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   Fire Insurance Proposal Form (for corporate Sector Only)

1. Name of Proposer
2. Address
3. Telephone No.
4. Cellular No.
5. Fax No.
6. Risk Address
7. Nature/Type of Business
8. Period From
  To
9. Interest to be insured  
(A)    Building(excluding,plinth,
   foundation and pavment)Rs.
                  (B) Machinery .
                  (C) Stock in Process Rs..
                  (D) Stock Rs..
                  (E) Furniture,Fixture and Fittings.
                  (F) Total Sum To be insured in Rs
10. Risks to be Insured Please Tick Y/N
 
  • Fire
Yes No
 
  • Explosion
Yes No
 
  • Riot and Strike
Yes No
 
  • Atmospheric Disturbance
Yes No
 
  • Earthquake Fire and Shock
Yes No
 
  • Air Craft Damage
Yes No
 
  • Impact Damage
Yes No
 
  • Malicious Damage
Yes No
 
  • Burglary
Yes No

11. Existing Insurer name
12. Expiry Date of existing Insurance
13. Claims experience (Past 3 years)

Declaration
 
I       being desirous of effecting an insurance with Central Insurance Co.Ltd do hereby declared that the above statements are true and complete and I have not concealed anything material to be known to the company that the sums set out above approximately represents the full value of the property to be insured and I hereby agree that this proposal and declaration shall be the bases of contract between me and Central Insurance Co. Ltd, and that I am willing to accept a policy subject to the provisions prescribed by the company and expressed in the policy.
  
  Date Name
  Liability does not commence untill the proposal has been accepted by the company and the premium paid