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’
- (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.
- NATURE OF YOUR BUSINESS: Wholesale % Retail %
Manufacturing % PawnBroking %
- (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?
- 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.
- 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.
- 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.
- 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)
- 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
- 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.
- REFERENCES :
Unless proposing for renewal give two references from
your trade
- 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.