efo v³et Fefv[³ee SM³eesjvme kebÀHeveer efueefceìs[

(Yeejle mejkeÀej keÀe GHe¬eÀce)

Hebpeerke=Àle SJeb ÒeOeeve keÀe³ee&ue³e : v³et Fefv[³ee SM³eesjvme efyeefu[bie, 87, cenelcee ieebOeer ceeie&, HeÀesì&, cegbyeF& - 400 001.
mesJee keÀj mebK³ee
AAACN4165CST178 cegbyeF& #es$eer³e keÀe³ee&ue³e - I : v³et Fefv[³ee YeJeve, 34/38, yeQkeÀ mì^erì, HeÀesì&, cegbyeF& - 400 023.
ceevekeÀ Deefive leLee efJeMes<e DeeHeoeSB Hee@efuemeer kesÀ efueS ÒemleeJe
Òeerefce³ece kesÀ Yegieleeve kesÀ yeeo peesefKece mJeerke=Àle nesves lekeÀ mebHeefÊe DeeJeefjle veneR mecePeer peeSieer ~
Òeerefce³ece ®eskeÀ DemJeerke=Àle nesves Hej Hee@efuemeer Meg© mes jÎ keÀj oer peeSieer ~
GlHeeo keÀes[ 11 keÀe³ee&ue³e efJekeÀeme DeefOekeÀejer veece : keÀes[ :
peesefKece/oj
keÀes[ oueeue / SpeWì veece : keÀes[ :
jsnve / yebOekeÀ
yeerceeOeejkeÀ keÀe veece
Hebpeerke=Àle keÀe³ee&ue³e
Helee Deewj efHevekeÀes[
peesefKece DeJeefmLeefle
Helee (efHevekeÀes[
pe©jer nw)
Hee@efuemeer DeJeefOe mes lekeÀ mece³e
efìHHeCeer : ke̳ee DeeHekesÀ Heeme Dev³e keÀesF& Deefive Hee@efuemeer nw : neB / veneR ~ ³eefo nes lees ke=ÀHe³ee Hee@efuemeer mebK³ee Deewj DeJeefOe yeleeSb ~
peesefKece efJeJejCe
DeeJeefjle mebHeefÊe keÀe yeerefcele jeefMe meefnle efJeJejCe
yeerefcele jeefMe (©.)
DeJeefmLeefle efpeme ©He ceW efyeefu[bie efHuevLe leLee efyepeueer leLee efJeÐegleer³e mìe@keÀ Òeef¬eÀ³eeiele kegÀue
GHe³eesie nes jne nw veeRJe Dev³e keÀe³ee&ue³e mLeeHeveeW meefnle mìe@keÀ
GHekeÀjCeeW meefnle HeÀveea®ej efHeÀkeÌme®ej
meb³eb$e Je ceMeervejer efHeÀefìbie

(©.) (©.) (©.) (©.) (©.)

