The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001

GUN INSURANCE PROPOSAL FORM

1. a. Name of the Proposer (in full) : _____________________________________________

b. Address : _____________________________________________

_____________________________________________

c. Profession or Occupation : _____________________________________________

2. SCHEDULE OF GUNS TO BE INSURED :

Name of Maker Number of Gun Date of Make Value

5. What Insurance is required ? (a) Loss of or Accidental Damage to the Gun
Please strike out type of cover not (b) Liability to the Public
Required. (c) Personal Accident

6. Has any proposal for insurance of
the risk been previously made or
has the risk been previously insured?
If so, state with what Insurers and
Whether such insurance or renewal
Thereof has been declined or an
Increased rate required.

7. What claims have been made against
the proposer in connection with shooting
accidents and what losses if any, in
respect of guns has the proposer
sustained during the past five years.

8. Has the proposer ever sustaine bodily
injury by accident while shooting ? if,
so, please give details.

I / We hereby confirm that I / We are in good health and have no physical infirmity or disability. I / We warrant that the answers to the above queries are true and complete and that no material affecting the risk has been concealed by me, and agree that this proposal shall be the basis of the Contract between me / us and The New India Assurance Co. Ltd. and I / agree to accept a policy in the Company’s usual for this of insurance.

Place : ________________

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

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.
.