UNITED INDIA INSURANCE COMPANY LIMITED

REGD & HEAD OFFICE: NO 24 WHITES ROAD CHENNAI 600 014

COMMERCIAL PACKAGE KIT (COMPACT) INSURANCE P !"!#$% F! & DO/BO Code: 1 . $ . % . & . Dev. Officer Code: Na e of !he "ns#red: Address for co #nica!ion: Fresh Proposal Renewal Agency Code: 1. $. %. /

Descrip!ion of B#siness / Profession:

a' Address of !he pre ises !o (e ins#red )"f &. a' differen! fro $ a(ove (' Please indica!e whe!her !he pre ises is own or (' Own / Ren!ed ren!ed c' Do yo# wish !o cover !he (#ilding #nder c' 0es / No *ec!ion "+ "f so whe!her #nder Reins!a!e en! "f yes1 on R", / -, ,al#e )R",' (asis or -ar.e! ,al#e )-,' (asis (asis+ )please con!ac! o#r office for e/ac! defini!ion of R", and -,' 2 3as any of !he i!e s covered #nder !he following sec!ions/ endorse en!s . s#ffered any da age previo#sly+ "f so1 give de!ails of !he sa e in !he following for a!. A!!ach a separa!e shee!1 if necessary. Da!e of De!ails of A o#n! of 4oss Na e of !he "ns#rance Occ#rrence 4oss )Rs.' Co pany 5 6ive de!ails of previo#s ins#rance1 if any . 7 3as any Co pany in respec! of any of !he i!e s proposed for ins#rance . here#nder a' Declined yo#r proposal+ (' Cancelled / ref#sed !o renew yo#r Policy+ c' Accep!ed yo#r proposal on special !er s and condi!ions+ 8 Please indica!e !he *ec!ions !o (e covered #nder !he Policy (y p#!!ing a !ic. . ar. in !he appropria!e col# n. *ec!io Descrip!ion of proper!y *# "ns#red Ra!e )Rs. Per n No. )Rs.' 1999'

". Fire A. B#ilding. )Refer & )c' a(ove' : B. Con!en!s )"nciden!al s!oc. !o Allied (e declared specifically' Perils )Please a!!ach a separa!e lis!'. C. ;enan!<s 4egal 4ia(ili!y "". Con!en!s B#rgla )Please a!!ach a separa!e lis!' ry : 3o#se (rea.i ng """. "!e *erial 0ear of -fg. >lec!rical N : o -echanica . l Please a!!ach a separa!e lis! Appliance No!e: All i!e s wi!ho#! s selec!ion have !o (e declared for "ns#rance ",. "!e *erial 0ear of >lec!ronic N -fg. Appliance o. s Please a!!ach a separa!e lis! No!e: All i!e s wi!ho#! selec!ion have !o (e declared for "ns#rance ,. -oney Please indica!e !he a o#n! !o "ns#rance (e ins#red a' "n !ransi! -a/. 4i i! per carrying Rs========== (' "n *afe c' "n ;ill ,". Na Age e Designa!ion Personal Capi!al Acciden! *# "ns#red )Rs.' Please a!!ach a separa!e lis! ,"". Na e Designa!ion "nfideli!y / Dishones! y of e ployees

Rs=========== Rs=========== Rs========== Rs =========

Rs ============

Rs ============

Rs ============ Rs ============ Rs ============ Rs ============

4i i! Rs. 5.99 on of !he *# lia "ns#red (ili selec!ed !y ? Rs. 19

Please a!!ach a separa!e lis!

,""". 4egal 4ia(ili!y

A. ;owards ;hird Par!ies AOA@ AO0@ *# "ns#red B. ;owards > ployees >s!. Na!#re >s!. Aages No of . A of or e . p. Please a!!ach a separa!e lis!

per person on !he n# (er of persons !o (e covered Rs. ==========

As per A. C Ac!

"B. Fi/ed Descrip!ion of pla!e glass / 6lass / sani!ary fi!!ings Rs ============ *ani!ary Fi!!ings Please a!!ach a separa!e lis! B. Neon / Descrip!ion 0ear of -fg. 6low *ign Please a!!ach a separa!e lis! / 3oarding

Rs.============

C Do yo# wish !o cover any of !he following endorse en!s+ "f so1 please indica!e . !he endorse en!s !o (e covered #nder !he Policy (y p#!!ing a !ic. ar. in !he appropria!e col# n. A Do yo# wish !o cover (aggage+ 0es / No. . "f yes1 please indica!e !he a o#n! !o (e covered. )"f yo# wish !o cover ;ravelling Advance and B#siness *a ple1 please specify and !he val#e !hereof' B Do yo# wish !o cover !he 4oss of Profi!s+ "f yes1 0es / No . please indica!e a' *# "ns#red for Rs =========== i. 6ross "nco e Rs =========== ii. Addi!ional >/pendi!#re =========== on!hs iii. CA<s Fees (' "nde ni!y Period op!ed for )"nde ni!y period canno! e/ceed 1$ on!hs'

