Bajaj Allianz General Insurance Company Limited

Head Office & Regd. Office: GE Plaza, Airport Road, Yerawada, Pune 411 006

Standard Fire and Special Perils policy

Proposal Form
Name of Proposer

Address of Proposer

Pin Code
Address of Risk to be covered

Pin Code
Occupation of Risk
Total Sum Insured Rs.
Building : Rs. Stocks : Rs.
Contents : Rs.
Insurance Period : From To
Previous Insurance Details : Company Name & Address

Pin Code
Previous Policy No. Policy Expiry date
Add. on Covers : Earthquake
Premium Payable : Rs Rate : (Per Mille) %0
Amount Paid : Rs. Cash / Cheque
Insured Property : (Please give description)
A) Dwellings, offices, shops, hotels etc.
B) Industrial / Manufacturing Risks
C) Storage outside Industrial / Manufacturing Risks
Whether Burglary cover required on contents? if so sum insured : Rs.
Description of Risks
S. No. Description Sum Insured

Declaration by Insured :
If additions or alterations are carried out in the risk proposal after the submission of this form, then the same would be conveyed to the insurance immediately.
Declaration by Insurer :
It is hereby confirmed that the risk as detailed in the above proposal is held covered as per the terms and conditions of the standard fire and special perils policy from
date and time of debit of premium in the borrowers account. This temporary confirmation of cover shall hold good till replaced by a policy document.

Date :
Place : Signature of Proposer & Seal of the Company
Note : Proposal should be accompanied by photo-copy of existing policy for renewals.

Insurance Act 1938, Section 41 - 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 or 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 on 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.