UNITED INDIA INSURANCE COMPANY LIMITED
Head Office: 24, WHITES ROAD, CHENNAI - 600014

PROPOSAL FORM
CONSEQUENTIAL LOSS OF PROFITS

1. (a) Name of proposer (in full)
(b) Address
2. (a) Situation of premises where proposer's trade or business is
carried on and to which inurance is to apply (the various locations
to be included should be described in detail)
(b) Nature of business carried on in each situation
(c) How long has the proposer carried on the business in these
premises or elsewhere?
3. Amount to be insured on:
(a) Gross Profit (viz) Net trading profit and standing charges
(Please specify the standing charges to be covered in detail)
(b) Wages
(1) on weeks wages to all employees other than those whose
wages are included under standing charges or
(2) on wages (dual basis); 100% for weeks and % for the
remainder of the indemnity period.
4. Are the proposer's books regularly audited? Give the name and
address of the Auditors and enclose one copy of the latest audited
accounts
5. Please give particulars (ie., Sum Insured, Period of Insurance and
Premium) of all Fire Insurances (material Damage) in repsect of the
Premises now proposed for loss of profits.
6. State the basis of indemnity required:
(a) Turn over basis or
(b) Output basis or
(c) Difference basis
7. Does the proposer wish to include lay of or retrenchment
compensation? If so, give particulars
8. Does the proposer wish to include fees payable to Auditors for
certifying particulars required in connection with a claim? If so,
state the amount
9. (a) Is the proposer at present or has he been insured for loss of
profits now proposed for Insurance? If so, give details
(b) Has the Proposer ever sustained any loss by fire or other
perils?
(c) Has the proposer made any claim under loss of Proifts Policy
(d) Has any Company
(i) declined any proposal or cancelled any insurance?
(ii) require special items or refused thereof?
10. Is cover required in repsect of other perils in addition to Fire or
Lightning such as Riot and Strike Risks, Earthquake, Explosion,
Storm, Tempest, Flood, Aircraft Damage, etc? Please specify perils
for which cover is required.
11. Does the proposer require the following extensions
(a) His property at other situations
(b) Electricity, Gas works or water works
(c) Supplier's premises. If so, give details
12. (a) Period of insurance
(b) Period for which indemnity is required
We declare that the foregoing Statements are true to the best of our knowledge and belief.
Place:
Date: Signature of proposer
(Acceptance of this proposal is subject to current rules and regulations of the company)
CONSEQUENTIAL LOSS (FIRE) INSURANCE
The consequential Loss (Fire) policy provides cover against:
(a) Loss of Net Profit
(b) Standing Charges
(c) Increase in cost of working
Consequent on interruption of business in the premises following material loss or damage by fire or
other insured peril
This insurance can be given only in conjunction with fire insurance of the property and should cover all
the perils which the fire policy covers.