8/12/2019 Liquid Petroleum Gas Proposal Form

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UNITED INDIA INSURANCE COMPANY LIMITED

LIQUID PETROLEUM GAS DEALERS COMBINED POLICY

PROPOSAL FORM

IMPORTANT INFORMATION

PLEASE COMPLETE CLEARLY IN BLOCK LETTERS. SUM INSURED TO BE GIVEN IN INDIAN RUPEES ONLY.1. Proposers Detai sProposers !" Na#e$

Na#e o% !i&a&'i&( Ba&)$

!" B"si&ess *S+op , A--ress$Go-o & A--ress $Pi& 'o-e$Te ep+o&e No$Mo/i e No$E0#ai a--ress$Date o& +i'+ i&s"ra&'e is to 'o##e&'e$ !ro# To

Cover Required +et+erre2"ire- S"# I&s"re- i& INRSection Des'riptio& o% Propert3 I&s"re-

IFire ! A""iedPeri"#

10 S$o% Cu& Godo'n a, B"i -i&( *O% C ass A Co&str"'tio& o& 3,/, Co&te&ts it+i& S+op0'"#0(o-o & *E4' "-i&( Mo&e3 5 Va "a/ es, i, Sto') i& Tra-e ii, !"r&it"re6 !i4t"res 5 !itti&(s

T$i##ection i#

&(nd(tor)

II0 S$o% ! Godo'n Se%(r(te") "oc(ted $A* GODO+N E,CLUSI-ELYa, B"i -i&( *O% C ass A Co&str"'tio& o& 3,/, Co&te&ts it+i& Go-o & *E4' "-i&( Mo&e3 5 Va "a/ es, i, Sto') i& Tra-e ii, !"r&it"re6 !i4t"res 5 !itti&(sTota $

B* S.OPa, B"i -i&( *O% C ass A Co&str"'tio& o& 3,/, Co&te&ts it+i& S+op *E4' "-i&( Mo&e3 5 Va "a/ es, i, Sto') i& Tra-e ii, !"r&it"re6 !i4t"res 5 !itti&(s

IIBur/"(r) ! .ou#eBre(0in/

Co&te&ts *E4' "-i&( Mo&e3 5 Va "a/ es,1. I& t+e S+op0'"#0(o-o &7. *a, I& Go-o &

*/, I& S+op

The Sum Insured of contents under Section II should beequal to Sum Insured under Section I for Contents

Yes 8 No

IIIG(# C)"inder# inTr(n#it

Co9er is o& 3 i& respe't o% '3 i&-ers 'arrie- o"tsi-e t+e pre#ises -" 3 a"t+ori:e-/3 t+e i&s"re-$

a. Lia/i it3 %or A&3 O&e A''i-e&t8e9e&t0 Rs. 7;6

8/12/2019 Liquid Petroleum Gas Proposal Form

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SECTIONS I6 -II ! -III ARE COMPULSORY IN OT.ER SECTIONS6 789 SECTIONAL DISCOUNT ISA-AILABLE IF : TO ; SECTIONS ARE OPTED AND ?@PRO.IBITION OF REBATES

7. No perso& s+a a o or o%%er to a o eit+er -ire't 3 or i&-ire't 3 as a& i&-"'e#e&t to a&3 perso& to ta)e o"t or re&e or'o&ti&"e a& i&s"ra&'e i& respe't o% a&3 )i&- or ris) re ati&( to i9es or prope rt3 i& I&-ia a&3 re/ate o% t+e +o e or part o%t+e 'o##issio& pa3a/ e or a&3 re/ate o% t+e pre#i"# s+o & o& t+e po i'3 &or s+a a&3 perso& ta)i&( o"t or 'o&ti&"i&( apo i'3 a''ept a&3 re/ate e4'ept s"'+ re/ate as #a3 /e a o e- i& a''or-a&'e it+ t+e prospe't"s or ta/ es o% t+e I&s"rer.

=. A&3 perso& #a)i&( -e%a" t i& 'o#p 3i&( it+ t+e pro9isio&s o% t+is Se'tio& s+a /e p"&is+a/ e it+ %i&e6 +i'+ #a3 e4te&-

to Rs.;