UNITED INDIA INSURANCE COMPANY LIMITED
PROPOSAL AND QUESTIONNAIRE FOR BOILER AND PRESSURE PLANT INSURANCE
(The liability of the Company does not commence until this proposal has been accepted by the Company and the premium paid)

1. Information given herein will be treated in strict Confidence.
2. Put a (Ö ) mark wherever applicable.
S. No. Details Answer
1. a) Name & Address of the Insured a)
b) Work Address (Site of the Property to
be Insured)
b)
2. a) Period of Insurance -
b) From ___________ to __________
3. Total Sum Insured
4. A) BOILER AND PRESSURE PLANT -
S. No. Location Description – Maker’s
Name, Maker’s No.,
Capacity
Registration
Number
Year of
Make
Sum
Insured
B) SURROUNDING PROPERTY OF THE INSURED INCLUDING
PROPERTY HELD IN TRUST OR COMMISSION
C) LEGAL LIABILITIES TO THIRD
PARTIES
a) Personal Injury Rs.
b) Property Damage Rs.
D) On payment of additional
premium do you wish to cover the
following?
a) Express freight (excluding
airfreight), Overtime and Holiday
rates of wages.
b) Airfreight.
c) Owner’s Surrounding Property.
d) Third Party Liability.
i) Any one Accident
ii) Any one Year
e) Additional Customs Duty.
If Yes provide Limits of
Indemnity
Rs………
Rs………
Rs………
Rs………
Rs………
Rs………
No
No
No
No
No
No
5. a) In case of Boiler, state if it is
Water tube type?
a) Yes No
b) If so, what is the evaporative
capacity per hour
b)
6. State how Boiler is fired, e.g. Oil, Gas
Coal or Pulverized fuel.
7. a) Do you wish to include the main
steam piping? Yes No
b) If so, state whether cover required
within 20 meters or 100 meters radius
of the Boiler
20 m 100 m
8. a) Are all the items in good condition? Yes No
b) Give particulars of any defects. b)
9. a) Which items of Plant are subject to
periodical inspection?
a)
b) By whom are they inspected, and at
what intervals?
b)
c) Date of last inspection, working
pressure approved, and period of
such approval (attach copy of last
report).
c)
10. a) What is the maximum load on safety
valve per square inch?
a)
b) What is the working pressure? b)
11. a) Are the Boiler Attendants solely
employed on the Boiler Plant?
Yes No
b) What are their qualifications? b)
c) What proportion of their time is given
to other duties, if not solely employed
on the Boiler Plant?
c)
12. a) Is the Boiler Plant now Insured? Yes No
b) If so, state name of Insurer, and date
policy expires.
b)
13. a) Has the Boiler Plant at any time been
insured by you?
a) Yes No
b) If so, state name of Insurer, and date
of policy expired?
b)
14. In respect of Boiler Insurance, has any
Insurer -
a) permitted withdrawal of or declined
any proposal from you?
OR
a) Yes No
b) cancelled or refused to renew your
policy? b) Yes No
Note - Name of Insurer to be stated.
15. a) Have you ever had an accident to
your Boiler Plant? a) Yes No
b) If so, give full particulars on separate
sheet.
b)
16. Have your any Boiler Plant in use other
than that specified in the schedule? Yes No
17. a) Are any of the Boilers shown in the
proposal automatically controlled? a) Yes No
b) If so, which ones? b)
18. a) Is any of the automatically controlled
Boilers not under continuous
supervision by person competent to
operate it?
a) Yes No
b) If so which ones b)
19. Is Boiler under regular and frequent
supervision whilst working? Yes No
I/We the undersigned hereby declare that the above statements and particulars are true and
complete and I/We declare and agree that this declaration and the answers given above shall be
held to be promissory and shall be the basis of the contract between me/us and the Company.
Proposer's Signature
Place ___________________
Date ____________________
Note -
i) The term `Boiler' where used in the above schedule includes fittings, integral super heaters and
integral economisers but does not include steam or feed water piping, separate super heaters,
separate economisers, such items being covered by the Policy only if specifically listed in the
schedule.
ii) Value of the Boiler and/or Pressure Plant older than 20 years must be indicated separately.