THE NEW INDIA ASSURANCE COMPANY LIMITED

Registered & Head Office- 87, M.G. Road, Fort, Mumbai-400001.

PROPOSAL FORM FOR MULTI PERILS INSURANCE FOR LIQUIFIED PETROLEUM GAS DEALERS

This Multi-peril Insurance Policy has been specially designed to meet the Insurance
requirements of LPG Dealers. The Scheme provides for as many as 12 coverages covering almost
all the needs of LPG Dealers. Please note that this cover cannot be given where the value of
property at risk (including building) exceeds Rs. Five lacs, at the rate of 2.5%o but allowed at 5.5%o
for exceeding Rs. Five lacs.

It is not obligatory for a proposer to take all the 12 coverages available under this policy.

The option of selecting coverages is subject to the following :-

i) Fire Risk under section I and Burglary and Housebreaking cover under Section II is
compulsory.

ii) 10% discount will be given if 3 non-tariff sections are taken and 15% discount if 4 non-tariff
sections are taken and 20% if more than 4 non-tariff sections are taken.
This discount is available on non-tariff portion of the premium only. The cover under
sections I & VIII are tariff covers.

iii) The Sum Insured is fixed in some cases. In other cases the proposer is free to choose the
Sum Insured at his discretion; however, subject to maximum as shown below :

Section Premium Rate (Rs.%0 ) Risk Covered Max. Sum Insured

I Risk of Fire & Allied Perils Fire, Riot, Strike & Malicious
(For Building & Contents) damage, Air craft damage,
[ (Rs.2.50%o+Above Rs.5 Impact damage, Earthquake Rs. 5 lacs
Lacs- As per fire tariff) + Fire & Shock damage, Flood + Extra as indicated
Terrorism Extra @ Rs. & Storm damage. Above.
0.50%o,If taken)]

II Burglary and House Theft involving violent & First Loss Basis 25%
Breaking (Contents) forcible entry into the of the value of the
[ Rs. 3%o] premises/exit from the property at risks.
premises.
 Gas Cylinders in transit Loss of or damage to gas Rs.15,000/- per claim
III [ Rs. 10%o ] cylinders whether filled or and Rs.30,000/- per
empty by theft whilst the gas annum.
cylinders are in the hands of
insured/insured’s employees
and in transit between
insured’s premises &
customers’

IV Cash-in-Transit a) Loss of money whilst Rs.50,000/- per

[ Rs. 10%o ] in transit between any transit (other than
two places within a delivery boys)
radius of 25 Kilometers Rs.5000/- for delivery
from the insured boy/s
premises.
b) Loss of money by Rs. 25,000/-
Burglary or
Housebreaking whilst
contained in locked
safe or fixed
immovable cash box in
the insured premises.
c) On counter Rs. 5,000/-

V Fidelity Guarantee Employee’s Act of forgery Rs.20,000/- per

[Rs.10%o] embezzlement, larceny or named employee.
fraudulent conversion of
moneys or Gas cylinders

VI Pedal Cycle/Tri Cycle Loss or damage by accidental Market value of

[ Rs.10%o] external means. Pedal cycle/tri cycle
T.P. Liability Rs.10,000/-
 Public Liability “Indemnity against legal Rs.10,00,000/- per
[Rs.3%o or AOY Limit + liability in respect of claims by event Rs.40,00,000/-
Rs.0.10%o on Turnover] the Public for bodily injury per policy period.
and property damage during
installation of Gas cylinders
or whilst they are carried for
installation at the customer’s
residence and at Insured’s
premises.”

VIII Workmen’s Compensation Death or bodily injury to As per W. C. Act,

As per Tariff Insured’s employees in Fatal Accident Act
connection with handling and and Common Law.
delivery of Gas cylinders
arising out of and in the
course of employment.

IX Personal Accident Partner, Proprietor, Director For named persons

[As per P.A. Guidelines] or Office Staff only as per Table
chosen under
P. A.. Coverage
X P.A. Benefit to customers Death or permanent Rs.15,000/- per
[Rs.300/- per 1,000 customers disablement benefit to any customer as per P.A.
or customer or member of his Scale.
Rs.30/- per 1,000 cylinder] family or any other person in
the premises arising out of
accident in connection with
use of L.P.G. Cylinders.
XI Accidental breakage of Plate Breakage Rs. 5,000/-
Glass [Rs.40%o]
XII Damage to Neon sign/Glow Accidental Damage Rs. 10,000/-
sign [Rs.15%o]

NOTE : THE FOREGOING IS ONLY A BROAD INDICATION OF THE COVER OFFERED. FOR
DETAILS PLEASE REFER TO ANY OFFICE OF THE COMPANY.

PROHIBITION OF REBATES :
The following is the copy of Section 41 of the Insurance Act, 1938 :
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 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 be extended to Five Hundred Rupees.
 THE NEW INDIA ASSURANCE COMPANY LIMITED
Registered & Head Office- 87, M.G. Road, Fort, Mumbai-400001.

PROPOSAL FORM FOR LIQUIFIED PETROLEUM GAS DEALERS POLICY

1) Name of proposer in full :

(IN BLOCK LETTERS)

2) Address of the Business premises :

3) Period for which Insurance is

Required : From ___________To_________

4) Have you previously held any

insurance in respect of any of the
risks proposed for insurance. If
yes, give details. :

5) Have any insurance company ever

a) declined your proposal? :
b) Refused to renew or cancelled
the policy? :
c) Imposed any special conditions/
Limitations.

SECTION I
FIRE AND ALLIED RISK (BUILDING & CONTENTS) INSURANCE

1. Nature of trade or business : _______________

2. Property to be insured Sum to be Insured Showroom Godown
Items Items
2 to 7 2 to 7

i) Building – Godown/showroom i) Rs.

ii) Stock in trade including cylinders
in Godown/Showroom ii) Rs.

iii) Furniture, fixture & fittings in Godown/ iii) Rs.

