Hotel n Restaurant

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My Business My ChoiceHotel & Restaurant

Note: 1) Policy wordings are available on request. 2) Please complete all sections in capitals and tick boxes wherever applicable. 3) Failure to disclose facts materialto the assessment of the risk or providing misleading information may render the contract VOID. 4) Attach separate sheets if space given is insufficient.

Insured / Business Name

Address for

Correspondence

Contact Person

Tel: Fax: M

PIN

Description of Business

Bank / Financing Institution

Paid-up Capital

Period ofInsurance

15 Cr 15 Cr

From: hrs:

To: (midnight)

D D M M Y Y

Risk Location (L) & Details: (RCC / Brick Work structure aged 30 yrs only is covered. Kutcha / Temporary structure not covered)

D. No. Street Village / City District / State

STANDARD COVER : FIRE & SPECIAL PERILS

L1

2

3*Occupancy: ** Location: Residential (R) / office (O) Shop (S) Godown (G) Mfg. Unit (MU) / Others - Specify Ground Floor (GF) / Mezzanine Floor (MF) / Higher Floor (H) / Dwelling in Mfg. Unit (DMU)

PIN

Occupancy* Location** Age ofStructure

(Yrs)

EQZone

SICCode

HGCode

to Exclude Covers ‘ ’✓ to Include Add-on Covers ‘ ’✓ Fire Extinguishing Appliances Installed Voluntary Deductible Desired‘ ’✓

Riot Strike &Malicious Damage

Storm TempestFlood & Inundation

Earthquake (Fire and shock)

Terrorism damage

Other Add-on Covers : 1) Omission to Insure additions etc., 2) Spoilage

Material Damage Cover, 2) Start-up Expenses, Architects, Engineers etc.,Fees, 4) Leakage & Contamination Cover, 5) Spontaneous Combustion,6) Temporary Removal of Stocks, 7) Deterioration of Stocks due to power failure, 8) Deterioration of stocks due to change in temperature, 9) Removalof Debris, 10) Forest Fire, 11) Impact Damage by own Vehicle, 12) Loss ofRent, 13) Addl. Rent for alternate accommodation.

I confirm FEA is maintained in efficient workingcondition. (Attached certificate of approved agency of TAC)

Hand aapliance & Trailer pump / Fire engine

Hand appliance & Hydrant system

Hand appliance & Independent sprinkler /Fixed water spray

Hand appliance + Hydrant & Independentsprinkler / Fixed water spray

AOG 10 lakhs / Others 5 lakhs





Enter Sum Insured Particulars per Location (L). (Inadequate Sum Insured will attract provisions of Under Insurance clause).

STOCKS

CONTENTS

BUILDING

Plinth & Foundation(separate Sl)

Compound Wal l Sum InsuredTotal

BasicFire (1)

Discounts DiscountsExclusions Add on Covers

RSMD(2) STFI(3)(1-1) Age< = 5 yrs

FEA (4)% (1-2-3)

(1-2) Const.Type *AA or A*

VD (5)% (1-2-3-4) EQ Terrorism

Rate% 0

Premium

Sum InsuredTotal

Fruniture & Fixture/Off. Equipment

Electrical Fittings Plant & Machinery /Equipment

Stock in trade

TOTAL

Note: Stocks-in-open cannot be covered unless approved by Office

OPTIONAL COVERS (Select minimum 2 covers)

L

1

2

3

Fruniture & Fixture /Office Equipment

Plant & Machinery /Equipment

Stocks Others - specify Sum - Insured First Loss(50%)

First LossSum Insured

Covers Theft by visible and forcible means only.Do you have dedicated security arrangement round the clock? YES NO

Are the insured premises protected with Solid Doors / Gates / Gril ls / Rolling Shutters / Glass Door

Portable Equipment Equipment Details Make Yearof Mfg.

Serial No. ForIdentification

AMC Sum Insured(Reinstatement Value)

Sum Insured(Reinstatement Value)

Rate% 0

Premium

TOTAL

TOTAL

TOTAL

Yes / NoYe s / No

AMCUPS

Yes / NoYe s / No

Yes / NoYe s / No

Yes / No

Yes / No

Rate%0

Rate% 0

Premium

BURGLARY

ALLRISK

(PE)

ELECTRONICEQPT/

MACHINARYBREAKDOWN

L1

2

3

Electronic Eqpt/Machinary Breakdown

Equipment Details Make Yearof Mfg.

Serial No. ForIdentification

EEI / MB

EEI / MB

EEI / MB

* Basis of SI should be new replacement value of same make / model. # Mobile Phones / PDA’s are excluded.

Covers Electronic Equipment (upto 7 yrs) / Data Media Storage / Machinery Breakdown (upto 7 yrs)If above Equipment is also covered for Fire & Allied perils, 10% discount is given on the base of rate.

* Basis of SI should be new replacementvalue of same make / model.

Burglary Alarm system

RISK LOCATION

D D M M Y Y

‘ ’✓ for Reinstatement Value Policy (Bldg. & Contents only)Not for Stocks

Small Business Solutions

Business Guard

‘ ’✓

Building(with P&F)L

1

23

L

1

2

3

L

1

2

3

Premium

8/9/2019 Hotel n Restaurant

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Money in Safe Money in TillFrom To

Money in Transit

Sum Insured : _________________

Approx Annual Carrying (Rs.) Limit per TransitL1

2

3

First Loss Rate% 0

PremiumLimit per Transit

Rate% 0

Premium

Rate% 0

Premium

Rate% 0

Premium

Rate% 0

Premium

Rate% 0

Premium

TOTAL

Sum Insured

TOTAL

TOTAL

Sum Insured

Covers Money / Monetary Instruments (Indian currency) belonging to your business while inTransit or in Safe. Choose either Money in Transit on Annual basis or First basis.

