UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE: NO 24 WHITES ROAD CHENNAI – 600 014
PROPOSAL FORM FOR BANKERS INDEMNITY POLICY

NOTE : PLEASE ANSWER EVERY QUESTION FULLY

1. (a) Name of the Bank
(BLOCK LETTERS) __________________________
2. Address
(i)Regd. Office _____________________________________
(ii)Head/Central office __________________________
3. Nature of Business(Corporate/Retail Banking) _________________________
4. State the total number of employees(Officers,clerks and sub-staff)
Whether permanent,temporary,whole-time or
part-time,on contract or
otherwise including apprentices.__________________________
5. State the total number of Branches in India __________________________
6. Is the risk currently insured against a Bankers Blanket Policy?________________
If so,
(a) The name of Insurance Company _________________________
(b) Policy No. _________________________
(c) Period _________________________
(d) Limit of Indemnity _____________________________
11. Has any Company in respect of your Bankers Blanket Policy
Insurance :
(a) Declined your proposal ? _________________________
(b) Cancelled or refused to renew your policy? __________________
(c) Accepted your proposal on Special
terms and conditions ? _________________________
12. Have you ever sustained a loss of money and/securities?
If so, give details _________________________
13. Please indicate the Limit of Indemnity in respect of each Insuring Clause and
the General Aggregate.___________________________________________________
14. Do you need cover against Riot and
Strike,Earthquake and Terrorist
activities? _____________________________________________
15. Do you need cover for Internet Liability?________________________
16. Policy Period ______________________To ______________________________
We,the undersigned,do hereby warrant and declare the truth of all the above statements and that we
have not withheld any material information and we agree that this declaration and proposal shall
be the basis of the contract as mutually and finally agreed between us and UNITED INDIA
INSURANCE CO. LTD
Place :
Date : Signature of Proposer
Note : The liability of the Company does not commence until the proposal
has been accepted by the Company and the premium paid.
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 or 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 rebate as may be allowed in accordance
with the prospectus or tables of the insurers.
Any person making default in complying with the provisions of the section shall be
punishable with fine which may extend to five hundred rupees.