The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001
PROPOSAL FORM FOR LIQUIFIED PETROLEUM GAS DEALERS POLICY

1) Name of proposer in full :
(IN BLOCK LETTERS)

2) Address of the Business premises :

3) Period for which Insurance is
Required : From ___________To_________

4) Have you previously held any
insurance in respect of any of the
risks proposed for insurance. If
yes, give details. :

5) Have any insurance company ever
a) declined your proposal? :
b) Refused to renew or cancelled
the policy? :
c) Imposed any special conditions/
Limitations.

SECTION I
FIRE AND ALLIED RISK (BUILDING & CONTENTS) INSURANCE

1. Nature of trade or business : _______________
2. Property to be insured Sum to be Insured Showroom Godown
Items Items
2 to 7 2 to 7

i) Building – Godown/showroom i) Rs.
ii) Stock in trade including cylinders
in Godown/Showroom ii) Rs.

iii) Furniture, fixture & fittings in Godown/ iii) Rs.
Showroom.

3. Construction : State materials used e.g.
concrete or bricks, iron sheets or timber
etc.
a) Walls
b) Roof
c) Floor
4. State whether premises solely occupied by the proposer.
If not, give details of other Occupants and trade carried on

5. State whether the building is completely detached on all
four sides, if not give particulars of how attached.

6. Have you insured your Building and contents/stock-in-trade
elsewhere, if so, state i) name and place of issuing office
ii) Policy No. iii) period iv) sum insured.

7. Addresses of Showroom and Godown

SECTION II
BURGLARY AND HOUSEBREAKING
Showroom Godown
1. Property to be insured Value Items 1 to 4 item 1 to 4
Sum Insured
25% of value

i) Stock in trade including cylinders
In attached godown i) Rs.

ii) Furniture, fixture and fittings ii) Rs.

N.B. : The Sum Insured is on First Loss Basis for an
amount equivalent to 25% value to the Property at risk.

2. Are all doors protected by lock/locks?

3. Are all windows protected by bars?
4. Do you keep daily sales and purchases
invoices and other books of accounts?

SECTION III
GAS CYLINDERS IN TRANSIT

1. Maximum No. of cylinders carried at any one time.
2. Mode of carriage
3. Value of cylinders.
i) Gas filled cylinders
ii) Empty cylinders
4. Maximum distance between the Proposer’s
premises and the Customer’s premises/house.

5 Are the cylinders carried during normal office
hours or beyond office hours also. If they are
carried beyond office hours also, please state
upto what hours they are carried ?

6. Who authorizes issue of cylinders to customers?

SECTION IV
CASH IN TRANSIT

1. How is money carried and between what hours? :

2. How many employees will carry money at a time? :

3. State per transit limit other than delivery boys. :

4. State per transit limit if delivery boys. :

5. Whether money collected are retained in the
proposer’s premises ? :
If so, where and what arrangements are made
for their safety?

6. Insurance required for cash in safe /fixed cash box : Rs.

on counter : Rs.

7. Particulars of the safe
i) Measurement of safe/s
a) Height
b) Width
c) Depth
d) Weight
e) Makers Name
ii) Is it marked burglary resisting?

SECTION V
FIDELITY GUARANTEE

Name of Employee Designation & Total Monthly Amt. of guarantee
nature of duties remuneration per employee
Rs.

1)
2)
3)
4)
1. How often & by whom are your cash
and Bank balances agreed, entries in
cash books verified with vouchers and
stocks checked ?

2) Are the books audited by an independent
auditor and if so, how often ?

3) Has/have the proposed employee/s been
suspected of dishonesty in the past?

SECTION VI
PEDAL CYCLE/ TRI CYCLE
Maker & Name of Year of Mfg. Frame No. Accessories Estimated
Manufacturer attached, if any present value

1)

2)

3)

SECTION VII
PUBLIC LIABILITY INSURANCE

1. State the existing number of customers
the proposer has and the number
estimated to be included during the
year.

2. Are the gas filled cylinders tested for
leakage before delivery to customers ?

3. Whether the employees carrying cylinders
are trained on safety methods for
installing gas cylinders.

4. Amount of indemnity desire | ANY ONE ACCIDENT RS.____________
ANY ONE YEAR RS._____________

ANNUAL SALES TURNOVER RS._____________

SECTION VIII
WORKMEN’S COMPENSATION
Name of Employee ( s ) Nature of work Monthly wages

SECTION IX
PERSONAL ACCIDENT FOR
PROPRIETORS/PARTNERS/EMPLOYEES

Name Age Details of Occupation Table of Name of Assignee
existing Benefits and Relationship
infirmity/
disability

(For assignment of benefit please use prescribed form.)
SECTION X
P.A. BENEFIT TO CUSTOMERS
1. Are you interested in covering your
customers for personal accident Risk YES/NO

2. Please state how many customers you
are servicing ?
3. Please also state Number of cylinders
sold domestic/industrial.

SECTION XI
ACCIDENTAL BREAKAGE OF PLATE GLASS

1. Please give the details of glasses :

Sr.No. Type No. of Size Position Estimated
(i.e. Plate/ Squares each where Replacement
Sheet/Plain etc. square fixed value

2. Is any of the glasses proposed for :
Insurance scratched, damaged or
Insecurely fixed ? If yes, give full
Details.

SECTION XII
LOSS OF OR DAMAGE TO NEON SIGN / GLOW SIGNS

1. Please give the particulars of Signs :

Sr.no. Description of Situation Date when Date when Estimated
Signs created last inspe- replacement
cted and by
whom

2. Are the signs in good state of repair
and will be so maintained ? :

D E C L A R A T I O N

I do hereby declare that all the information given and statements made above are true and complete and that I have withheld no information whatever regarding the insurance applied for therein. Further, I declare that the premises are in sound condition and 9n a good state of repair and they are not specifically exposed to the risk of fire, or theft. Further I also declare that the premises will not be left uninhabited for more than a continuous period of SEVEN days. I also declare that aggregate value of the Building and contents/stock in trade relevant to Section of the cover does not exceed Rs. whether insured under one or more policies or whether issued by one or more officers of the subsidiaries.

I further agree that this Declaration and the information given and statements made above by me or any one acting on my behalf, shall form the basis of the contract between me and the Company and I further agree to accept Indemnity subject to the conditions in and endorsed on the Company’s Policy.

PLACE :

DATE : PROPOSER’S SIGNATURE
______________________________________________________________________________

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. Insurance is the subject matter of solicitation.
4. Premium will be quoted on application.

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

ACCEPTED BY DATE & TIME RATE REMARKS
CODES - OFFICE /DEV. OFFICER / AGENT /BROKER-
COLLECTION / SCROLL NO POLICY NO.
.