Nature of Work Work Place (Office /Godown etc.)

No. of Employees(Permanent)

Total Annual Wages /Salaries

Contract Workers(attach details)

Covers permanent employees on Un-Named (Designation / Nature of occupation) & Total Annual Wages basis.Contractual employees are covered on Name & Total Annual Wages basis.

Name Age Occupation Any Infirmity /Disability

NomineeName

Relation CatetoryI / II / III

BenefitTable

A/B/C/D

Capital SumInsured (Rs)

1. Covers only persons in the Age Group 18 to 65 years. 2. Death, permanent disability, partial disability & temporary total disabilitycovers are available. Temporary total disability is available only for class I & II employees.

Liability Type Paid upcapital (Rs.)

Annual Turnover(Rs.)

Any OneAccident Limit (Rs.)

Non-Industrial

Any One YearAggregate (Rs.)

Covers accompanied Baggage co nnected with business / personal effects of the Insure d / Partner / Employees carried during

Travel anywhere in India.

Permanent Employees

Purchase Protection Sum Insured

Tenant’s Legal Liability Sum Insured

Designation Department Any One Event LimitAny One Year

Aggregate Limit

Un-named

Named

Details Location Year of Loss

No Claims

Yes, please furnish details

Cause of Loss Loss Amount

MONEY

ATM

WORKMEN’s

COMPENSATION

PERSON

AL

ACCIDE

NT

PUBLIC

LIABILITY

TlPP

BAGGAGE

FIDELITY

PAST3year

LOSS

RECORD

Assignment for Personal Accident Insurance

Place: ____________________

Date:_____________________

AML Guidelines

Signature of Proposer

L1

23

Rate% 0

PremiumDescription Site Location

Plate Glass / Neon Sign



No’s * Dimensions (L x B) Sum Insured

TOTALCovers All Plate Glass and Neon Signs secured & fixed within the stated premises only.* For ornamented / curved / glazed / etched glass and cover for specific items, give item wise dimensions.

PLATE

GLASS/

NEONSIGN

IMPORTANT

Prohibition of Rebates (Section 41 of the Insurance Act’ 1938)

1. Nopersonshallallowor offerto alloweitherdirectlyorindirectlyasinducementto anyPersontotakeor reneworcontinueanInsurancein respectof anykindof riskrelatingto livesorpropertyinIndiaanyrebateofthe wholeorpart ofthe commissionpayableorany rebateof thepremiumshownon thePolicy,notshallany persontakingoutor renewingor continuinga Policyaccept sucha rebateexceptsuchrebate asmaybeallowedinaccordancewiththepublishedprospectusesortablesoftheInsurer.

2. Any Person making default in complying with the provision of this section shall be punishable with fine which may extend to five hundred rupees only.

Declaration by Proposer

I / Weherebydeclarethatthe statementsmade byme / ushereinand inthe attachmentsheretoare trueto thebestof myknowledge andbeliefandI / Weherebyagreethat thisProposalshallfrom thebasis ofthe insurancecontractbetweenme / usand TataAIGGeneralInsuranceCompanyLtd.(referred toas theCompany).I / Wefurtherconfirmthatif anyadditions oralterationsare carriedout intherisk proposed forinsurance herein after thesubmission of this proposal then particulars of such shall be forthwithconveyedto theCompany. I / We further agreethat thesubmission of thisProposaltothe Companyandits receiptthereofshallnotconstitutean acceptanceof riskbythe Company.

1.I/weherbyconfirmthatall premiumshave been/willbe paid from bonafidesourcesand no premiums have been/willbe paidout of proceedsof crimerelatedto anyof theoffencelistedin Prevention ofMoney Laundering Act,2002.2. I understand thatthe Companyhas therightto callfor documents to establish sourcesof funds. 3.The insurance companyhas right tocancelthe insurance contractin caseIam/havebeenfoundguiltyby anycompetentcourtof lawunderanyof thestatutes,directlyor indirectlygoverningthe preventionof money launderingin India.

I / Weherebyassignthe moneypayable byTata-AIGGeneralInsuranceCo. Ltd,in theeventof mydeath tothe nomineenamedabove andI furtherdeclarethat his/her/their receiptshall besufficientdischargetothe Company

Tata AIG General Insurance Company LimitedRegistered Office : Peninsula Corporate Park, Piramal Tower, 9th Floor, G.K. Marg, Lower Parel, Mumbai – 400013.

Toll Free Nos. 1800 266 7780 • Visit us at www.tataaiginsurance.in

Payment Details

Tata AIG General Insurance Company LtdPayment Mode: Cheque DD Cash Credit Card (Only Visa / Master Card accepted) (Payable to .)

Cheque / DD No. Date

Bank Name Branch

Credit Card No. Expiry Date

PAN Card No. In the absence of PAN Card, please give details of any other authorized Photo ID

Photo ID Type Photo ID No.

Sources of funds (please where applicable) Salary Business Other (Please specify)______________________________✓

D M Y YD M Y Y

M Y YM Y Y

Hotel n Restaurant

Documents

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