UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE: NO 24 WHITES ROAD CHENNAI – 600 014
PROPOSAL FORM FOR PLATE GLASS INSURANCE
1 a) Name of Proposer (in full) a)
. b) Address b)
c) Business
2 a) Address of premises in which Glass is fixed a)
. b) Trade or Business carried on in the premises b)
3 Are the premises at the corner of a street or in an exposed
. position?
4 Is any of the Glass now broken?
. If so, describe its position and size.
5 Is the Glass insured at present?
. If so, for what amount(s) and with which Insurer (s)?
6 What breakages have occurred during the last twelve months
. and from what causes?
7 Has the Proposer ever made any claim for breakage loss of or
. damage to any Plate Glass? If so give below particulars.
Date of Details of breakage Name of Amount Amount to be recovered Rs.
Occurrence loss or damage Insurer Recovered Rs.
8 Has any Insurer in respect of any plate glass cover ever
. a) Declined a proposal from the Proposer, or
b) Cancelled or declined to renew any policy or
a)
c) Demanded or increased rate, or
d) Required any special terms to insure or grant any b)
renewal? c)
d)
9 Period of insurance From To
.
I / We hereby declare that the above statements and answers are true and correct and that no material
fact has been with-held, mis-stated or mis-represented and that I / We agree that this proposal and
declaration shall be the basis of the contract between me / us and
------------------------------------------- whose standard policy for the insurance proposed is acceptable to
me/us.
Place :
Date : Signature of the Proposer
Note: The liability of the Company does not commence until the Proposal has been accepted by the
company and the premium paid.
Section 41 of Insurance Act, 1938 – Prohibition of Rebates
a. 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 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 prospectus or tables of the Insurers.
b. Any person making default in complying with the provisions of this section shall be punishable with fine
which may extend to ten lakh rupees.
PROPERTY TO BE INSURED
State PARTICULARS AND DIMENSIONS
whether
Glass is Whether Plate or Sheet and Sum to
Size of each Pane
fixed in whether Plain, Silvered Embossed, Square be
No. of in Cms.
shop front, Curved, Stained, Lettered or Cms. insured
rear or side Panes Each Rs.
Ornamented or more than 1/4 in.
or door Height Width Pane
thick
Total ….
Note: In the event of a loss All Glass is considered plain and of ordinary glazing quality unless the
CONTRARY is specially named in the Policy. No Lettering, Embossing, Silvering or any Ornamental
work is considered insured unless named on the Policy and the additional premium paid thereon. No
insurance is granted in respect of glass not completely and securely fixed.
