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

householder’s INSUrANCE

Proposal form cum schedule attached to & forming part of policy no.

AGENCY							PERIOD OF INSURNACE					                                                FROM   :
                                                                                                      TO      :													  
INSURED :
										:
	1.	NAME OF PROPOSER IN FULL

2.	RESIDENtIAL ADDRESS

3.	OCCUPATION

SECTION NO .  DESCRIPTION OF PROPERTY       SUM              RATES              PREMIUM
                                                                                 INSURED        (per mille)           (for the use 
                                                                                                                               of the company)                              	             Rs.                                                                                       
                              
----------------------------------------------------------------------------------------------------------    

I                   (A)BUILDING(OFCLASS-ACONTRUCTIONONLY)                                            0.50
FIRE AND     (B)CONTENTS : (Excluding Jewellery/Valuables)					Belonging to the proposer and members of his family permanently		
allied  perils	Residing with him....................                                                                               0.50

II		CONTENTS : 
burglary and		All contents in the Premises stated at the address above                                2.40	
housebreaking
INCLUDING         	note  :  Insurance on contents should be for value equivalent to       
LARCENY OR		              the value mentioned under item I (B) above
THEFT

III		jewellery & valuables :	
ALL RISKS		Description of  jewellery and valuables-value........                              10.00
	 
IV	
PLATE GLASS	Description of plate glass and its value....................                                               10.00	

V		Description of all Electrical, Electronic and     Year of Make              Values            2.50
BREAKDOWN	Mechanical Appliances, Apparatuses or		
OF DOMESTIC	Gadgets belonging to the proposer
APPLIANCES		                                                                                 Total...............		
VI	
T.V. SET	         Name of Manufacturer    Make                    Model      Year of              Value          10.00
			                                                                          Make

VII		Make & name of      Year of mfgr.            Frame                  Value including  
pedal		Manufacturer                                             No.                       accessories
cycles		1.	                                                                              Rs.
		2.	                                                                              Rs.
3.	                                                                              Rs
4.	.                                                                             -------------------------- 
			                                                                              Rs.                                        20.00
                                                                                                                  -------------------------
VIII		Details of Personal Baggages, Personal effects and other articles carried                      
BAGGAGE		(During the period of Travel anywhere in India)..........                                                 7.50
Insurance		Total...............Value

IX		Name              Age     Occupation      Relationship         Details of       Table    	Name of   As per         
PERSONAL			                                                        with                 Existing      opted        Assignee	         Schedule               accident		 	                                                   Proposer            infirmity/                   & relation-		 			                                                                                  disability                           ship	                                        						 
	NOTE : 	(i) 	For Table of Benefit sheet information sheet.
		       (ii)	for assignment of benefit in case of death (Please see below)	
 
X	(A)	Public Liability                                                                                                              0.50                                       
PUBLIC	(B)	W.C. Liability for domestic servants                                                                           as per     
                                                                                                                                                              tariff	                                                

 	                               
Note :	1.	The liability of the company does not commence until the proposal
		has been accepted by the company and the full premium paid.	                                              	2.	If space found is insufficient please attach separate sheets for details                                                                                                      
                                                                                                                                         												   		                                                                                                TOTAL  PREMIUM       Rs.
                                                                                                                                   Less : Discount for 
	.                                                                                                                     covering more than 
				                                                                                                 4 Sections  ..........%   Rs.
		                                                                                                                  Service Tax 5%           Rs
                                                                                                                                                                       -------------------. 	
					          Rs	                                            .
I/we hereby declare the particulars contained herein are true and correct and that no  material fact has been withheld,misstated or misrepresented  and also that this Proposal-cum-Schedule forming part of the company's standard policy shall be the basis of the contract between me/us and the company.I/we further declare that  the sum insured herein represents the full  value of the property described herein.

PLACE :

DATE   :                                                    Signature of Proposer