Form: A1 NATIONAL INSURANCE COMPANY LIMITED GUWAHATI REGIONAL OFFICE APPLICATION FO RM FOR REGISTRATION UNDER CENTRAL COMPREHENSIVE INSURANCE SCHEME, 1997 (CCIS, 97) (This Form duly completed to be submitted along with the necessary documents with respective DI & CC). 1.1 Name of the Industrial unit : 1.2 Office Address with telephone No : 1.3 Factory address with telephone No : 2.1 Constitution of the unit (whether : proprietorial / partnership/private Ltd/Limited company/co-operative. 2.2 Names(s) & address(es) of the proprietor : /Partners/directors/secretary & presidents Of the Co-operative society/trustee 2.3 Date of registration under the companies : Act/ the concerned Act including the Act 2.4 Registered Head Office of the Company : 2.0 Details of registration of the Unit : 3.1 SSI Registration: a) Provisional Regn. No. : b) Permanent Regn.No. : 3.2 Large & medium : No. and date of Industrial Licence/ Letter of Intent/Industrial Entrepreneurs Memorandum. 4.1. Date of commencement of commercial : Production. 4.2 Whether the Unit was set up after : 24.12.97. 4.3 What is the percentage of investment : Upto 24.12.1997. 4.4 Whether the new unit is undergoing : Expansion, if so proposed date of commission Of expansion part. 5.0 Actual Capital Investment: Upto 24.12.1997 After 24.12.1997. (Capitalised Value) ( Rs ) _____ (Rs) 5.1 (a) Cost of land (b) Cost of Site Development (c) Cost of Boundary Wall 5.2 Buildings: (a) Office (b) Factory 5.3 Plant & Machinery 5.4 Accessories 5.5 Cost of Electrical Installation 5.6 Cost of Erection/Installation 5.7 Miscellaneous fixed assets Total : 5.8 Whether a Certificate from a : Registered Chartered Accountant (which needs to be enclosed) on Capital Investment is attached. 6.0 Means of Finance : 6.1 Whether availed Central Capital : Investment Subsidy Scheme, 1997. 6.2 If yes, name the Financial Institution : Through which subsidy availed. 6.3 Whether the subsidy is availed as a : New unit or expanded unit. 6.4 If Capital Subsidy is not availed/ : granted specify the reason thereof. 7.0 Power 7.1 Date of sanction of power & load. : 7.2 Connected load & date of connection : 8.0 Details of Production of the New Unit : 8.1 Give brief details of the manufacturing : process of the unit (a separate sheet may be attached, if required) 8.2 Name of the Product(s) Installed Annual Actual Annual (yearwise) Production capacity 11. Declaration: I/we hereby solemnly declare that the information furnished in this application for the grant of registration under the Central Comprehensive Insurance Scheme, 1997 are correct and true to the best of my/our knowledge and belief. Place: Date: Signature of the applicant(s) Status in relation to the Industrial Unit Seal: ENQUIRY REPORT: Certified that I have personally visited the above mentioned industrial unit land examined the relevant documents presented to me and found correct. Further certified that in the absence of proper information/documents, the information furnished in their application against item nos. ____________ could not be verified properly and to the best of my knowledge except item nos. ________ given below with proper correction. Items: 1. 2. 3. Date: Signature of the Enquiry Officer, Place: Designation: O R D E R The application has been accepted for Registration as New Industrial Unit under the Central Comprehensive Insurance Scheme, 1997, for reimbursement of Fire Insurance premium and the allotted Registration number is __________ dt. ________ and the same is communicated to the party vide this office letter No. _______ dt. ________ Signautre of the General Manager DI &CC: Seal: Attested/Certified copies of the following documents to be submitted alongwith the application Form with DI &CC for registration under CCIS, 1997. List of Documents: 1.0 Constitution of the unit: 1.1 In case of partnership: Registered Deed of partnership with General Power of Attorney. 1.2 In case of Private Limited/Public Limited company: (a) Registration Certificate under the Companies Act , (b) Memorandum & Article of Association, and (c) Name of Board of Directors. 1.3 In case of Co-operative Society: (a) Resolution of the General Body for registration of the Unit, (b) Registration certificate from Registrar of Co-operative, and (c) Memorandum & Article of Association. 2.0 Registration Certificate from the District Industries & Commerce Centre (provisional & Final) and, if any, LOI/IL/IEM etc. 3.1 Title of the Landed Property or Lease Deed 3.2 Sanctioned Plan & NOC of the Factory Buildings. 4.0 Power: (a) Power sanction letter (b) First Bill of Electricity 5.1 List of Plant & Machinery with its capitalised values 5.2 List of Buildings and Civil works. 6.0 Any other documents required by the concerned authority.
