L&T GENERAL INSURANCE COMPANY LIMITED
SME PRE-UNDERWRITTEN PRODUCT
my:business Insurance Package (Retail Establishment/ Commercial
Establishment/ Hospitality & Leisure/ Educational Institution)
PROPOSAL FORM
1. The liability of the Company does not commence until this proposal has been accepted by the Company
and the premium paid.
2. Information given herein will be treated in strict confidence.
3. Failure to disclose facts material to the assessment of the risk may render the Contract void.
4. Please attach extra sheets wherever the space is insufficient to provide the additional underwriting
information. Put a (√) mark wherever applicable.
DETAILS ABOUT PROPOSER:
a) Name Of Proposer
b) Contact Address Of Proposer including the phone, fax No. and
e-mail address
c) Business Address Of Proposer including the phone, fax No. and
e-mail address (list all locations to be covered)
d) Brief Description of business of Proposer
e) Policy to be issued in favour of (list out all the parties who have
insurable interest) including the Bank/financial institutions.
f) Period Of Insurance required From: To:
PLEASE TICK MARK THE SEGMENT CHOSEN : Retail/Commercial/Hospitality & Leisure/
Educational Institution
PLEASE INDICATE THE PLAN CHOSEN : PLAN NO. ----------------
PLEASE INDICATE THE OPTIONAL SECTIONS
CHOSEN UNDER THE ABOVE PLAN : SECTION NAME SUM INSURED
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GROUP 1 (Compulsory Sections)
SECTION 1: STANDARD FIRE & SPECIAL PERILS
5. Please provide a brief description of Risk Occupancy
6. Sum insured-
a) Contents (Machinery/Stocks/Others) as per Plan- Rs. .........................b) Building (Sum insured of Building
would be restricted to Rs 30 crs in any of the Plans)– Rs………………….
Total Sum Insured (a+b) Rs. …………………..
7. A) Please tick if you are dealing with/storing any of the following commodities in your Premises. Yes/No
(Applicable under Retail Segment only)
LTGICL/COM/SME-PUP/F&U 24/Jan.12
If so please specify the items/commodities you are dealing with:
a) Celluloid Goods b) Coir Loose c) Crackers and Fire Works
d) Loose cotton e) Explosives of f) Hay/Straw
any kind
g) Hemp h) Jute Loose i) Matches
j) Methylated Spirit k) Nitro-Cellulose l) Oils/Ether/Industrial Solvents and
Plastics other inflammable liquids
flashing at and below 32 degrees
C (Closed Cup test)
m) Paints with inflammable n) Varnishes o) Disinfectant liquids and liquid
base having Flash point having Flash insecticides–other than in sealed
below 32 degrees C point below tins or drums
0
(Closed Cup test) 32 C (Closed p) Vegetable fibres of any kind
Other than in sealed Cup test) including Rayon Fibre
tins or drums other than in q) Jewellery
sealed tins or
drums
(Note: Shops keeping the above items of value more than 5% of total Sum Insured cannot be
covered.)
Please mention any 2 peak seasons in your business (not exceeding 46 days per peak season and
91 days in aggregate)
B) Is the proposal is in respect of coverage of standalone storage risk : Yes/No
(If yes, the standalone storage risk can not be covered under SME-PUP)
8. a) Do you have any stocks kept in open, if so will it exceed 5% of the total Sum Insured: Yes/No
b) Does the Risk is situated in basement : Yes/No
b) Do you have any stocks kept in basement, if so will it exceed 5% of the Sum Insured: Yes/No
(Note: Stocks in open/basement will not be covered if value exceeds 5% of the Sum Insured.)
9. Do you want Terrorism to be covered : Yes/ No
SECTION 2: BURGLARY & HOUSEBREAKING:
10. Do you have minimum security arrangements at the premises as below: Yes/No
(The minimum security arrangements required are - common night watchman, and rolling shutters
and/or grills for doors and windows)
SECTION 3: PUBLIC LIABILITY:
11(a). Has there been any incidence in the past at your premises giving rise to liability claims: Yes/No
11(b). Retroactive Date :
11(c) Sales Turnover in the last financial year :
11(d) Estimated Sales Turnover during Policy Period :
GROUP 2 (Optional Sections) – Mark tick for the Sections opted for
SECTION 4: MACHINERY BREAKDOWN (MB SI not to exceed Contents SI): Yes/No
12. Details of Machinery
a) All machinery (except more than 7 years old)
are covered and to be declared compulsorily. List of Machinery (with respective SI Value, Make,
Please provide list of all such machinery. Model, Identification)
Note- Pl. mention capacity of DG sets.
b) Note- DG sets more than 15 kva cannot be
covered even if less than 5 years old)
LTGICL/COM/SME-PUP/F&U 24/Jan.12
SECTION 5: ELECTRONIC EQUIPMENT (EEI SI not to exceed Rs.10.0 cr): Yes/No
13. Details of Equipments
a) All equipments (except more than 5 years old) List of equipment (with respective SI Value, Make,
are covered and to be declared compulsorily. Model, etc.)
