The New India Assurance Company Limited 
                    Head Office: 87, M G Road, Fort, Mumbai-400001

Agency _________ Branch ___________ Inspector ___________ Policy No. _________

Proposal Form For Insurance of Hull-Motor Launches, Dredgers, Trawlers, Tugs Barges, Sailing/Fishing Vessels, etc.

Proposer(s) (Owner’s) Name :

Address

Name of Vessel	Type of Vessel	Gross Regd. Tonnage	Registered  Length	Registered Breadth	Registered Depth	Draft	

							

Name of Builders	Place where Build	Material of which built	If built of wood, state whether Copper Sheathed or not	Year in which Built	

Year of purchase	Price paid by Proposed	Present Estimated Value of	Amount proposed for Insurance Rs.	
	Hull	Machinery	Accessories		

Port of Registry	Name of Registration Authority	Number of Registration Certificate	By whom where & when was the vessel last surveyed	

				
If rebuilt state when and give details of reconstruction carried out

If exact year of built is not known particularly for old Vessels give approximate age of vessel.

1. Is the vessels classed with a recognized classification society ? If so state symbols allotted.		
2.a. Is the vessel licensed or approved by any local authority ?  If so, please give full particulars.
2.b. Date upto which current licence is valid.		
3. Is the vessel equipped with
(a)	Windlass?
(b)	Rubbing Bands ?
(c)	Fire Fighting Appliances ? (State type)
(d)	Twin Screw ? 
(e)	Double Bottom ?
(f)	Collision Bulk Head ?	
	
4. Is the vessel covered in Forward, Aft and Round Sides	
	
5. State the cruising speed of the vessel.		

Particulars of Engine / Machinery :
Maker’s Name	Type of Engine and year of Manufacture	Fuel used and capacity of fuel tank	Is Reverse Gear provided	No. of Propellers	Horse Power	No. of Cylinders	Type of Engine Casing	

Particulars Relating to employment of the vessel :
1. For what purpose is the vessel used ?  If the vessel is trading give full particulars of the trade engaged in		
2. For what geographical limits is insurance required ?  N.B As the insurance of the vessel will be restricted to the above geographical limits, it is important to state your requirements clearly.		
3. Will the vessel be laid up during the South West or North East Monsoon ?
If so, please state.
(a)	Where she will be laid up
(b)	Period for which she will laid up		
4. Does the vessel ever undertake any tow ?
If so, please attach from used by you laying down conditions on which towage is accepted ;		
Particulars of Master and Crew :

1.	(a) Is the vessel in charge of a qualified master
(b) State his qualifications
(c) How long has he been in your employ ?
(d) Will he live aboard the vessel ?
	(a)

(b)
(c)

(d)	
2. What is the total number of crew on board the vessel ?		
General	
1.	(a) What accidents have happened during the past three years to any vessels owned by you ?
(b) If any, which of them are occurred in connection with the vessel herein proposed.	(a)

(b)	
2.	Has any Company or Insurer in respect of any of the risks to which this proposal applied 
(a) Declined to accept your insurance?
(b) Refused to renew your insurance?
(c) Increased the premium on renewal?	

(a)
(b)
(c)	
3.	Is the vessel at present insured with any other insurers		
4.	State the risks against which you wish to insure your vessel		
5.	(a)	State whether any Bank or other financing authority is interested.  If so give details of loan granted.
(b)	Also confirm that you will assign the policy in their favour
(c)	Also indicate details of loan repayment and confirm repayment is regularly done.  If not state reasons for default in repayment of loan.		
6.	State amount of your paid-up Capital		
	For what period or voyage is the Insurance required?	From__________
To    __________

I/We, the undersigned, hereby declare that the above statements and particulars are true and complete and further declare that I/We have not with-held any information which is calculated to influence the decision of the Company in accepting this Insurance and agree that this declaration shall be the basis of the contract between me/us and THE NEW INDIA ASSURANCE COMPANY LIMITED.
Dated at ____________this ________day ________of _________20 ____.

								Proposer’s Signature
Note 1.The liability of the company does not commence until the acceptance of the proposal has  
            been formally intimated by the  Company and  full premium paid.
        2. If space is found insufficient, please attach separate sheets for details.
        3. Premium will be quoted on application.
        4. Insurance is the subject matter of solicitation.

PROHIBITION OF REBATE  -- Section 41 of the Insurance Act 1938
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 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 rebates as may be allowed in accordance with the published prospectuses or tables of the Insurer.
Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to Five Hundred Rupees.

FOR OFFICE USE -  
MARKETING / DEVELOPMENT OFFICER'S REPORT
The Proposer is known to me/my agent / Broker for___years and I recommend acceptance of this proposal.

 Name and Code No.                                                                             Signature of Dev. Officer /  A/AO-D

ACCEPTED BY		DATE & TIME		RATE		REMARKS
CODES - OFFICE /DEV. OFFICER / AGENT /BROKER-
COLLECTION / SCROLL NO                                POLICY NO.
    								.