 Showroom.

3. Construction : State materials used e.g.

concrete or bricks, iron sheets or timber
etc.
a) Walls
b) Roof
c) Floor
4. State whether premises solely occupied by the proposer.
If not, give details of other Occupants and trade carried on

5. State whether the building is completely detached on all

four sides, if not give particulars of how attached.

6. Have you insured your Building and contents/stock-in-trade

elsewhere, if so, state i) name and place of issuing office
ii) Policy No. iii) period iv) sum insured.

7. Addresses of Showroom and Godown

SECTION II
BURGLARY AND HOUSEBREAKING
Showroom Godown
1. Property to be insured Value Items 1 to 4 item 1 to 4
Sum Insured
25% of value

i) Stock in trade including cylinders

In attached godown i) Rs.

ii) Furniture, fixture and fittings ii) Rs.

N.B. : The Sum Insured is on First Loss Basis for an

amount equivalent to 25% value to the Property at risk.

2. Are all doors protected by lock/locks?

3. Are all windows protected by bars?

4. Do you keep daily sales and purchases
invoices and other books of accounts?
 SECTION III
GAS CYLINDERS IN TRANSIT

1. Maximum No. of cylinders carried at any one time.

2. Mode of carriage
3. Value of cylinders.
i) Gas filled cylinders
ii) Empty cylinders
4. Maximum distance between the Proposer’s
premises and the Customer’s premises/house.

5 Are the cylinders carried during normal office

hours or beyond office hours also. If they are
carried beyond office hours also, please state
upto what hours they are carried ?

6. Who authorizes issue of cylinders to customers?

SECTION IV
CASH IN TRANSIT

1. How is money carried and between what hours? :

2. How many employees will carry money at a time? :

3. State per transit limit other than delivery boys. :

4. State per transit limit if delivery boys. :

5. Whether money collected are retained in the

proposer’s premises ? :
If so, where and what arrangements are made
for their safety?

6. Insurance required for cash in safe /fixed cash box : Rs.

on counter : Rs.

7. Particulars of the safe

i) Measurement of safe/s
a) Height
b) Width
 c) Depth
d) Weight
e) Makers Name
ii) Is it marked burglary resisting?

SECTION V
FIDELITY GUARANTEE

Name of Employee Designation & Total Monthly Amt. of guarantee

nature of duties remuneration per employee
Rs.

1)
2)
3)
4)
1. How often & by whom are your cash
and Bank balances agreed, entries in
cash books verified with vouchers and
stocks checked ?

2) Are the books audited by an independent

auditor and if so, how often ?

3) Has/have the proposed employee/s been

suspected of dishonesty in the past?

SECTION VI
PEDAL CYCLE/ TRI CYCLE
Maker & Name of Year of Mfg. Frame No. Accessories Estimated
Manufacturer attached, if any present value

1)

2)

3)

SECTION VII
PUBLIC LIABILITY INSURANCE

1. State the existing number of customers

the proposer has and the number
 estimated to be included during the
year.

2. Are the gas filled cylinders tested for

leakage before delivery to customers ?

3. Whether the employees carrying cylinders

are trained on safety methods for
installing gas cylinders.

4. Amount of indemnity desire | ANY ONE ACCIDENT RS.____________

ANY ONE YEAR RS._____________

ANNUAL SALES TURNOVER RS._____________

SECTION VIII
WORKMEN’S COMPENSATION
Name of Employee ( s ) Nature of work Monthly wages

SECTION IX
PERSONAL ACCIDENT FOR
PROPRIETORS/PARTNERS/EMPLOYEES

Name Age Details of Occupation Table of Name of Assignee

existing Benefits and Relationship
infirmity/
disability
(For assignment of benefit please use prescribed form.)
SECTION X
P.A. BENEFIT TO CUSTOMERS
1. Are you interested in covering your
customers for personal accident Risk YES/NO

2. Please state how many customers you

are servicing ?
3. Please also state Number of cylinders
sold domestic/industrial.

SECTION XI
ACCIDENTAL BREAKAGE OF PLATE GLASS

1. Please give the details of glasses :

Sr.No. Type No. of Size Position Estimated

(i.e. Plate/ Squares each where Replacement
Sheet/Plain etc. square fixed value

2. Is any of the glasses proposed for :

Insurance scratched, damaged or
Insecurely fixed ? If yes, give full
Details.

SECTION XII
LOSS OF OR DAMAGE TO NEON SIGN / GLOW SIGNS

1. Please give the particulars of Signs :

Sr.no. Description of Situation Date when Date when Estimated

Signs created last inspe- replacement
cted and by
whom

2. Are the signs in good state of repair

and will be so maintained ? :
 DECLARATION

I do hereby declare that all the information given and statements made above are true and
complete and that I have withheld no information whatever regarding the insurance applied for
therein. Further, I declare that the premises are in sound condition and 9n a good state of repair and
they are not specifically exposed to the risk of fire, or theft. Further I also declare that the premises
will not be left uninhabited for more than a continuous period of SEVEN days. I also declare that
aggregate value of the Building and contents/stock in trade relevant to Section of the cover does not
exceed Rs. whether insured under one or more policies or whether issued by one or
more officers of the subsidiaries.

I further agree that this Declaration and the information given and statements made above by
me or any one acting on my behalf, shall form the basis of the contract between me and the
Company and I further agree to accept Indemnity subject to the conditions in and endorsed on the
Company’s Policy.

PLACE :

DATE : PROPOSER’S 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. Insurance is the subject matter of solicitation.
4. Premium will be quoted on application.

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.
.