UNITED INDIA INSURANCE CO. LTD

(Regd H.O. : No.24, Whites Road, Chennai – 600 014.)

BRANCH / DIVISIONAL OFFICE ……………………………

PROPOSAL FORM FOR JEWELLER’S BLOCK INSURANCE

Please reply fully to all the following questions. If the answer to any question is none state ‘NONE’

  1. (a) Name of the Proposer (in full)

(b)  Address to which all communications should be sent

(c)  State address of all premises to which policy is

to apply (if more than one, please attach a statement)

the floor(s) on which your premises are situated in each location.

(d) Since when established.

  1. NATURE OF YOUR BUSINESS: Wholesale % Retail %

Manufacturing % PawnBroking %

  1. (a) Give the Safe Makers name,cost when purchased

(state whether new or second-hand and whether

marked “Thief Resisting” or Burglar Proof)

(b)  Will the premises be occupied at night by the

Proposer?

(c)  Will there be a watchman on the insured premise(s)?

If ‘Yes’ specify:- (Answer for all premises.)

i)  Whether he/they is/are your employees and is/are

employed for all the 24 hours of the day

OR

ii)  Whether he is/they are common watchman for

the whole building /locality or only a night

watchman to guard the insured premise(s) or the

building or the locality

(d)  Is a burglar alarm system installed or any other special

Means of protection adopted? If so, state what protection?

(e)  Is an inside grill fitted to your Gold and Gems

Showroom, window or is any other protection

Installed against loss by window smashing? If so,

State what protection

(f)  Are your display window protected by Rolling

Shutter outside business hours?

(g)  How are the doors secured outside business hours?

(h)  How are the windows protected?

(i)  How are skylights, if any, protected?

  1. WINDOW DISPLAY:

State the approximate maximum value of any one article

of Jewellery or Gem Stock which will be displayed in

the window (A pad or tray containing a number of rings

or other articles to be counted as one article.)

(Give separate answer for each location.)

Note : Window Display at Night is not covered.

  1. STOCK:

(a)  What was i ) the average daily total value of your

Stock during the past 12 months?

ii) cash and currency noted during the past 12 months?

(b)  Will the whole of your stock when on your premises

be kept in safe at night and at all times when the

premises are closed? If not, state value and class of

stock which will be left outside safes.

Note : We do not cover stocks kept out of safe after business hours at night.

  1. VALUATION BASIS are the figures in this form compiled

on the basis of cost price for your own stock? If not give details

N.B.: Unless otherwise mutually agreed claims in respect of your

own stock will be related on the basis of cost price.

  1. LOSSES:

(a)  Have you ever sustained a loss or losses?

(b)  If so, give statement covering past five years with

Particulars.

(c)  Where you insured and if so, give the name of the

Insurance company and whether they paid the

Claim in full or a part thereof?

(Please state how much)

  1. Anywhere in India sum to be insured

(only total to be insured may be given)

SECTION I :

(a)  Property Insured on the Premises …

(b)  Property Insured in display windows …

(c)  Property Insured in locked safe on the premises…

(d)  Cash and Currency Notes …

(e)  Property Insured in Bank lockers subject to …

insured maintaining a separate register to record

all deposits/withdrawals in such lockers,Address

of the Branch of the Bank.

SECTION II (Outdoor Risk):

(a)  Property in the custody of the insured;his … Rs.

Partners,employees

(b)  In the custody of brokers, cutters and/or … Rs.

Goldsmiths

SECTION III :

(a)  Registered insured parcel post … Rs.

(b)  Air Freight … Rs.

(c)  Angadia … Rs.

SECTION IV :

Furnitues,fixtures,fittings at premises not used as … Rs.

Residence and safes at residences

  1. Does the sum to be insured on Trade and Office

furniture, fixtures & fittings, machinery plant and all other

contents (except your stock & goods in trust) represent

the full value thereof. If not state the approximate

present value.

  1. REFERENCES :

Unless proposing for renewal give two references from

your trade

  1. OTHER INSURANCES :

(a)  Has any insurer ever cancelled or refused to issue

or to continue any insurance for you?

(b)  Have you been previously insured? If so, state

with whom risks covered and for what amount.

Signing this form does not bind the proposer to complete the insurance, but is agreed that this form shall be the basis of contract should policy be issued.

I/We have read the above and agree that to the best of my/our knowledge and belief it represents true and complete statement.

I/We agree that if this insurance is completed the protection and/or safeguards mentioned above shall not be withdrawn or varied to the detriment of the interest of the underwrites without their consent.

Date : Proposer’s Signature

PROHIBITION OF REBATES

The following is the copy of section 41 of the Insurance Act, 1938.

1)  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 or risk relating to lives or property in India any rebate of the whole or part of commission payable or any rebate or the premium- shown on the policy not shall any person taking out or renewing continuing a policy except any rebate as may be allowed in accordance with the published prospectuses or tables of 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.