leueIej - ³eefo keÀesF& nes lees neB / veneR cebefpeueeW keÀer mebK³ee : leue cebefpeue mes kegÀue TB®eeF& : ceerìj
SkeÀeefOekeÀ DeefOeYeeskeÌleeDeeW kesÀ ceeceues ceW ÒemleeJekeÀ keÀer cebefpeue mHeä keÀjW
yeercee kesÀ efueS ÒemleeefJele DeeOeej (efyeefu[bie / ceMeervejer / HeÀveea®ej Deewj efHeÀefìbime)
yeepeej cetu³e DeeOeej (cetu³eËeefmele) neB / veneR
Hegve&mLeeefHele cetu³e Hej DeeOeeefjle neB / veneR
keÀ) mìe@keÀ kesÀ ceeceues ceW ke=ÀHe³ee Hee@efuemeer keÀe ÒekeÀej mHeä keÀjW :
1) mìe@keÀ Iees<eCee Hee@efuemeer
2) HeÌueesìj Hee@efuemeer
3) HeÌueesìj Iees<eCee Hee@efuemeer
(ke=ÀHe³ee DeeJeM³ekeÀ Hee@efuemeer keÀes ef®eefvnle keÀjW)
Ke) mìe@keÀ keÀe efJeJejCe
ie) ke̳ee DeeHekesÀ Heeme keÀceerMeve Hej / efJeéeeme Hej mìe@keÀ nw : ³eefo neB, cetu³e
Ie) Iees<eCee keÀe DeeOeej
1) cenerves kesÀ Òel³eskeÀ efove Hej peesefKece keÀe cetu³e ³ee
2) cenerves kesÀ oewjeve DeefOekeÀ peesefKece cetu³e
petì / keÀe@ìve / keÀes³euee kesÀ mebûenCe kesÀ ceeceues ceW - mìesj keÀer ieF& DeefOekeÀlece cee$ee keÀe GuuesKe keÀjW
DeewÐeesefiekeÀ efJeefvecee&Ce FkeÀeF& kesÀ ©He ceW Òe³eesie nesves Hej, ÒemleeefJele DeJeefmLeefle Hej GlHeeoeW keÀe efJeJejCe oW ~
efJeefvecee&Ce meb³eb$e kesÀ ceeceues ceW ke̳ee GHe³eesie ceW ueeS pee jns / mebûeefnle (F¥Oeve kesÀ DeefleefjkeÌle) pJeueve efyebog 320C mes keÀce nw ~ neB / veneR
³eefo ogkeÀeve keÀer lejn GHe³eesie nw lees ke=ÀHe³ee Ieesef<ele keÀjW efkeÀ ke̳ee, mebûeefnle mìe@keÀ ceW veer®es oer ieF& met®eer ceW mes keÀesF& meeceeve Meeefceue nQ ~ ³eefo neB, lees ke̳ee
Fme ÒekeÀej kesÀ mìe@keÀ keÀe cetu³e, kegÀue mìe@keÀ cetu³e kesÀ 10% mes DeefOekeÀ nQ ? neB / veneR
1. mewu³etuee@³e[, 2. veeefj³eue peìe keÀe {sj, 3. HeìeKes Deewj DeeefleMeyeepeer, 4. Dev³e ÒekeÀej kesÀ efJemHeÀesìkeÀ, 5. Yetmee / eflevekesÀ, 6. meve, 7. petì keÀe {sj, 8. ceeef®eme, 9. cesLeeruesìs[ efmHeefjì, 10.
veeF&ì^es-mesu³etueespe HueeefmìkeÀ, 11. lesue / F&Lej / DeewÐeesefiekeÀ efJeuee³ekeÀ leLee 32 ef[ûeer Hej DeLeJee Fmemes keÀce Hej peue jns pJeueveMeerue lejue HeoeLe& (yebo keÀHe Hejer#eCe), 12. 32 ef[ûeer mes
keÀce kesÀ pJeueve efyebog Jeeues DeeOeej kesÀ pJeueveMeerue HeWì (yebo keÀHe Hejer#eCe) - meerueyebo efìve ³ee [^ce kesÀ DeefleefjkeÌle, 13. 32 ef[ûeer mes kesÀ pJeueve efyebog kesÀ JewefYeMewpe (yebo keÀHe Hejer#eCe) - [^ce Deewj
efìve ceW meerueyebo kesÀ DeefleefjkeÌle, 14. jesieeCegveeMeer leLee keÀerìveeMeer lejue HeoeLe& - meerueyebo efìve ³ee [^ce kesÀ DeefleefjkeÌle, 15. je@³eve HeÀeFyej meefnle Dev³e efkeÀmeer ÒekeÀej kesÀ meefype³eeW kesÀ HeÀeFyej ~
1
 The New India Assurance Co. Ltd.
(Government of India Undertaking)

Regd. & Head Office : New India Assurance Building, 87, M. G. Road, Fort, Mumbai - 400 001.
Service Tax No.
Mumbai Regional Office - I : New India Bhavan, 34/38, Bank Street, Fort, Mumbai - 400 023.
AAACN4165CST178

PROPOSAL FOR STANDARD FIRE AND SPECIAL PERILS POLICY

The Property is not covered until the risk is accepted and premium paid. In case the premium cheque is
dishonoured policy will be null and void ab-initio
Product Code 11 Office Dev. Officer Name : Code :
Risk/Rate
Code Broker / Agent Name : Code :

Hypothecation
Insured's Name
Registered Office
Address & Pincode
Risk Location
Address (Pincode is
mandatory)
Policy Period From To Time
Note : Do you have any other Fire Policy for this location : Yes/No. If Yes please provide Policy Numbers & Period :
Risk Details
Details of Property Covered with Sum Insured
Sum Insured (Rs.)
Location Occupied as Building Plinth & Plant & FFF including Stocks Stocks in Total
Foundation Machinery Electrical Process
including Installations
Electronic and
Other Office
Equipments
(Rs.) (Rs.) (Rs.) (Rs.) (Rs.)

