8/9/2019 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
AOG 20 lakhs / Others 10 lakhs
AOG 30 lakhs / Others 15 lakhs
AOG 60 lakhs / Others 30 lakhs
AOG 100 lakhs / Others 50 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
Plate Glass / Neon Sign
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
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