Proposal Form - Standard Fire & Special Perils Insurance

Transcription

1 Toll Free Number ( LTIN) Website Proposal Form - Standard Fire & Special Perils Insurance SMS LTI to (56070LT) GUIDELINES TO FILL THE FORM (Information given herein will be treated in strict confidence.) 1. Please fill the form in BLOCK LETTERS and leave one box blank between two words. All details marked with * are mandatory. 2. Please answer all the questions completely. If a particular question is not applicable to you and/or your business please mark that question as not applicable N/A. 3. Please attach extra sheets wherever the space is insufficient to provide the additional underwriting information. Put a ( ) mark wherever applicable. 4. You/Your wherever used in this proposal means the Proposer considered for this insurance 5. Kindly contact the Company's Office or Agent for any doubts or clarifications on the proposal form. Note: The liability of the Company does not commence until this proposal has been accepted by the Company and the premium paid. FOR OFFICE USE ONLY Branch Code : Intermediary Code : Intermediary Location Code : Intermediary Employee Code : Intermediary Reference Code : Sales Manager Code : PROPOSER INFORMATION Name of Proposer: F I R S T M I D D L E L A S T Correspondence Address: Block/Flat No.*: Floor No.: Building Name*: Street Name*: Locality: Landmark*: City/Village*: Pincode*: Post Office: PAN No.: Mobile No.*: ID 1*: ID 2: Bussiness of Proposer*: Landline*: S T D Policy to be issued in favour of (list out all the parties who have insurable interest) including the financial institutions. (Use extra sheet, if required) Location of risk to be covered - Address same as above: Yes No If not, please provide below (If there are multiple risk locations, use extra sheet) Block/Flat No.*: Floor No.: Building Name*: Street Name*: Locality: Landmark*: City/Village*: Pincode*: Post Office: Distance of Risk from place of water bodies (Approx K.M.): Distance of Risk from Fire Brigade (Approx K.M.): Is the Risk is in a low lying area? Yes No Period of Insurance: From To D D M M Y Y Y Y D D M M Y Y Y Y Would you like to delete any of following covers from the basic cover? Flood, Cyclone, group of perils Yes No Riot, Strike & Malicious Damage (RSMD) Yes No Do you want Terrorism Cover (applicable only if RSMD cover is opted) Yes No Would you like to cover Plinth & foundation along with your building? Yes No 1/6

2 ADD-ON COVERS REQUIRED Yes No Architects, Surveyors & Consulting Engineers Fees (in excess of 3% claim amount) Debris Removal (in excess of 1% claim amount) Deterioration of Stock in cold storage premises on account of Accidental power due to damage at power station due to an insured peril; Deterioration of stocks in cold to storage premises due to change in temperature arising out of loss or damage to the cold storage machinery(ies) in the Insured s premises due to operation of insured peril. Forest Fire Impact damage due to insured s own Rail/Road vehicle etc. Spontaneous Combustion Omission to Insure addition etc. Earthquake (fire and shock) Spoilage material cover Leakage and/or contamination cover (Please mention whether the tanks are within the propose s own premises or located elesewhere Temporary removal of stocks Loss of rent Additional expenses of rent for an alternate accommodation Start-up expenses Whether you have insured the same property with any other Insurance Company with the same type of coverage? Yes No If Yes, give details Premium/Claim details for the past 36 months excluding the expiring policy period Serial. No. Policy Period Premium Claims OCCUPANCY DETAILS The Insured property is: Residence, Office, Shops, Hotels etc. Yes No Shopping Malls/ Complex Yes No Located in Basement Yes No Industrial/Manufacturing risks Yes No Storage outside industrial risks Yes No Tanks/Gas Holders outside Industrial Manufacturing risks Yes No Utilities located outside Industrial manufacturing risks Yes No If used as shop please declare whether the goods handled as per the following list Yes No If Yes, whether stock will exceed 5% of shop value Yes No Celluloid goods Coir Loose Crackers & Fire Works Explosives of any kind Hay/Straw Hemp Jute Loose Matches Methylated Spirit Nitro-Cellulose Plastics Oils/Ether/Industrial Solvents and other inflammable liquids flashing at and below 32 O C (Closed Cup test) Paints with inflammable base having flash point below 32 O C (Closed Cup Test) - Other than in sealed tins or drums Varnishes having a Flash point below 32 O C (Closed Cup test) - Other than in sealed tins or drums, Disinfectant liquids and liquid insecticides - Other than in sealed tins or drums Vegetable fibres of any kind including Rayon Fibre. If used as warehouse/godown (not located in a manufacturing unit) please give the list of goods stored Are there any electrical connections inside the godown? Yes No (Provide details)... 2/6

