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cvBIwbqvi BÝy¨‡iÝ †Kv¤úvbx wjwg‡UW Pioneer Insurance Company Limited Sympjhony (5th Floor) Plot # SE(F)9, Road # 142, South Avenue, Gulshan-1,Dhaka-1212. Phone : 8817512 (Hunt) PROPOSAL FOR FIRE INSURANCE Full Name of Proposer Name of Partners ( if any) Address Trade or Profession Term of Insurance From 200 to 200 AMOUNT TO BE INSURED All building AS PER DIAGRAM AT BACK standing apart On Building only No. 1 No. 2 No. 3 or nor communicating On Machinery internally must be separately On Household Furniture and Effects insured. Separate sums On Merchandise or stock-in Trade must also be declared upon Total the contents of each (A) SITUATION 2. Is the Building detached ? 1. (a) Name of Building If so, state distance of nearest Building (b) Owner of Building (c) Plot No. 3. Does the Building adjoin another Building ? If so, is the (d) Holding No. division wall a perfect party wall i.e. 13” inches thick, (e) Name of the Street carried through at least 18” inches above the roof having no (f) Town (g) District openings therein except for shafts straps steam gas and water pipes sufficient size for the purpose and not exceeding 4 square feet in area.

(B) CONSTRUCTION 1. Number of storeys 1. 2. Construction (a) Walls 2. (a) (b) Roof (b) (c) Floors in each storey (d) Buildings within 50 feet (c) N.B.- If any building within 50 feet is ‘Kutcha’ built (d) state wheather the wall facing such ‘Kutcha’ building is built of brick or stone and has no opening or otherwise. (C) OCCUPATION 1. Occupation of Building : Ground Floor 1. First Floor Upper Floor 2. 2. Occupation of Adjoining Building. 3. Is any trade or process of manufacture carried on in the building ? 3.

(D) LIGHTING, HEATING AND POWER 1. 1. How is the Building lighted ? 2. 2. How is the Building Heated ? 3. 3. State full particulars of any power used in the Building 4. 4. Whether any naked light is used inside the premises. (E) STORAGE

1. Are Hazardous goods stored in the building ? ( See List of hazardous goods overleaf )

LIST OF HAZARDOUS GOODS The following is a list of Caustic Potash Jute in full-pressed bales or Resin of all kinds goods deemed to be Celluiod Xylonils and other otherwise Rubber solution Hazardous : similar substances. Lime ( unslaked) Saw dust Acetylene (Liquid) Charcoal Lubricants containing Shoddy Acid of all kinds ( except Chiorates of all kinds mineral products Spirit of all kinds not in acetic. citric and tratarie) Chiorate of potash Menthol of all kinds bootles Aluminium Carbide-dust Cinematograph films Metalic potassium Stearine powder or resinate Cocogem other than in tins Mungo Sulphides metalic of all Apline or in bottlnr Codills Naptha kinds Asphalt Coir yarns, coir matting and Napthaline Sulphide of potash Bamboo Mate coir rope Nirates of allkinds Sulphar Benzene Copra cake and copra meal Nitrate of Potash Sulphar dyes or colours Benaoerine Cotton ( whether in fully- Oils of all kinds( other than ( excluding vessel tabelied Bichromate of Potash pressed bales or otherwise) vegetable ) with a certificae by the Bi-sulphide of Carbon Explosive of all kinds Oils in tins not exceding 10 manufacturer that the dyes Bitumen ( other than ( includng ammunition and lb in weight and or in or colorus contained 10 emsallied Bitumen per cussion caps fireworks bottles) percent of inet inogranic containin not less than 40 of all kinds) Oil seed cake ( including salts) percent of water and Fish guano and fish manure cotton seed cake) Tallow(Manufactured or packed in metal drums) Ghee(other than vegetable Oil seed meal unmanufactured) Blacks of all kinds ghee in tins not exceding to Paint Tar and/pr its liqueid Calcium Carbide 10lb in weight and/or Paper, asphalted tarred and products (other than in Calcium Cyanamid except botlles) oiled bottles ) when Glycerine Perchiotae of potash Tupetine Packed in hemetically Grasses of all kinds and Petroxide of potash Varnish sealed straw ( potassium) Vegetable fivers of all kinds Drums, and each Gunny Bags ( other than in Petroxide of potash Waste of all knds consignment fully pressed iron bound ( pottassium) ( exlcuding silk and gas Accompanied by the bales) Petroxide waste Manufacturers Hessians ( other than in Petroleum and its liquid Wax of all kinds Certificate that the tins fully pressed iron bound products contain not more than 0.3 bales) Phosporous percent of carbide Rags Camphine Camphor Candles N.B. The above lists not necessarily Comprehensive. A full list is available at the Company’s Office for inspection. (F) GENERAL INFORMATION 1. 1. How long have you carried on this business ? 2. Name of Banker and whether interested in 2. insurance ? 3. Are the stock book kept in a fire proof safe? 3. 4. If not, what precautions are taken to prevent the stock books destroyed by fire? 4. 5. Do you keep a duplicate set in other premises? 6. Are there any existing insurance on same 5. property with this or any other office? 7. Are there any other circumstances which appear 6. to increase the risk? If so, describe the same particularly? 7. 8. Has any office reason whatsoever (a)declined (b) 8. (a) (b) (c) cancelled or, (c) refused to renew any Policy on this or any other risk? If so, give particulars. 9. Have you or your partners ever had a loss by fire 9. (a) In these premised ? (b) In other premises under your control or management, if the claim was admitted. What assistance can be relied upon in case of fire. Describe fully Fire Extinguishing Appliances on the 10. premises, if any. I/We hereby declare that the above information is correct and I/We agree that this Proposal shall be the basis of contract between me/us and the PIONEER INSURANCE CO. LTD. Signature of the Proposer