Basement if any - Yes / No. No. of Storeys : Total Hight from ground level : metres
In case of multiple occupancy, specify floor occupied by the proposer
The basis proposed for insurance (Building / Machinery / Fumiture & Fittings)
Market Value Basis (Depreciated) Yes / No
Reinstatement Value Basis Yes / No
A) Please specify the type of Policy required in case of Stocks :
1) Stocks Declaration Policy
2) Floater Policy
3) Floater Declaration Policy
(Please tick type of policy required)
B) Description of Stocks
C) Are you holding goods held in trust / commission. If Yes, Value
D) Basis of Declaration
1) The average of values at risk on each day of the month or
2) Highest value at risk during the month
In case of storage of Jute / Cotton / Coal, the maximum quantity stored to be mentioned
If used as an Industrial Manufacturing unit, state the details of products manufactured at the location proposed
In case of Manufacturing Plant whether material having flash point below 320C in use / stored (other than fuel) Yes / No

If used as shop, please declare whether the stock stored include any Stocks appering in the list given below. If yes,
whether the value of such stocks exceed 10% of total value of stock Yes / No
1. Celluloid, 2. Coir Loose, 3. Crackers & Fire Works, 4. Explosives of any kind, 5. Hay / Straw, 6. Hemp, 7. Jute Loose, 8. Matches, 9. Methylated
Spirit, 10. Nitro-Cellulose Plastics, 11. Oils / Ether / Industrial Solvents and other inflammable liquids flashing at and below 32 Deg. C (Closed Cup
test), 12. Paints with inflammable base having flash point below 32 Deg. C (Closed Cup test) - other than in sealed tins or drums, 13. Vamishes having
a Flash point below 32 Deg. C (Closed Cup Test) - Other than in sealed tins or drums, 14. Disinfectant liquids insecticides - other than in sealed tins
or drums, 15. Vegetable fibres of any kind including Rayon Fibre.
2
1) ke̳ee mebHeefÊe keÀe Henues Yeer yeercee keÀje³ee ie³ee Lee ³ee Jele&ceeve ceW keÀje³ee ie³ee nw ? ³eefo Ssmee nw lees HetCe& efJeJejCe oW ~
2) ke̳ee efHeíues 4 Je<eeX ceW DeeHekeÀes Deefive ³ee mebyebefOele peesefKeceeW mes neefve ngF& nw ? HetCe& efJeJejCe oW ~
3) ke̳ee efkeÀmeer yeercee kebÀHeveer ves DeeHekesÀ ÒemleeJe keÀes DemJeerke=Àle efkeÀ³ee nw DeLeJee DeeHekeÀer Hee@efuemeer keÀes jÎ efkeÀ³ee nw ~ HetCe& efJeJejCe Deewj keÀejCe yeleeSb ~
efJemleejCe keÀer DeeJeM³ekeÀlee neB yeerefcele jeefMe
1 YetkebÀHe
2 DeelebkeÀJeeo
3 DeekeÀefmcekeÀ efJemHeÀesìve
4 Dev³e keÀesF& efJemleejCe (ke=ÀHe³ee GuuesKe keÀjW)
5
6

HeÀce& keÀer Hes[ - DeHe Hetbpeer - ©.