3 Are there multiple insured s storages in the same location? (Godown) Yes No If used as an Industrial Manufacturing Unit give products manufactured at the location proposed. (Detailed block plan showing various facilities to be enclosed)... If used as an Industrial Manufacturing Unit, please state whether the Factory is working or silent? Yes No (If silent, since when?)... FIRE EXTINGUISHING APPLIANCES DETAILS Fire Protection devices installed List out the various blocks and indicate the type of protection provided for each block: Portable Extinguishers Yes No Small bore hose reels Yes No Trailer Pumps/Fire engines Yes No Hydrant System Yes No Sprinkler System Yes No Fixed Water Spray System Yes No Foam systems Yes No Fire alarm systems Yes No Gas flooding systems Yes No Indicate whether Annual Maintenance contract for the Appliances in force? Foam systems Yes No Fire alarm systems Yes No Gas flooding systems Yes No The basis proposed for insurance (Bldg, machinery, furniture, fixtures & fittings) Market Value basis Yes No Reinstatement Value Basis Yes No Whether escalation clause is required Yes No CONSTRUCTION DETAILS Construction Details - Please state material used Walls... Floor... Roof... Height of Building meters Age of Building Less than 5 years 5-10 years years above 20 years Note: Building having walls and/or roofs of wooden planks/thatched leaves and/or grass/hay of any kind/bamboo/plastic cloth/asphalt cloth/canvas/tarpaulin and the like are treated as Kutcha construction. Building wise values (Please include the Kutcha buildings also in this list and give individual values against such buildings) Description Amount in ` of Block Building Plinth & Plant & Furniture & Stock** Property Total Age including/ Foundation Machinery Fixtures and to be (Yrs) excluding (if to be other insured plinth covered equipments separately Ht (Mts) Construction Total **Indicates those stocks which are covered on normal basis and do not fall under, A,B,C, and D below SPECIAL COVERAGE DETAILS FOR STOCK Special Coverage for Stocks only A) On Floater Basis Stocks at various locations (warehouses/godowns and/or open etc.) can be covered on floater basis for a single Sum Insured. Floater Basis Yes No Amount `... B) On Declaration Basis Stocks which fluctuate in value can be covered on (monthly) declaration basis. Declaration Basis Yes No Amount `... Note: Minimum Sum Insured is Rs. 1 Crore, and policy not issued on short period basis Stocks in process & stocks stored at Railway sidings are not covered 3/6

4 Please state basis of declaration: Average of the highest value at risk on each day of the month highest value at risk during the month C) On Floater Declaration Basis Stocks which fluctuate in value as well as stored in various locations can be covered on (monthly) floater declaration basis. Floater Declaration Basis Yes No Amount ` Note: Minimum Sum Insured is Rs. 2 Crore Stocks in process & stocks stored at Railway sidings are not covered Please state basis of declaration: Average of the highest value at risk on each day of the month highest value at risk during the month D) Stocks stored in open Location Amount ` Stocks in open (located outside the factory compound) SUM INSURED DETAILS Total Sum Insured (as per relevant serial numbers shown against each) Sum Insured Premium (for office use only) Plinth & Foundation Architects, Surveyor s & Consulting Engineers Fees (in excess of 3% claim amount) Debris Removal (in excess of 1% claim amount) Deterioration of Stock in cold storage premises on account of Accidental power due to damage at power station due to an insured peril; Deterioration of stocks in cold storage premises due to change in temperature arising out of loss or damage to the cold storage machinery(ies) in the Insured s premises due to operation of insured peril. Forest Fire Impact damage due to insured s own Rail/Road vehicle etc. Spontaneous Combustion Omission to Insure addition, alteration, extension Earthquake (fire and shock) Spoilage material cover Leakage and/or contamination cover (Please mention whether the tanks are within the Insured s own premises or located elsewhere Temporary removal of stocks Start-up expenses Loss of rent Additional expenses of rent for an alternate accommodation Molten Material Damage Would you like to avail Discount for Voluntary Deductibles? Yes No If Yes, indicate the choice of Deductible amounts: ` 4/6

5 DECLARATION 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 L&T General Insurance Company Limited. 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. I/We authorize L&T General Insurance Company Limited to share my/our contact information like name, company name, address, phone number and id etc. relating to me / us, with their affiliate/group companies and also for communicating any promotional marketing offers and other transactional / features / products / services of L&T General Insurance Company Limited and its affiliate group companies via SMS Telephone Place:... Date:... Signature of Proposer PROHIBITION OF REBATES UNDER SECTION 41 OF INSURANCE ACT 1938 No person shall allow or offer to allow either directly or indirectly as inducement to any person to take out 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. Any person making default in complying with the provision of this section shall be punishable with fine which may extend to ` 500/- 5/6

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