* The forms consists of four pages KERALA STATE INSURANCE DEPARTMENT, THIRUVANATHAPURAM PROPOSAL FOR MACHINERY INSURANCE (The liability of the Department does not commence until this proposal has been accepted by the Department and premium paid) (Information given herein will be treated in strict confidence) PUT (V) MARK WHEREVER APPLICABLE (a) Proposer's Name (b) Proposer's Trade or Business (c) Proposer's Postal Address (d) Address where plant to be insured is located (e) Nearest Railway Station and Distance 1. Do the items listed represent the whole of the plant Yes No 2. (a) Are you at present insured ? (a) Yes No (b) If so, with whom ? (b) 3. Has any Company (a) Declined to insure any of (a) Yes No the machinery now proposed? (b) Required an increased premium or imposed special conditions? (b) Yes No (c) Requested for repairs or made other special stipulations for (c) risk improvement ? Yes No 4. (a) Are you aware of any defects/ damages existing in the machinery (a) Yes No (b) If so, give details thereof (b) 5. (a) Has your machinery sustained any damage from breakdown (a) Yes No or other cause during last 3 years ? (b) If so, give details of damages (b) and reparing cost 6. (a) Are regular periodical inspections of the Machinery carried out (a) Yes No (b) If so by whom and at what (b) intervals ? 7. On payment of addittional premium do If yes, provide limits you wish to cover : of indemnity (a) Express Freight (excluding (a) Rs...................................... airfreight), overtime and Holiday rates of wages (b) Owner's surrounding properity (b) Rs...................................... (c) Third pary Liability (c) Rs ...................................... 8. Period of Insurance From To SCHEDULE OF MACHINERY TO BE INSURED GUIDE NOTES : I. Each Machinery should be entered separately with necessary specifications as mentioned in Schedule Column No. 3. II. The sum Insured must be calculated on the present day new replacement Value of the Machinery to be insured including provision for packing, freight and also value of foundations, erection costs, customs duty, etc., to afford full protection under this Policy. III. If any of the Machine is a 'Standby' this fact should be mentioned. IV. All portable Machines must be so designated. All items in the open must be so described separately. V Separate value for foundations masonary and brickwork or oil in transformers and other electrical equipments are to be specified if cover is required. Sl. No. Quantity Description Type, Model, Capacity of Machine/ Serial No. HP/KVA Volts, AMPS, RPM Maker's Name & Country of Orgin Year of Make Sum Insured 1 2 3 4 5 6 I/We, the undersigned hereby declare that the above statements and particulars are true and complete and I/We declare and agree that this declaration and the answers given above shall be held to be promissory and shall be the basis of the contract between me/us and the Department. Place.............................................. Dated.............................................. Proposer's Signature Section 41 of Insurance Act 1938 : PROHIBITION OF REBATES (1) No person shall allow or offer to allow, either directly or indirectly 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 except, such 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 punishalble with fine which may extend to five hundred rupees.
