NATIONAL INSURANCE COMPANY LTD.
(Subsidiary of General Insurance Corporation of India)
Regd. Office : 3, Middleton Street, Calcutta – 700 071

CODE For OFFICE USE ONLY
DEV.OFFICER/ AGENT
ACCEPTED BY…………………………………….
ADDRESS OF ISSUING OFFICE DATE & TIME……………………………………..
RATE……………………………………………….
REMARKS…………………………………………
POLICY NO……………………………………….
COLLECTION/SCROLL NO……………………..
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PROPOSAL FORM FOR BURGLARY AND HOUSE-BREAKING INSURANCE
BUSINESS PREMISES
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SCOPE OF COVER
This Insurance Policy provides cover against loss or damage by Burglary or House Breaking (i.e. theft following an actual, forcible
and violent entry of and/or exit from the premises) in respect of contents of offices, warehouses, shops, etc. and cash in safe or strong
room and also damage caused to the premises, except as detailed below :
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EXCLUSIONS
The Policy does not cover loss or damage arising form War and War like operations, Riot and Strikes, Civil Commotion, Terrorist
Activities, Convulsions of nature and/or Consequential Loss, by use of the keys to safe unless obtained by force or threat, caused by
Insured’s employee(s) or Members of the family.
However, on payment of additional Premium, cover can be extended to include Riot and Strike Risks and Terrorist activities.
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THE FOREGOING IS ONLY A BROAD INDICATION OF THE COVER OFFERED. FOR DETAILS PLEASE REFER TO ANY
OFFICE OF THE COMPANY.
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NOTE : PLEASE ANSWER EVERY QUESTION AND FULLY
1. (a ) Name and address of the proposer
(in full) (Block Letters)
(b ) Name of the Financial Institution/s
(if any financial interest is involved)
(c ) Nature of Trade or Business
(a )
(b )
(c )
2. Address of the premises to be insured
3. (a ) Whether Warehouse, Godown Shop or Office ?
(b ) How long have you been an occupant of premises ?
(a )
(b )
(c ) Are you the sole occupant ?
(d ) If not, who are other occupants ?
(c )
(d )
4. What Materials are used for construction? e.g.Concrete,
Bricks, Iron Sheet or Timber etc.
(a ) Walls
(b ) Roof
(c ) Floor
(a )
(b )
(c )
5. What protection is provided to :
(a ) Doors ?
(b ) Windows ?
(c ) Skylights, Ventilators, Exhaust Fans, Lights,
Airconditioners, Trap Doors ?
(d ) Any other openings ?
(e ) Mention any special precautions you have adopted for
safeguarding your property.
(a )
(b )
(c )
(d )
(e )
6. (a ) Are the premises occupied by you at night ?
If not, by whom ?
(b ) Will the premises be guarded by Watchmen ? If so, by
how many and during what time ?
(c ) Will the Premises at any time be left un-occupied ?
(d ) If so, how often and for how long ?
(a )
(b )
(c )
(d )
7. (a ) Are all valuables secured in safe(s), outside business
hours ?
(b ) Give
(1) Maker’s name
(2) Height
(3) Width
(4) Depth and
(5) Weight of Safe(s)
(c ) How many keys are there to the safe(s) and with whom
are they kept ? Can the safe(s) be opened by a single
key, or by a combination of two or more keys ?
(a )
(b )
(1)
(2)
(3)
(4)
(5)
(c )
8. (a ) Are Stock and Sales books maintained ?
(b ) How frequently are these entered ?
(c ) How often is stock taken ?
(d ) Where are these books kept outside business hours ?
(a )
(b )
(c )
(d )
9. (a) Have any premises occupied by you been entered by
thieves ?
(a )
(b ) If so, give full particulars stating when and how access
was obtained and the extent of the loss.
(c ) What precautions have been adopted to prevent such
a recurrence ?
(b )
(c )
10. (a ) The name of Insurance Company
(b ) Policy No.
(c ) Period
(a )
(b )
(c )
11. Has any Company in respect of your Burglary Insurance
(a ) Declined your proposal ?
(b ) Cancelled or refused to renew your policy ?
(c ) Accepted your Proposal on Special terms and
conditions ?
(a )
(b )
(c )
12. Have you ever claimed upon any Company for loss by
Burglary or House breaking ? If so, give details.
13. Amount for which contents are currently insured against
Fire and name of the Company
14. Give full description of contents (i.e. the property to be
Insured) of the premises.
15. Do you need cover against Riot and Strike, terrorist
activities on Payment of additional Premium ?
16. PROPERTY TO BE INSURED (Give full details)
(a ) Stocks-in-Trade (as described in item 14 above).
(b ) Goods held by the Proposer in trust or on commission
for which he is responsible.
(c ) Furniture, Fixtures, Fittings, Utensils and Appliances
in trade.
(d ) Coins and/or Currency Notes in locked safe.
(e) Others (To be specified)
SUM TO BE INSURED (Rs.)
(a )
(b )
(c )
(d )
(e )
Total Rs. ________________________________
N.B. : To obtain full indemnity it is a necessary to insure for the full value of the property in the premises.
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17. Period of Insurance
From…………………………..To…………………………………..
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I/We do hereby declare that the above statements and answers are true and that I/We have not with held any information whatsoever
regarding the Proposal. I/We agree that this proposal and declaration shall be the basis of the contract between me/us and National
Insurance Co. Ltd. where Policy for the Insurance proposed is acceptable to me/us. I/we undertake to exercise all ordinary and
reasonable precautions for safety of the property as if it were uninsured.
Place :
Date : Signature of Proposer
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Note : 1. The liability of the Company does not commence until the proposal has been accepted by the Company and the premuim
paid.
2. Premium will be quoted on application.
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Development Officers Report
The Proposer is known to me/my agent for…………years and I recommend acceptance of this proposal.
Place :
Date : Signature of Dev. Officer
Name and Code No.
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PROHIBITION OF REBATE
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 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.
(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.