Please provide list of all such electronic
equipments.
b) Note- Cover excludes Laptops, Mobiles,
Blackberries, Ipads, Ipods, Note books, Camera,
GPS devices and diagnostic medical equipments.
SECTION 6: PLATE GLASS: Yes/No
14. Please mention if any ornamental plate glass is fixed in the premises : Yes/No
(Note - ornamental plate glasses can not be covered under this Section.)
SECTION 7: SIGNAGE: Yes/No
15. Describe the type of signage to be covered: Neon/others
(Note - Only Neon Signs can be covered under this Section)
SECTION 8: MONEY: Yes/No
16 a) Please mention the maximum amount of cash carried at any one point of time
b) Please mention the maximum amount of cash stored in the premises at any point of time
c) Is the cash carried by authorized employees only: Yes/No
(Note - Loss of Cash carried by authorized employees only is covered upto Sum Insured limit available under
the chosen Plan)
SECTION 9: BAGGAGE: Yes/No
17. Whether business travel would involve overseas travel?
SECTION 10: FIDELITY GUARANTEE: Yes/No
18. Please provide details-
Do you entrust cash to your authorized Yes/No
employees only
Please provide the list of employees to be
covered.
(Note - Loss due to infidelity of employees on rolls only is covered)
SECTION 11: PERSONAL ACCIDENT COVER: Yes/No
19. Please provide the list of employees to be covered.
Name Age Name of Nominee Relationship of Nominee with
Employee
SECTION 12: HOSPITAL CASH BENEFIT: Yes/No
20. Please provide list of employees to be covered under this Section.
LTGICL/COM/SME-PUP/F&U 24/Jan.12
21. Please mention the Scheme Opted: Scheme A/ Scheme B/ Scheme C
Name of the Age Gender Pre-existing disease/ illness/ Name of
Employee condition (if any) Nominee/Relationship
SECTION 13: GROUP HEALTH COVER: Yes/No
22. Please provide list of employees to be covered under this Section.
23. Please mention the Scheme Opted: Scheme A/Scheme B
Pre-existing
Name Illness/disability/Hospitalization
of the Date Designation/ (if any) Sum Nominee
Person Location of Gender Category/ Plan
Insured name*
to be Birth position
Insured
24. Good Health Declaration
Are the employees proposed for insurance currently in good health and not
Yes No
undergoing any medication/ treatment? If No Please give details:
Details of Pre-existing diseases/illness/conditions (if any) (please attach separate sheet if required)
____________________________________________________________________________________
SECTION 14: PEDAL CYCLE (Applicable for my:small business Retail Insurance only): Yes/No
25. Please provide the number of bicycles/tricycles involved in your business
SECTION 15: ALL RISK COVER – Applicable for Plans 10 onwards, i.e. for Fire sum insured Rs.2.0 cr.
and more: Yes/No
26. Please provide details of laptops and projectors belonging to Owners, Promoters, Partners, MDs and
Directors only
LTGICL/COM/SME-PUP/F&U 24/Jan.12
GENERAL INFORMATION
PAST INSURANCE
Are you now or have you previously been insured for any of the coverage(s) you are applying? Yes { } No { }
Insurer Sum Insured Policy Period of Type of Cover
Number Insurance
PAST LOSS EXPERIENCE (3 YEAR RECORD)
Details location Year of Loss Cause of loss Loss Amount
Has the Insurance for Risks proposed to be insured been declined, cancelled, refused renewal or subjected to
special terms or increase in premium by any other Insurance Company? Yes { } No { }
If ‘Yes’, Please give details.
Note- Pl. attach additional sheets for any additional information to be provided.
Declaration by the Proposer
I/We the undersigned hereby declare that the above statements and particulars are true and complete and
I/We declare and agree that this declaration and the answers given above shall be held to be promissory and
shall be the basis of the contract between me/us and the Company.
Place.................
Date.................. Proposer’s Signature.....................
Section 41 of Insurance Act 1938
PROHIBITION OF REBATES -
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 lives 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 or continuing a policy accept any rebate, except such
rebate as may be allowed in accordance with the published prospectus or tables 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.
LTGICL/COM/SME-PUP/F&U 24/Jan.12
