The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001

PROPOSAL FOR DIRECTORS & OFFICERS LIABILITY INSURANCE
SIGNING THIS PROPOSAL DOES NOT BIND TO COMPLETE THIS INSURANCE

1. Name of Company

2. Address of Head Office

3. Country of Registration

4. A. How Long has the Company continually carried on business ?
B. Business Activities of the Company and its subsidiaries ?

5. During the last five years has :

A. The name of the parent company been changed ?
B. Any acquisition or merger taken place ?
C. Any subsidiary Company been sold or ceased trading ?
D. The capital structure of the parent Company changed ?

If so please give details

6. A. Has the company any acquisition, tender offer or merger pending or under
consideration ?
B. Is the Company aware of any proposal relating to its acquisition by another
Company?
C. Is the Company intending a new public offering of securities within the next year in
India or elsewhere?

7. Is the Company

A. Private ?
B. Public ?
C. Listed on any Indian Stock Exchange ?
D. Listed on Foreign Stock Exchange? Please specify
E. Traded in any other way? Please specify

8. Please List :

A. Total Number of Shareholders

B. Total Number of Shares issued

C. Total Number of shares held by Directors and Officers (both direct and beneficial)

D. All holdings representing 15% or more of the Ordinary Share Capital of the Company giving the holder and the percentage held by each.

9. A. Please give a list of Directors and Officers of the Company

B. Please give details of any change to the list of Directors and Officers given in the
Company’s last report and accounts.

10. Give complete list of all Subsidiary Companies including country of registration and
percentage owned by parent Company other than shown in the last report and
accounts.

11. Does the Company or any Director or Officer have Directors and Officers Liability
Insurance currently in force?
YES / NO
If YES, State
A. Insurer
B. Indemnity Limit
C. Expiry Date

12. Has the Company ever had any Insurer decline a proposal or cancel or refuse to
renew a Directors and Officers Liability Insurance ?
YES / NO
If YES, Please give details

The following questions are to be completed by all proposers

13. Have claims ever been made against any past or present Director or Officer of the
Company or its Subsidiaries ?
YES / NO
If YES, Please give details

14. Is the Proposer aware, after enquiry, of any circumstances of incident which may
give rise to a claim ?
YES / NO
If YES, Please give details

15. Jurisdiction for Coverage required for – India / World wide (including / excluding
North America )/ Others ______________

16. Any other material Information / Requirement

17. Amount of Indemnity required : For One Accident (AOA) Rs.
: For One Year (AOY) Rs.
DECLARATION : I declare that the statements and particulars in this proposal are true and that no material facts have been misstated or suppressed after enquiry. I agree that this proposal, together with any other information supplied shall form the basis of any Contract of Insurance effected thereon. I undertake to inform Insurers of any material alteration to those facts occurring before completion of the Contract of Insurance.

Date- Signed ……………………………………………………
To be signed by Chairman / Chief Executives
Please enclose with this Proposal Form :
a) The Last two Annual Reports and Accounts for the Company
b) The last two Interim Statements (If applicable)
c) Any offer Document/Listing Particulars published in the last 12 months.
Note 1.The liability of the company does not commence until the proposal has been accepted by the
Company and full premium paid.
2. If space is found insufficient, please attach separate sheets for details.
3. Premium will be quoted upon application.
4. Insurance is the subject matter of solicitation.
PROHIBITION OF REBATE -- Section 41 of the 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 the whole 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 rebates 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.

FOR OFFICE USE -
MARKETING / DEVELOPMENT OFFICER'S REPORT
The Proposer is known to me/my agent / Broker for___years and I recommend acceptance of this proposal.

Name and Code No. Signature of Dev. Officer / A/AO-D