<p> THE ORIENTAL INSURANCE COMPANY LIMTED</p><p>Reg. Office: Oriental House, PB No: 7037 a-25/27 Asaf Ali Road, New Delhi 110 002 AGENCY CYODE:</p><p>EMPLOYER’S LIABILITY INSURANCE (W.C. POLICY) PROPOSAL</p><p>1 Proposer’s Name in full</p><p>2 Business Address</p><p>3 Trade or Occupation</p><p>4 Particulars of Work</p><p>SCHEDULE OF EMPLOYEES WITH WAGES. Description of Employees with Estimated nature of work, like, clerical, Number of Annual Wages Per Annual Wages of Total supervisors, etc. Employee Employee Employees s Cash Other Total Cash Other Total Allowan Allowan ces ces</p><p>Do you wish to insure your liability under the Workmen compensation Act, 1923 and subsequent amendments to the said Act and to insure workmen of sub contractors. Then give the following details.</p><p>5 Name of Contractors with Nature of Sub contract 6 Amount of Sub Contract. 7 Does the above schedule include a) All person in your services? a) b) All your sub contractors? b) 8 Is any part of your premises or Factory within the meaning of Factory ACT? 9 Type of Machinery used in the premises</p><p>10 If factory, is your boiler registered and also state what acids, gases, chemicals or explosives used to what extent. 11 What medical service is provided for your employees?</p><p>12 Give details of Past insurances and compensations paid Year Premium paid Total Wages Fatal Accident Compensation paid for disablement.</p><p>PERIOD OF INSURANCE: FROM:……………………………TO……………………………………………….</p><p>I/We hereby declare that the statements made by me/ us in this Proposal Form are true to my / our knowledge and belief and I / We agree that this declaration shall form the basis of the contract between me/ us and the “THE ORIENTAL INSURANCE COMPANY LIMITED”.</p><p>If any additions or alterations are carried out in the risk proposed after the submission of this proposal form then the same should be conveyed to the Insurers immediately.</p><p>Date: Place: Signature of Proposer.</p>