The New India Assurance Company Limited

Head Office: 87, M G Road, Fort, Mumbai-400001

PROPOSAL FORM FOR ALL RISKS INSURANC

SCOPE OF COVER This Insurance Policy provides cover against Loss or Damage to Gold and Silver Ornaments, Jewellery, Watches, ameras and other valua!les due to "ire, The#t or $ccident #rom any "ortuitous cause, anywhere in India e%cept as detailed !elow & EXCLUSIONS The Insurance Policy does not cover &' (a) Loss or damage arising #rom War, War li*e operations, ivil ommotion, Terrorism, Depreciation, wear and tear, moth, mildew, vermin, the process o# cleaning, dyeing, repairing, overwinding o# cloc*s and watches, mechanical derangement, electrical !rea*down, !rea*age o# glass, china and articles o# !rittle nature, the#t #rom unattended vehicles, detention or con#iscation !y ustoms or other $uthorities and conse+uential loss, (!) -oney, Securities, -anuscripts, Deeds, .onds, .ills o# /%change, Promissory 0otes, Stoc* or Share erti#icates, Stamps, .usiness .oo*s and documents, articles dispatched under contract o# a##reightment

T1/ "O2/GOI0G IS O0L3 $ .2O$D I0DI $TIO0 O" T1/ O4/2 O""/2/D, "O2 D/T$ILS PL/$S/ 2/"/2 TO $03 O""I / O" T1/ O-P$03 This type o# Insurance is also availa!le under Section III o# 1ouseholders Policy 0OT/ & PL/$S/ $0SW/2 /4/23 56/STIO0 $0D "6LL3 7, (a)
(!)

0ame o# Proposer in "ull (In .LO 8 L/TT/2S)

2esidential $ddress

(c) ;,

Occupation 9 Pro#ession : $ddress

Paid 6p apital (i# applica!le) &

Property to !e insured

S2 0O, I0S62/D 2S,

"6LL D/S 2IPTIO0 O" P2OP/2T3

S6-

(-a*e9Weight9 arritage93r, O# -#g,9Type9-odel, etc,)

(Ensure that the property is correctly described and insured for full value to get adequate Indemnity)

<, 1as Jewellery !een recently e%amined and valued !y an approved 4aluer= I# so, #urnish the 4aluation erti#icate, >>>>>>>>>>>>>>>>>>>>>>>>>>>>> ?, Whether cover is also re+uired out'side India, I# yes, give details & >>>>>>>>>>>>>>>>>>>>>>>>>>>>> @, Is the ris* currently insured against "ire, The#t or $ll 2is*s= I# so, please state& >>>>>>>>>>>>>>>>>>>>>>>>>>>>> (a) 0ame o# the ompany >>>>>>>>>>>>>>>>>>>>>>>>>>>>> (!) Policy 0o, : Period A, (a) 1ave you su##ered any loss or damage >>>>>>>>>>>>>>>>>>>>>>>>>>>>>> to Jewellery and9or valua!les in the past= (irrespective o# whether insured or not) (!) I# so, give #ull details thereo# as under >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Date o# Occurrence Details o# Loss $mt, o# Loss 2s, 0ame o# the Insurers

B, 1as any ompany in respect o# $ll 2is*s Insurance

(a) Declined your Proposal = >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> (!) ancelled or re#used to renew your Policy=>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> (c) $ccepted your proposal on special terms :>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> conditions= Period o# Insurance "2O- >>>>>>>>>>>>>>>>>>>> TO>>>>>>>>>>>>>>>>>>>>>

I9We do here!y declare that the a!ove statements and answers are true and that I9We have not withheld any in#ormation whatsoever regarding the proposal, I9We agree that this proposal and declaration shall !e the !asis o# the contract !etween me9us and The 0ew India $ssurance o, Ltd,, whose Policy #or the Insurance proposed is accepta!le to me9us, I9We underta*e to e%ercise all ordinary and reasona!le precautions #or sa#ety o# the property as i# it were uninsured, PLACE : DATE: Signature of Proposer
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.

<, Insurance is the su!Cect matter o# solicitation, ?, Premium will !e +uoted 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 !ny person making default in complying with the provisions of this section shall be punishable with fine which may extend to "ive #undred $upees FOR OFFICE USE -

-$28/TI0G 9 D/4/LOP-/0T O""I /2DS 2/PO2T

The Proposer is known to me/my agent / Broker for___years and I recommend acceptance of this proposal. Name and Code No.
ACCEPTED BY DATE & TIME RATE CODES - OFFICE /DEV. OFFICER / AGENT /BROKERCOLLECTION / SCROLL NO POLICY NO.

Signature of Dev. Officer / A/AO-D

REMARKS