THE NEW INDIA ASSURANCE COMPANY LIMITED

Head Office : New India Assurance Bldg.

87,M.G. Road, Fort, Mumbai – 400 001

PROPOSAL FORM

Important:

1. The property proposed for insurance is not covered until the proposal is accepted
and premium is paid.

Policy Issuing Office Address & Code

Intermediary/Agent Name & Code (if any)

A. Details about Proposer and Policy Period:

1. Name of Proposer
2. Address of Proposer
3. Telephone No ( Landline)
4. Mobile No
5. Email
6. Contact person details, if not an
individual
a. Name
b. Designation
7. Policy to be Issued in favour of (list out all
the parties who have insurable interest)
including the financial
institutions
8. Period of Insurance From :

To :

CIN No: L66000MH1919GOI000526 1 IRDA Reg. No.190

B. Business and Location of Business:
9. Business of Proposer
10. Location of risk/business to be
covered - full postal address with SL Address Pin Occupancy Age Floor*
Pin Code No. code of
unit
1.
2.
3.
4.
*Floor: Ground Floor (GF) / Mezzanine Floor (MF)
/ Higher Floor
C. Details about business covered at the insured location

11. The Insured property is Please tick in the space below :

a. Offices, shops, hotels etc.
Yes / No
b. Industrial / manufacturing risks
Yes / No
c. Storage outside Industrial/ manufacturing
risks Yes / No

d. Tanks / gas holders outside industrial/

manufacturing risks. Yes / No

e. Utilities located outside

Industrial/manufacturing risks. Yes / No

f. Boundary wall
Yes / No
g. Basement storage
Yes / No

If, yes Value stored S.I. ₹………….

h. Others ( please specify)

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12. If used as warehouse / godown (not
Located in a manufacturing unit) please give
the list of goods stored.
13. If used as an Industrial Manufacturing unit give
products manufactured at the location
proposed(detailed block plan showing
various facilities to be enclosed wherever
applicable)
14. If used as an Industrial Manufacturing unit,
please state whether the factory is
working or silent?
15. Fire Protection devices installed Please Tick the correct answer in the
box below.

Portable Extinguishers
Small bore hose reels
Trailer Pumps/Fire engines
Hydrant System
Sprinkler System
Fixed Water Spray System
Foam System
Fire Alarm System
Gas Flooding System
Others, please specify below.

16. Indicate whether AMC( Annual

Maintenance contract) for the Fire Yes / No
Protection Appliances is in force :
17. Construction Details
a. Please state material used Please tick the correct answer in the box
i. Walls Kutcha / Pucca

ii.Floor Kutcha / Pucca

iii.Roof Kutcha / Pucca

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 Note:
Kutcha: Building(s) having walls and/or roofs of wooden planks/thatched leaves and/or
grass/hay of any kind/bamboo/plastic cloth/asphalt/ canvas/tarpaulin and the like are
treated as Kutcha Construction.
Pucca: Buildings other than Kutcha are treated as Pucca constructions.
b. Number of Floors
c. Age of the Building Less than 5
years
5-10 years
10-20 years
Above 20 years
18. Distance between the risk to be covered and
nearest Fire Brigade

19. Whether You have insured the same

property with any other Insurance Company
with the same type of coverage. (Give
details)

20. Whether Insurance was declined by any

other Company (Give details)

21. Premium / Claim details for the past 36 Year Premium Claim
months excluding the expiring policy period ₹ ₹
₹ ₹
₹ ₹
₹ ₹
₹ ₹
TOTAL ₹ ₹

D. Sum Insured and Other details of Insured Property

(Indicate Sum Insured on the following basis:
 For Building, Plant and Machinery, Furniture, Fixture and Fittings and other contents:
Reinstatement Value;
 For raw material: Landed Cost;
 For stock in process: Input cost;
 For finished stock: Manufacturing cost of the finished stock

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22. Description Building Plant & FFF Raw Stock in Finished Other Total
of Block including Machinery and Mat- Process Stock Contents
plinth, other erial (Please
Basement equipme specify)
and nt
additional
structures

I. Details of Floater Cover: Yes/No (strike off what is not applicable). If yes, give
details below:

23. Floater Cover (for stocks at Location (Postal Sum Insured (in ₹)
various locations) Address with Pin Code )

i) Maximum value at any one location: ₹……….

ii) Whether stocks stored in open: Yes / No

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 II. Details for Declaration Policy: Yes/No (strike off what is not applicable). If yes,
give details below :
24.
Stocks which fluctuate in value to be covered on (monthly) declaration basis:

Amount (₹)

[1] Policy will not be issued on short period basis

[2].Stocks in process & stocks stored at Railway sidings are not covered

F Additional covers [add-ons] offered with the Please tick in the space below :
policy [S.I. if specific]
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No

G. Premium Details

Mode of Payment
25. Payment Details
Amount

H. 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
form the basis of the contract between me/Us and the .

If any additions or alterations are carried out in the risk proposed after the submission of this
proposal form then the same should be conveyed to the insurers immediately.

Date:
Place: Signature of the Proposer
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