C Do yo# wish !o e/!end !his Policy !o cover . s!#den!s !owards Personal Acciden!+ "f yes1 please indica!e a' li i! of lia(ili!y i. per s!#den! per acciden! ii. per acciden! for all s!#den!s iii. per year for all s!#den!s for all acciden! );his endorse en! also covers hospi!alisa!ion e/penses arising o#! of acciden! !he li i! for which depends on !he Co pensa!ion li i! chosen for a s!#den!' D Do yo# wish !o cover Professional Negligence+ . "f so1 please indica!e 4i i! of lia(ili!y for !he es!a(lish en! a' per acciden! (' per year > Do yo# wish !o cover occ#pan!s Benefi!s+ . "f so1 please specify !he li i!s for !he following s#(=sec!ions )AO0 @ Any One Acciden!' )AO0 @ Any One 0ear' )AOO @ Any One Occ#pan!' a' 4oss of (elongings (' 4egal 4ia(ili!y !owards i. ,al#a(les #nder care1 con!rol and c#s!ody ii. Food and (everages iii. >/!ra facili!ies s#ch as heal!h cl#(s1 (ea#!y parlo#rs1 shops1 swi ing pools1 indoor and o#!door spor!s iv. AD#a spor!s facili!ies v. For incl#sion of s.ydiving1 s.iing and hang gliding c' Personal Acciden! for occ#pan!s

Rs. =============== Rs. =============== Rs. ===============

Rs. =============== Rs. ===============

AOO occ#pan!s a'Rs. 21999/= Rs.11991999/= ('AOA )Rs.' )Rs.'

AO0= for all

AO0

c' AOA )Rs.' )Rs.'

AO0

F Do yo# wish !o cover addi!ional ren! for . al!erna!ive acco oda!ion as conseD#en! of fire !o ins#red pre ises+ "f so1 please indica!e !he a o#n! for which !he Rs.=================== coverage is reD#ired+ 4i i! of "nde ni!y: ;he s# )s' prod#ced (y #l!iplying !he on!hly addi!ional ren! or ac!#al addi!ional ren! whichever is lower (y n# (er of on!hs for which !he "ns#red Pre ises was #nfi! occ#pancy or !he a/i # inde ni!y period of 1$ on!hs. ;he s# ins#red is !he a/i # lia(ili!y of !he Co pany #nder !his >ndorse en!. -on!hly Addi!ional Ren!: a' "f !he "ns#red is owner=occ#pan! i! is calc#la!ed (y dividing 19E of !he *# "ns#red #nder *ec!ion 1)A' (y 1$ )!welve'. (' "f !he "ns#red is !enan!1 i! is calc#la!ed (y dividing !he $2E of !he *# "ns#red on con!en!s #nder *ec!ion " )B' (y 1$.

F! O''()* U#* !+%, ;o!al Pre i# Add: Pre i# for endorse en!s No. *#(=;o!al )"' 4ess: *ec!ion Disco#n! covering ore !han ======sec!ions / >ndorse en!s s#( ;o!al )""' less: Renewal Disco#n! for ===== Renewal s#(=;o!al )""' N>; PR>-"FRs. Rs. Rs. Rs. Rs. Rs. Rs.

No!e: 1. *ec!ion / Renewal Disco#n!s are applica(le on all sec!ions/endorse en!s e/cep! *ec!ions "1"""1 ",1 ,""" and >ndorse en!s B. $. *ec!ion " is co p#lsory. ;he policy sho#ld (e !a.en for a ini # of 2 sec!ions incl#ding *ec!ion ". T-* %($.(%(/, !' /-* )!&"$+, 0!*# +!/ )!&&*+)* 1+/(% /-* " !"!#$% -$# .**+ $))*"/*0 ., /-* )!&"$+, $+0 /-* '1%% " *&(1& "$(0 /! /-* C!&"$+,2 Ae here(y declare !ha! !he par!ic#lars con!ained herein are !r#e and correc! and !ha! no a!erial fac! has (een wi!hheld1 iss!a!ed or isrepresen!ed and also !ha! !his proposal c# sched#le for ing par! of !he co pany<s s!andard policy shall (e !he (asis of con!rac! (e!ween #s and !he "ns#rance Co pany. Ae f#r!her declare !ha! !he s# ins#red herein represen!s !he f#ll val#e of !he proper!y descri(ed herein.

Place : Da!e : !' P !"!#* S(3+$/1 *

S*)/(!+ 41 !' T-* I+#1 $+)* A)/ 1456 P !-(.(/(!+ !' R*.$/*# 1. No person shall allow or offer !o allow ei!her direc!ly or indirec!ly as an ind#ce en! !o any person !o !a.e o#! or renew or con!in#e an ins#rance in respec! of any .ind of ris. rela!ing !o lives or proper!y in "ndia any re(a!e of !he whole or par! of !he co ission paya(le or any re(a!e of !he pre i# shown on !he policy nor shall any person !a.ing o#! or con!in#ing a policy accep! any re(a!e e/cep! s#ch re(a!es as ay (e allowed in accordance wi!h !he prospec!#s or !a(les of !he ins#rer. $. Any person a.ing defa#l! in co plying wi!h !he provisions of !his *ec!ion shall (e p#nisha(le wi!h fine which ay e/!end !o Rs. 299/=