yeerceeOeejkeÀ Üeje Iees<eCee :
ceQ / nce ³ee Iees<eCee keÀjlee / keÀjles ntB / nQ efkeÀ Fme ÒemleeJe ÒeHe$e ceW cesjs / nceejs Üeje efo³ee ie³ee efJeJejCe cesjer / nceejer peevekeÀejer Deewj efJeéeeme kesÀ Devegmeej mel³e nw Deewj ceQ / nce mencele nQ efkeÀ
³en Iees<eCee cesjs / nceejs meeLe ``efo v³et Fbef[³ee SM³eesjbme kebÀ. efue.'' kesÀ DevegyebOe keÀe DeeOeej nesiee ~
efoveebkeÀ : ÒemleeJekeÀ kesÀ nmlee#ej
mLeeve : veece
yeercee DeefOeefve³ece 1938 keÀer Oeeje 41
ítì keÀe efve<esOe
1. efkeÀmeer Yeer J³eefkeÌle keÀes, Yeejle ceW efkeÀmeer Yeer mebHeefÊe ³ee peeveceeue kesÀ peesefKece mes mebyebOeerle yeercee Hee@efuemeer uesves DeLeJee veJeerkeÀjCe keÀjeves kesÀ efueS Òel³e#e ³ee DeÒel³e#e lejerkesÀ mes ÒeueesYeve mJe©He
HetCe& DeLeJee DeebefMekeÀ ítì osves keÀe ÒemleeJe keÀjves ³ee keÀceerMeve osves keÀer DeLeJee Hee@efuemeer Hej ÒeoefMe&le Òeerefce³ece Hej ítì osves keÀer Devegceefle veneR nw Deewj ve ner keÀesF& J³eefkeÌle pees Hee@efuemeer ues jne
nes ³ee veJeerveerke=Àle keÀje jne nes ³ee Hee@efuemeerOeejkeÀ nes, keÀes, Fme ÒekeÀej keÀer ítì ner mJeerkeÀej keÀjveer ®eeefnS DeefleefjkeÌle Gve ítìeW kesÀ pees yeerceekeÀlee& Üeje cegefêle efJeJejefCekeÀe keÀer met®eer kesÀ
Devegmeej Devegcele neW ~
2. keÀesF& Yeer J³eefkeÌle pees ieueleer mes Yeer Fme Oeeje kesÀ ÒeeJeOeeveeW keÀe GuuebIeve keÀjlee nw lees GmekesÀ THej DeLe&ob[ ueeiet nesiee efpemes HeeB®e meew ©HeS (500 ©.) lekeÀ Yeer efkeÀ³ee pee mekeÀlee nw~
kesÀJeue keÀe³ee&ue³e GHe³eesie kesÀ efueS
efoveebkeÀ : mLeeve : Hee@efuemeer mebK³ee :
efJekeÀeme DeefOekeÀejer / DeefYekeÀlee& / ye´eskeÀj keÀer mebmlegefle :
Devegceesove keÀjvesJeeues ÒeeefOekeÀejer :
Devegceesove mebK³ee : Devegceesove efoveebkeÀ :
efJeefMeä efìHHeefCe³eeB (³eefo keÀesF& nes lees) :
men yeercee efJeJejCe :
DeûeCeer DebMe
men yeerceeOeejkeÀ DebMe
Yegieleeve efJeJejCe efoveebkeÀ jeefMe yeQkeÀ pecee He®eea pecee efoveebkeÀ Dev³e efJeJejCe
®eskeÀ
vekeÀo
yeer peer / efveefOe DeblejCe

efkeÀmeer ÒekeÀej keÀer ítì oer ieF&

............................% Üeje Devegceesefole :
ceveesveerle yeerceeuesKekeÀ keÀe veece
Heo :
Devegceesove mebK³ee :
Jesleve mebK³ee :
nmlee#ej :
efoveebkeÀ :
3
1) Has the property been insured in the past or at the present time ? If so, give full particualrs.
2) Have you sustained loss by fire and allied perils during the last 4 years ? Give full particulars.
3) Has any Insurance Company ever declined a proposal from or terminated your policy. Give particulars and reasons.
Extension Required Yes Sum Insured
1 Earthquake
2 Terrorism
3 Spontaneous Combustion
4 Any other extension (Please specify the same)
5
6

Paid up Capital of the Firm - Rs.

Declaration by Insured :
I/We hereby declare that the statements made by me / us in this Proposal Form are true to the best of my / our knowledge and belief and I / We hereby agree
that this declaration shall from the basis of the contract between me / us and the "THE NEW INDIA ASUURANCE COMPANY LIMITED".
Date : Proposer's Signature

Place : Name

Section 41 of Insurance Act 1938

PROHIBITION OF REBATES
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 rebate 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.

FOR OFFICE USE ONLY

Date : Place : Policy No. :

Recommendations of Dev. Officer / Agent / Broker :

Approving Authority :

Approval No. : Approval Date :

Special Comments (if any) :

Coinsurance Particulats :
Leader Share

Follower Share

Payment details Date Amount Bank Deposit Slip Deposit Date Other Details

Cheque

Cash

BG/Funds Transfer

Type of Discount

............................% Approved by :

Name of the designated underwriter

Designation :

Approval No.

S. R. No. :

Signature :

Date :