1. Name and Address of Proposer
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PROPOSAL FORM
1. Name and address of proposer Type of Business Location of equipment to be Insured (address of building/Storey) Structure of Building Steel skeleton Brick Work Concrete Wood 2. Has any of the equipment to be Yes No If so, which items of the insured previously been covered by specifications and by which other insurance companies? Date: companies? a) State when the insurance is to Time: Period of the insurance to expire at commence the same date and time next year 3. Is all the equipment to be insured Yes No If not, which items of the new? specification are second hand? What equipment can still be State items of the specifications obtained ex-works? 4. Condition of equipment Is the equipment maintained in accordance with the manufacturer’s instructions? Yes No 5. Quality of Staff Have operators been trained with manufacturer? Yes No 6. Is there a risk of flood and Yes No If so by _bodies of water inundation? _torrential rainfall _ by sewer backflow _ or by others 7. Are dangerous materials used in the Yes No If so, specify _ acids _ prepared or vicinity? sensitized papers _ dyes _ test solutions _ developers _ explosives _ isotopes _ others 8. Valid Maintenance Contract in force Yes/No (If yes, copy to be enclosed) 9. Air conditioning Plant _Pressurized _ recommended by manufactures _ not necessary
I/We hereby declare that the statements made by us in this Questionnaire and Proposal are to the best of our knowledge and belief, complete and true, and we hereby agree that this Questionnaire and proposal forms the basis and is part of any policy issued in connection with the above risk(s). It is agreed that the Insurers are liable in accordance with the terms of the policy only and that the Insured will not lodge any other claims of whatever nature. The Insurers undertake to deal with this information in strict confidence. Executed at ______this day of 20
Signature ADDITIONAL QUESTIONNAIRE FOR THE INSURANCE OF ELECTRONIC DATA PROCESSING (EDP SYSTEM)
1. Name and address of proposer Type of business 2. EDP system a) If the system is rented, state monthly rent: b) Date of start of operation: c) Operation hours per day in shifts d) Name and address of Manufacturer and/or Lessor e) What are the provisions for your lease contract regarding your liability in the case of damage to the EDP system? (Please furnish copy of lease contract if available) 3. Housing of the EDP system a) Central Unit: _ basement ground floor floor b) Peripheral Unit: basement ground floor floor c) Total value of plant located In basement Rs.___ on ground floor Rs.___ d) Is installation in accordance with the on floor Rs.__ on floor Rs_ manufacturer’s recommendations ____Yes _____ No If not, specify deviations from instructions e) Manner in which the EDP Systems on vibration absorbers on rollers has been installed by rigid anchoring without anchoring 4. Air conditioning plant prescribed recommended by the a) Maintenance manufacturer b) Loss prevention used for EDP systems only c) Does the air-conditioning plant by the manufacturer by automatically shut off by limit ______switches if the normal control facility _ Yes, in case of excessive __ fails? No Is the air-conditioning plant also equipped __ Temperature __ Moisture with an independent signaling device in the case of disturbance or failure? __ Yes __ No ___Optical ____ Acoustic signal Are adequate loss prevention measures In the case of presence of corrosive gases initiated immediately even if the above Excessive Temp. Moisture protective devices are actuated outside __ Yes operational hours? __ No
5. External data media Mark those data media which are stored in the Note: please answer the following same hazard zone as the EDP system with an questions only if insurance is desired ‘A’ in the column location of the specification; a) Storage mark data media stored in another hazard zone with a “B” b) Air Conditioning on wooden shelves in steel cabinets in fire proof cabinets together with EDP system ___Yes _____ No If not how is air-conditioning effected Risk-aggravating circumstances in the Steam & Water line Vibrations Acidic storage rooms Atmosphere
6. Conditions (Excess) desired Excess 2 times 5 times 10 times __ 20 times 7. Exclusion of Fire & Allied Perils As per Yes No standard Fire & Special Perils Policy
We hereby declare that the statements made by us in this Questionnaire and Proposal are to the best of our knowledge and belief, complete and true, and we hereby agree that this questionnaire and proposal forms the basis and is part of any policy issued in connection with the above risk(s). It is agreed that the Insurers are liable in accordance with the terms of the policy only and that the insured will not lodge any other claims of whatever nature. The Insurers undertake to deal with this information under strict confidence. Executed at this day of 20
Signature ADDITIONAL QUESTIONNAIRE FOR THE INSURANCE OF INCREASED COST OF WORKING AS A RESULT OF FALIURE OF EDP SYSTEM
1. Name and address of proposer Type of business 2. EDP System to be insured a) Operational hours on average __ per day __ per month b) Is it possible in the event of failure to utilize Yes No other EDP system so as to obviate using an outside system? _ Yes _ No c) Are there any special arrangements regarding continued payment of the rent and other costs if the EDP system fails? If so, please specify 3. Outside EDP system available for use a) Name of address of _ owner _ lessee b) Is the use of outside EDP system subject to any Yes No special conditions? (waiting periods, conversion measures, etc.) If so, please specify Yes No c) Has the system already been used Max. duration Max. cost incurred If yes, how often 4. Sums to be a) Rent of substitute Equipments Rs. ……./hour insured Equipments b) Indemnity period per occurrence weeks c) Limit per occurrence (a x b) Rs. ……. d) Aggregate indemnity limit during the period Rs. ……. of insurance e) Personal expenses Rs…….. f) Transportation of materials Rs…….. 5. Conditions Period of indemnity per occurrence (Minimum) Week ___ desired Time Excess 4 days 7 days 14 days 28 days (96 hrs) (168 hrs) (336 hrs) (672 hrs)
We hereby declare that the statements made by us in this Questionnaire and Proposal are to the best of our knowledge and belief, complete and true and we hereby agree that this Questionnaire and proposal forms the basis and is part of any policy issued in connection with the above risk(s) It is agreed that the Insurers are liable in accordance with the terms of the policy only and that the insured not lodge any other claims of whatever nature. The Insurers undertake to deal with this information under strict confidence. Executed at this day of 20
Signature SPECIFICATION OF ITEMS TO BE INSURED Ite Description of Year of Remarks Replacement value A (Give particulars of any (Please state current m items: (Please give manu- or part of equipment to be cost of replacing the No full and exact facture B insured which has had equipment by new description of all a breakdown or failure equipment of the same equipment, including during the last three kind plus freight name of years and shows any charges, custom duties manufacture, type, signs of repair. In the costs of erection serial number case of mobile package material) voltage, power input, equipment state means etc. In the case of and frequency of outdoor, lines, transport, areas of indicate length and operation and method of laying) distances. Please state if Picture or Admitter tubes are built in)
1. For the Insurance of electronic data processing (EDP) equipment, an additional questionnaire for EDP equipment has to be completed. 2. In case of brought equipment, mark ”A” 3. In the case of hired equipment mark “B”. Total ______