Bajaj Allianz General Insurance Company Limited

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1 Bajaj Alliaz Geeral Isurace Compay Limited Regd. Office & Head Office : GE Plaza, Airport Road, Yerawada, Pue PROPOSAL FORM FOR OFFICE COVER Importat : This proposal for isurace will be the basis of ay subsequet isurace policy that we issue to you. It is essetial that you aswer fully ad accurately all of the questios cotaied i this proposal, ad that you provide us with ay ad all additioal iformatio relevat to the risk to be isured or our decisio as to the acceptace of the risk or the terms upo which it should be accepted. Your failure to comply with this obligatio ow may result i the rejectio of your claim ad the avoidace of your policy whe a claim is made. If you are i ay doubt about the iformatio to be give, please seek the advice ad guidace of your isurace advisor or aget. If there is isufficiet space i this proposal for you to provide relevat iformatio, whether as requested or otherwise, please attach a separate sheet to this proposal ad retur it to us. 1. Name of the Proposer : 2. Address : Phoe No. : 3. Locatio ad address of all premises to be covered : 1. (Please attach separate sheet, if required) Occupatio / Busiess Activity : Policy Period From : To : 6. Coverage Part (Please tick mark the Covers required ad aswer the relevat questios) COVER 1 A - BUILDING AND CONTENTS (EXCLUDING VALUABLES) Note: This sectio is compulsory. Please attach separate sheet wherever required. Moey ca be covered uder this sectio, if specifically metioed. a. Buildig: Costructio of Exteral Walls : Brick / Cocrete / Glass/ Asbestos / Others (Please specify) Costructio of Roof : Cocrete / Asbestos / Tiles / Others (Please specify) b. Age of the buildig : c. Is the Buildig owed by you? : Yes / No d. Are you the sole occupat of the Buildig? : Yes / No If o, who are the other occupats? Please give details : e. If you are the ower of the Buildig please idicate the sum To be isured : : Rs. (Please ote that the sum to be isured should represet the ew reistatemet value of the buildig) 1

2 f. Cotets (Please specify the sum to be isured for cotets) Item Sum to be Isured (Rs) Furiture, Fixture ad Fittigs Office Equipmets (Other tha Electroic Equipmets ad Portable Computers covered uder Sectio 7) Cash i safe or locked cupboard Other items (Please specify) g. Do you wish to cover the followig extesios? (i) Architects, surveyors ad Cosultig egieer's fees : Yes / No SI : (I excess of 3% of claim amout) (ii) Debris Removal Expeses : Yes / No SI : (I excess of 1% of the claim amout) (Please specify the required sum isured) COVER 1 B - TENANT'S LEGAL LIABILITY (The maximum liability of the compay will be restricted to 10% of the sum isured for Cotets uder Sectio 1A for ay oe accidet ad 25% i the aggregate durig the policy period) Do you wish to opt for this sectio? : Yes / No COVER 2 - BURGLARY & ROBBERY INCLUDING THEFT (Please ote that the sum isured for this sectio will be the same as that for cotets uder Sectio 1A other tha Moey.) a. Do you wish to opt this sectio? : Yes / No b. Please give break up of sum to be isured : Item Sum to be Isured (Rs) Furiture, Fixture ad Fittigs Office Equipmets (Other tha Electroic Equipmets ad Portable Computers covered uder Sectio 7) Cash i safe or locked cupboard Cash i Till /couter Other items (Please specify) COVER 3 - MONEY INSURANCE a. Please specify the locatios betwee which the trasit : Of moey to be covered? b. What is the Ay Oe Trasit Limit : c. How may trasits take place i a moth : d. What is the estimated Aual Trasit : e. What is the mode of trasit : f. Please specify security provided, if ay? : g. Whether casual employees are used for carryig moey? :

3 COVER 4 - PLATE GLASS a. Please provide brief details of the Plate Glass to be isured ad the value: Positio of each square of pae of glass Size of each square of plae of glass Height i cm Width i cm Descriptio of glass State whether plai, plate or plai sheet, silvered, embossed, staied, bet or orametal etc Value (Rs) Note: Please attach separate sheet if required. I the evet of a loss all glass is cosidered as plai ad of ordiary glazig quality uless specifically stated to the cotrary here ad i the schedule of the policy. b. Is there ay plate glass i the isured premises that is Not icluded i the above? : c. Is there at preset ay broke or damaged plate glass? : If Yes, please describe the positio ad size : Sr. No. COVER 5 - BREAKDOWN OF OFFICE EQUIPMENT Note: 1 Equipmets older tha 10 years caot be isured uder this sectio 2. The sum to be isured should represet the ew replacemet value of the same type of equipmet 3. Please add separate sheet, if required Descriptio of the equipmet Sr. No., Type ad Capacity of the Equipmet Year of Maufacture ad Name of Maufacturer Sum to be Isured (Rs) COVER 6 - BAGGAGE a. Please specify the limit to be isured per loss : b. Please specify the total limit durig the policy period : Sr. No. COVER 7A - ELECTRONIC EQUIPMENT Note: 1. Equipmets older tha 10 years caot be isured uder this sectio 2. The sum to be isured should represet the ew replacemet value of the same type of equipmet 3. Please add separate sheet, if required 4. Please specify the Exteral Data Media that you wish to isure. Descriptio of the equipmet Sr. No., Type ad Capacity of the Equipmet Year of Maufacture ad Name of Maufacturer Sum to be Isured (Rs) a. Please specify which of the equipmets are covered uder : Maiteace agreemet?

