KERALA STATE INSURANCE DEPARTMENT, THIRUVANANTHAPURAM. Questionnaire and Proposal for Electronic Equipment Insurance Policy (The liability of the Department does not commence untill proposal has been accepted by the Department and premium paid) PUT - A ( 3) MARK WHEREVER APPLICABLE 1. Name and address of Proposer : Type of business : Location of equipment to be Insured (address of building storey) : Structure of building Steel skeleton Brick work Concrete Wood 2. Has any of equipment to be insured previously been covered by other Insurance Companies? Yes No If yes, which items of thespecification and by which Companies? State when the Insurance is to commence? Date: Time : Period of the Insurance to expire at the same date and time next year 3. Is all the equipment to beinsured new? Yes No if not, which items of the specification are second hand? What equipment can still be obtained ex works? State items of the specification 4. Condition of equipment Is the equipment maintained in accordance with the Manufacturer's Instructions? Yes No 5. Quality of Staff Have Operators been trained with manufacturer? Yes No 6. Is there a risk or flood and Inundation? Yes No If so, by--Bodies of water Torrential rainfall Sewer backflow Other Yes No so specify Prepared or sensitized papers. Acids 7. Are dangerous materials Dyes Test solutions Developers used in the vicinity ? Explosives Isotopes Others We hereby Declare that And we hereby agree It is agreed that the The Insurers undertake the statements made by that this Questionnaire insurers are liable in to deal with this us in this Questionnaire and Proposal forms accordance with the information in strict and Proposal are to the the basis and is part terms of the policy confidence. best of our knowledge of any Policy issued in only and that the insu and belief, complete connection with the red will not lodge any and true. above risk (s) other claims of what ever nature. Executed at ............................................. this ................................... day of ........................ 20...... Signature of Proposer
