ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED.

Regd. Office : ICICI Towers, Bandra Kurla Complex, Bandra (East), Mumbai – 400 051

Tel: (+91 22) 653 1414 Fax : (+91 22) 653 1657

Marketing Officer:
Branch Address:
Phone #:

Business Sector: Urban Rural Social

Proposal Form No :

Group I.D. No :

Client I.D.No :

GUIDELINES FOR COMPLETION OF THE FORM

1.  Please answer all questions fully and correctly. Where any question does not apply, please mention clearly that the same is not applicable.

  1. Insurance is a contract of Utmost Good Faith requiring the Insured not only to disclose all material facts but also not to suppress any material facts in response to the questions in the proposal form. If you think any fact is material, please disclose it.
  1. The Policy shall become voidable at the option of the Insurer, in the event of any untrue or incorrect statement, misrepresentation, non-description or non-disclosure in any material particular in the proposal form/ personal statement, declaration and connected documents, or any material information having been withheld by the proposer or any one acting on his behalf.
  1. Kindly contact the Company’s Offices or the Agents for any doubts or clarifications on the proposal form.

NOTE

The liability of the Company does not commence until this proposal has been accepted by the Company and premium paid.

SCOPE OF COVER

The Insurance Policy broadly covers loss of Money[1] in transit by the Insured or Insured’s authorized employee(s) occasioned by robbery, theft or any other fortuitous cause. The policy also covers loss by Burglary, robbery or Hold Up whilst money is retained at the Insured’s premises in safe(s) or strong room.

SIGNIFICANT EXCLUSIONS

The Insurance Policy does not cover losses and /or damages due to floods, cyclones, earthquakes and other convulsions of nature, war and war like operations, civil commotion, riots and strikes and terrorist activities, shortage due to error, omission, by

use of keys to safe(s) or strong room (unless such keys are obtained by force or threat), whilst being carried under contract of affreightment, due to theft from unattended vehicle and consequential loss.

EXTENSIONS

Certain optional extensions are available, the details of which are provided in the relevant section of this proposal form.

NOTE

The foregoing is only a broad indication of the cover offered. For details please refer to the Policy.

DETAILS: Put a (a) mark wherever applicable

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1. CLIENT INFORMATION

(i)  Proposer’s name (please leave a space after each part of name)

(ii)  Proposer’s mailing address (please leave a space after each part of address)

City/Town/Village

State

Pin Code

Phone number

Fax number

E-mail address

(iii)  Proposer’s trade or business

(iv)  Paid-up capital of the firm (in Rs. Million)

2.  RISK DETAILS

(i)  Period of Insurance: (DDMMYYYY)

From: To: Midnight

(ii)  Number of Locations to be insured

(iii)  Address of the location(s) to be insured (please leave a space after each part of address and attach a separate sheet for multiple locations)

City/Town/Village

State

Pin Code

(iv)  Please provide the details of money to be insured in the following format:

Item I – Money in Transit

Item I / Description of Money / Transit / Limit of any one loss (AOL) (Rs.)
From / To
(a)  / Money in transit, from the bank to specified premises.
(b)  / Money in transit from the specified premises to the bank for remittance
(c)  / Money in transit to the specified premises or bank and in personal custody of Proposer or his employee for a period not exceeding 48 hours from time of collection.

(d)  What is the Estimated Annual amount of money in Transit (EAT[2])?
Rs. (in Million)
Item II – Money in Premises
Item II / Description of Money / Maximum amount of money held at one time (in Rs.)
(a)  / Cash whilst on the Proposer’s premises during the business hours or whilst secured in locked safe(s) or in strong room on the Proposer’s premises as specified in the schedule outside business hours, against risks of burglary, house breaking, dacoity, robbery and hold up.
(b)  / Money in counter in specified premises during business hours against the risk of holdup

(c)  Please specify whether transit will be within a radius of:

2 kms. Between 2 kms. and upto 25 kms. Beyond 25 kms.

(v)  How is the money carried (i.e. whether in bags, trunks etc)?

Bags Trunks

Any other

Please specify

(vi)  What is the designation of the employee handling money: ______

(vii)  What means of transport do the persons carrying the money use ?

Own vehicle Public transport

Any other

(viii)  Do armed guards accompany the persons carrying the money?

Yes No

If no, please state what protection, if any is provided?

(ix)  Please provide the following particulars of the safe(s) and/ or strong rooms where

money is held:

(i) for safe(s)-

Maker’s Name / Weight (kgs) / Identification Number

(ii) for strong room-

Maker’s Name
Specifications :
- dimension
- wall thickness

(x) (a) What is the address of the premises where the safe is kept and/or the address of the location of the strong room?

(b) Is the safe fixed to the wall or floor? Yes No

If yes, please specify-

Wall Floor

(c) Which floor is the strong room located on?

Basement Other floor (please specify) ______

(d) (i) Designation of the person in charge of keeping the keys of the safe(s) or strong

room?

(ii) Level in the organisation

Senior Management

Middle Management

Junior Management

(iii) Are the keys kept on the premises after business hours?

Yes No

(a) If Yes, where are they kept

(b) If No, please specify

(iv) Are daily records maintained for the cash in the safe(s) and/or strong room?

Yes No

(v) Are the premises guarded ?

Yes No

If yes, furnish details.

(vi) Has the risk been previously insured?

Yes No

If yes, please provide details in the following format (attach separate sheet if

required):

Policy number / Name of insurance company / Commencement of cover (DDMMYY) / Expiry of cover (DDMMYYYY) / Sum insured (EAT + Item II value (Rs.) / Premium

Please mention any special terms and conditions imposed:

Have you ever sustained any loss of money whilst in transit or whilst in your

premises? ( whether insured or uninsured )

Yes No

If yes, please provide details for the last three years in the following format: (attach

separate sheet if required)

Year of loss / Description of loss / Amount of loss

(xi)  Has any insurance company,

(a)  Declined to extend a money insurance policy to you? Yes No

(b)  Required an increased premium or imposed special Yes No

conditions?

(c)  Cancelled or refused to renew your policy? Yes No

If answer is yes to any of the above, please provide details in a separate sheet

(xii) Are the employees authorised to handle/carry money, covered under the Fidelity

Guarantee Policy? Yes No

If yes, please provide details in the following format:

Policy number / Name of insurance company / Sum insured (Rs.)

3. EXTENSION

If you want to avail of extension by payment of additional premium, please specify:

Do you want to include Riot, Strike and Terrorist damage cover?

Yes No

Any additional information relevant to the policy applied for

Note: Please use additional sheet, if space is not sufficient to complete details

I/We, the undersigned hereby declare that the above statements and particulars are true, accurate and complete and I/We declare and agree that this declaration and the answers given above shall be held to be promissory and shall be the basis of the contract between me/us and the Company.

I/We agree that the Company may exchange, share or part with any information to or with other ICICI Group Companies or any other person in connection with the Proposal, as may be determined by the Company and shall not hold the Company liable for such use/application.

Place: Proposer's Signature______

Date: Name: ______Designation ______

(DDMMYYYY)

STATUTORY WARNING

PROHIBITION OF REBATES.

(Under Section 41 of Insurance Act 1938)

1.  No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property, in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables of the Insurer.

2.  Any person making default in complying with the provisions of this section shall be punishable with fine, which may extend to five hundred rupees.

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[1] Money shall mean Cash including coins and currency notes, Bank Drafts, treasury notes Cheques, Postal orders and Current Postage Stamps

[2] Premium will be charged on the sum total of EAT as specified in Item and maximum amount of money as specified in Item II.