UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE : NO 24 WHITES ROAD CHENNAI – 600 014
PROPOSAL FORM FOR (PUBLIC LIABILITY) INSURANCE

1. a) Name of Proposer (in full)
b) Address
c) Business
a)
b)
c)
2. Furnish below details of all Lifts which are required to be covered.
Type
(Passeng
er Goods,
Hoist
etc.)
Premises
where
situated
Motive
Power
Maker’s
Name
and
Address
Year
of
Manuf
acture
Carrying
Capacity
Method of
control
(i.e.
switch,
button,
lever etc.)
No. of
Floors
Served
Dimensions
3. Trader or business carried on at the premises containing
the Lifts.
4. a) State the number of Attendants employed in each Lift
and their working hours.
b) Are the Lifts allowed to be operated by users without
the assistance of attendant?
a)
b)
5. a) Is each Lift shaft completely enclosed?
b) Is each Lift shaft fitted with a gate?
c) Is each Lift cage fitted with a gate which is securely
fastened when shut?
a)
b)
c)
6. a) State the name and address of the Engineer with
whom the Proposer has a contract for maintenance
and inspection of Lifts.
b) At what Intervals is the inspection made?
c) When was the last inspection made? Furnish a copy
of the Engineer’s report pertaining to that inspection.
a)
b)
c)
7. Is any notice displayed in the Lifts for the information of
the users thereof? If so give details?
8. Has the Proposer insured the Lifts under any Fire and / or
Machinery Breakdown policies?
If so, for what sums and with which Insurer?
9. a) Has anyone made any legal liability claim upon the a)
proposer in respect of the Lifts proposed or other
Lifts? If so give particulars.
b) Has the proposer ever made any claim for legal
liability in respect of this or other Lifts? If so, give
below particulars.
b)
Date of
Accident
Details of
Claim
Name of
Insurer
Amount
recovered Rs. Amount to be recovered Rs.
10. Has any Insurer in respect of any lift (public
liability insurance cover)
a) Declined a proposal from the proposer, or
b) Cancelled or declined to renew any policy, or
c) Demanded an increased rate, or
d) Required special terms to insure or grant any
renewal?
a)
b)
c)
d)
11. State the limit of indemnity required a) Any one accident or series of
accidents arising out of
anyone
event
b) All accidents during the
period of insurance
Rs.
Rs.
12. Period of insurance From: To:
I / we hereby declare that the above statement and answers are true and correct and complete that no
material fact has been with-held, mis-stated or mis-represented and that I / we agree that this proposal
and declaration shall be the basis of the contract between me/us and ------------------------------ whose
standard policy for the Insurance proposed is acceptable to me/us.
Place:
Date : Signature of the Proposer
Note: The liability of the Company does not commence until the proposal has been accepted by the
Company and the premium paid.
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 of risk relating to lives or
property in India any rebate of the whole or part of the commission payable or any rebate of
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
prospectus or tables of the insurer.
2. Any person making default in complying with the Provisions of this section shall be punishable
with fine which may extend to five hundred rupees.