Regd. Office: Akurdi, Pune 411 035 & Head Office: GE Plaza, Airport Road, Yerawada, Pune 411 006

MARINE CARGO PROPOSAL

Important: this proposal for insurance will be the basis of any subsequent insurance policy

that we issue to you. It is essential that you answer fully and accurately all of the questions

contained in this proposal, and that you provide us with any and all additional information relevant to the risk to be insured or our decision as to the acceptance of the risk or the terms upon which it should be accepted. Your failure to comply with this obligation now may result in the rejection of your claim and the avoidance of your policy when a claim is made. If you are in any doubt about the information to be given, please seek the advice and guidance of your insurance advisor or agent. If there is insufficient space in this proposal for you to provide relevant information, whether as requested or otherwise, please attach a separate sheet to this proposal and return it to us.

  1. PERSONAL DETAILS:

i. Proposer’s Name & Address
ii Customer ID, if any. / Pincode
iii Contact Person, if any.
iv. Telephone and E-mail ID:
  1. CARGO DETAILS :

i. Goods proposed for insurance
ii. Specify whether New or Secondhand
iii. Nature of Packing used
iv. Conveyance(s) and/or shipping
v. Containeriation details
vi. Terms of Sale, whether FOB or CIF or similar terms
vii. RR/GR/BL/AWB No. and date if any.
viii Details of the carrying vessel/vehicle
such as name/no. and name of the
transporter
ix. Value of Cargo (for specific voyage)
x. Basis of valuation
Xi Sum proposed for Insurance (for
specific voyage policy)
xii. Annual turn over (Other than specific
policy)
xiii. Limit per sending (other than specific
policy)
xiv. Limit per location (other than specific
policy)

3.COVER DETAILS:

i. Type of Policy
required (Please tick
whichever is
applicable) / 1. Inland Transit
2. Inland Transit plus FOB
3. Overseas Transit
4. Specific Policy / Declaration Policy / Open
Cover / Open Policy
5 Others (Please specify):
ii. Voyage details / From ______To ______
iii. Distance less than
100 kms. / YES/NO.
iv. Period of Insurance / From ______a.m/p.m To ______midnight
v. Multi transit
involved
(If yes, please state whether cover for intermediate processing is required) / YES/NO.
vi. Transhipment, if any
with details / YES/NO . If YES, specify the Place:
No. of weeks:
vii. Is Storage cover
required?
viii. Periodicity of
Declaration (other
than specific policy) / Specific / Weekly / Fortnightly / Monthly / Others
ix. Type of Cover
(Please tick whichever
is applicable) / 1. Inland Transit (Rail/Road) Clauses A / B / C
2. Institute Cargo Clauses A / B / C
3. War and / or Strikes Clause
4. Institute Cargo Clauses (Air)
5. Post Parcel Clause
6. Duty Insurance Clauses
7. Increased Value Insurance Clauses
8. Institute Theft, pilferage and Non Delivery Clause.
9. Others (Please specify)
x. Do you want to take
on part of every loss: / YES / NO :
If YES, please specify the % of loss

4CLAIMS EXPERIENCE : (For last Three years excluding current year)

Department / Year / Premium (Rs.) / Claims (Rs.)
Paid / Outstanding
MARINE
OTHER THAN MARINE

5OTHERS;

Has any other insurer refused to accept this insurance or imposed conditions to accept the same. If YES, give details.
Rate of premium charged by previous Insurer, if any.

I/We hereby declare and warrant that the above statements are true and complete in all respects and that there is no other information which is relevant to my application for insurance that has not been disclosed to you. I/We agree that this proposal and the declarations shall be the basis of the contract between me/us and Bajaj Allianz and I/We agree to accept a policy, subject to the conditions prescribed by Bajaj Allianz and to pay premium on the amount estimated above at the end of each policy period. I /We undertake to exercise all ordinary and reasonable precautions for safety of the property as if it were uninsured.

SIGNATURE OF THE PROPOSER

(WITH OFFICE SEAL, IF ANY)

SECTION 41 OF INSURANCE ACT, 1938

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 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 or continuing a policy accept any rebate except such rebate as may be allowed in accordance with the published prospectuses 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 Five Hundred Rupees.