The New India Assurance Company Limited
Registered & Head Office : New India Assurance,87,M.G. Road,Fort,Mumbai - 400 001

QUESTIONNAIRE AND PROPOSAL FOR ELECTRONIC EQUIPMENT INSURANCE POLICY

1. Name and address
of proposer _____________________________________________

Type of business ____________________________________________
Location of equipment
to be insured ______________________________________________
(address of building storey)____________________________________
Structure of building __________________________________________
Steel skeleton brickwork concrete wood
2. Has any of the Yes No If so, which items of the specification and
equipment to be by which companies ?
insured previously _________________________________________
been covered by other_________________________________________
insurance companies? _________________________________________

State when the insurance Date : Time : Period of the insurance
is to commence to expire at same date
and time next year
3. Is all the equipment Yes / No If not, which items of the specification to be insured new ? are second hand ?
__________________________________________
What equipment can still_________________________________________
be obtained ex works? State items of the specification
4. Condition of Is the equipment maintained in accordance with the
Equipment manufacturer’s instruction ? Yes/No
5. Quality of Staff Have operators been trained with the manufacturer
Yes
6. Is there a risk of flood Yes / No If so, by bodies of water / inundation torrential rainfall / sewer backflow /Other
7. Are dangerous yes/ No If so, specify acids / prepared or
materials used in vicinity ? sensitised papers/ Dyes/test
solution / developers/explosives
isotopes /others

-2-

8. External data media. Mark those data media which are stored in the same
Please answer the hazard zone as the EDP system with an “A” in the
following questions column “Location” of the specification; mark data
only if insurance is media stored in another hazard zone with a “B”.
desired. _________________________________________
Storage on wooden shelves in steel cabinets
_________________________________________
in fire proof cabinets together with EDP system,
__________________________________________

Air-conditioning If not, how is air-conditioning effected ?
__________________________________________
Risk aggravating
circumstances in Steam and Water Lines / Vibrations/ Acidic
the storage rooms Atmosphere
9. Conditions desired Excess 2 times 5 times
10 times 20 times
__________________________________________
Exclusion of fire & Allied Perils Yes/ No
as per Std. Fire Pol.

10. Whether there is any maintenance contract ?
If yes, copy of the contract is to be attached Yes / No
We hereby declare that the Questionnaire and It is agreed that the insurers The insurers undertake to
statements made by us in Proposal forms the are liable in accordance deal with this information
this Questionnaire and basis and is part of with the terms of the policy in strict confidence.
Proposal are,to the best any policy issued in only and that the insured will
of our knowledge and belief, connection with the not lodge any other claims of
complete and true and we above risk(s). whatever nature.
hereby agree that this

Executed at this day of 19

Signature
PROHIBITION OF REBATES
The following is the copy of Section 41 of the 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 live or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown in the policy; nor shall any person taking out or renewing continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses of rebates 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.
SPECIFICATION OF ITEMS TO BE INSURED

Item No. Description of Items:
Please give full and exact description of all equipment, including name of manufacturer type serial number, voltage, power input, etc. In the case of outdoor lines indicate length and method of lying.

Year of Manufacture Remarks
Give particulars of any part of the equipment to be insured which has had a breakdown or failure during the last three years and shows any signs of repair. In the case of mobile equipment, statements and frequency of transport, areas of operation and distances please state if picture or admitter tubes are built in. A2B2 Replaclement
Value
Please state current cost of replacing the equipment by new equipment of the same kind plus freight charges customs duties costs of erection, package material.
1. For the Insurance of electronic data
processing (EDP), equipment, an additional TOTAL
questionaire for EDP equipment has to be completed. ____________
2. In the case of bought equipment mark, "A"
3. In the case of hired equipment mark "B"