4 Sr. No. COVER 7B - PORTABLE COMPUTERS Note: 1. Computer older tha 10 years caot be isured uder this sectio 4. The sum to be isured should represet the ew replacemet value of the same type of computer 5. Please add separate sheet, if required Descriptio of the equipmet Sr. No., Type ad Capacity of the Equipmet Year of Maufacture ad Name of Maufacturer Sum to be Isured (Rs) COVER 8 - FIDELITY GUARANTEE A.Have there bee ay reported losses (whether isured or ot) due to fraud or dishoesty of employees, parters or directors durig the last five years? Yes/No. If yes please provide details (Please attach a separate sheet of paper if ecessary) Date Circumstaces Amout of loss (Rs) B. Details of Employees to be covered Category of staff No. of employees Employee Sum Isured (Rs) C a) Is there a requiremet of dual sigatories for issuace of cheques, ad is such requiremet met? b) Do the employees who receive cash ad cheques i the course of their duties issue pre-umbered official receipts as cofirmatio of the receipt? c) Are all the cash ad cheques received baked i daily or at the latest the ext bakig day? If o please specify d) Is there a imprest system for hadlig of petty cash fuds? If yes, please specify the persos who are authorised to maage the petty cash fuds. e) What is the system of operatio of Bak accout followed ad what are the precautios take? f) Whether such paymets/ withdrawals are authorized by a seior employee ad compared with supportig documets? D. a) How ofte are the bak recociliatios ad check of receipt couterfoils ad vouchers beig carried out? b) Uder what circumstaces will your customers qualify for credit privileges? c) How ofte is the balacig ad cotrol of debtor accouts with statemets set to all debtors? d) Are there stocks (of ay kid) kept for the coduct of your busiess? e) How ofte are stocktakigs coducted? f) Please list the persos resposible for carryig out stock-takig Yes / No Yes / No Yes / No Yes / No 5

5 E a) Please state the maximum amout of stocks each employee ca requisitio at ay oe time? Is this ever exceeded? b) Is there close supervisio of storage ad custody of all stocks maitaied? c) Are all deliveries to ad from stores properly authorised? F. Whe was the last stock audit udertake, by whom, ad what did it reveal? G. Whe was the proposer last audited, by whom, ad what did the audit reveal? COVER 9 - PERSONAL ACCIDENT Note: 1. Please attach separate sheet wherever required 2. The sum to be isured per employee to be restricted to..times the mothly salary 3. Please provide the details of the employees to be covered ad the cover opted. The maximum age is restricted to 60 years. 4. Please idicate uder the colum cover required: Part A for Death oly Part A & B for Death ad Permaet Total Disability Part A, B & C for Death, Permaet Total Disability ad Permaet Partial Disability Please add Part D if Temporary Disability is opted (available oly if A, B ad C are opted) Sr. No. Name of the Employee Mothly Salary Sum Isured (Rs) Coverage Required COVER 10 - PUBLIC LIABILITY Note: Liability uder Public Liability Isurace Act 1991 is ot covered Please select the limit to be isured Please select the limit to be isured i the aggregate per accidet : Rs. Has there or have there bee ay istaces of third party Bodily Ijury ad Property Damage i the past : Have you obtaied isurace for this cover with ay other isurer, ad if yes, please give details : : Rs. 10B. Workme's Compesatio 1. Name of employee mothly salary ature of work 2. Name of employee mothly salary ature of work 3. Name of employee mothly salary ature of work

6 COVER 11 - HOSPITAL CASH ALLOWANCE Do you opt for this cover? : Yes / No If Yes, please fill i the Aexure. Declaratios ad Warraty I/We hereby declare ad warrat that the above statemets are true ad complete i all respects ad that there is o other iformatio which is relevat to my applicatio for isurace that has ot bee disclosed to you. I/We agree that this proposal ad the declaratios shall be the basis of the cotract betwee me/us ad Bajaj Alliaz ad I/We agree to accept a policy, subject to the coditios prescribed by Bajaj Alliaz ad to pay premium o the amout estimated above at the ed of each policy period. I /We udertake to exercise all ordiary ad reasoable precautios for safety of the property as if it were uisured. I/We have read ad uderstood the Privacy Policy of your Compay ad I hereby ucoditioally agree ad bid myself to all terms ad coditios of your Privacy Policy, as ameded, from time to time. Date Proposer's Sigature Note : The liability of the Compay does ot commece util the proposal has bee accepted by the Compay ad the full premium paid SECTION 41 OF INSURANCE ACT, 1938 No perso shall allow or offer to allow either directly or idirectly as a iducemet to ay perso to take out or reew or cotiue a isurace i respect of ay kid of risk relatig to lives or property i Idia, ay rebate of whole or part of the commissio payable or ay rebate of the premium show o the policy, or shall ay perso takig out or reewig or cotiuig a policy accept ay rebate except such rebate as may be allowed i accordace with the published prospectuses or tables of the Isurer. Ay perso makig default i complyig with the provisios of this sectio shall be puishable with fie, which may exted to Five Hudred Rupees. FOR OFFICE USE ONLY Premium Calculatio : Total Premium : Rs. Discout for coverig more tha 4 Sectios : % : Rs. Net Premium : Rs. Service Tax : Accepted by : Date & Time : Policy No. :

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