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

1.	Name and address of the Poultry Farm: ________________________________

2.	Name and address of the Bank: _______________________________________

3.	Name and address of the owner/s: _______________________________________

____________________________________________________________________

4.	Date of filing of proposal form: ___________________________________________

5. Type of Birds: Broilers/Layers/ Hatchery 
                             Description of the Birds to be insured 
Unit	Date of Hatch of birds	Date of 
Purchase	No of birds purchased as per delivery challan 
	Total no of birds in the unit at proposal	Breed strain	Age in weeks at proposal	Source of purchase 	Expected date of disposal 	

6.	What is the system of Housing of the Birds? 
i. In brooding House          Deep Litter/cage system
ii. In grower House            Deep Litter/cage system
iii. In layer House  	         Deep Litter/cage system	

7.	Equipments: 
i.	No of feeders: ______________
ii.	No of Drinkers: ______________
iii.	No of Brooders: _____________

8.	Is a qualified Vet. Surgeon  employed to look after the farm:
9.	If yes, please give his:
1.	Name: ________________________________________________

2.	Qualification: ___________________________________________

3.	Regd. No. ______________________________________________

4.	Is he residing at the farm 24 hours

10.	If qualified Vet. Not employed then on 
    whose services you depend upon:        ______________________________

11.	Details of other Technical persons residing at the farm premises 
Name: ___________________________

Qualification: ______________________ 
       
           Job Description: ______________________

12.	Are the diagnostic equipment/agents maintained at the farm: ____________________

13.	Do you stock essential medicines at the farm: _________________________________

14.	Do you manufacture your own feed or get it from the market: _____________________

15.	Is the owner/partner/associate experienced in poultry farming 
Or have undergone any training: ____________________________________________

16.	Details of vaccination conducted during last six months:
Unit No	Date of vaccination	Age of birds 	Disease against which vaccinated vaccination 	Trade No 	Name of vaccine	Batch No	Vaccination done  	

  17. Details of debreaking                Unit No.                  Date of debreaking   

  18. Details of deworming                Unit No.                  Date of deworming   

  19. Has there been any epidemic outbreak during last 
        3 years? If so, give details: ________________________________________________

   20. Do you maintain the following records?
a)	Flock record on day to day basis: _____________________________

b)	Mortality record: __________________________________________

c)	Culling: _________________________________________________

d)	Vaccination and medication particulars: ___________________________

e)	Feed consumption: ___________________________________________

f)	Production: _________________________________________________

g)	Debreaking: _________________________________________________

h)	Incidence of diseases: __________________________________________

i)	Purchase and sales: ___________________________________________

    21. Since when the farm is established? _______________________________________
    22. Have you earlier at any time proposed 
         your birds for insurance? If so, give name
         and address of the Company: _____________________________________________
   23. Has any Company:
1.	Declined to issue a policy to you? ________________________________________
2.	Declined to continue insurance? _________________________________________
3.	Not invited renewal of policy? ___________________________________________
   24. Period of Insurance for the present proposal:
         From _________________________ to  ____________________________________

       I agree to declare daily mortality details on weekly basis to the company.
       I/We declare that the foregoing statements are true to the best of my/our knowledge and belief, that I/We have disclosed all particulars affecting the assessment of the risk. I/We agree that this proposal and declaration shall be the basis of contract between me/us and the company.

Date: ___________					_________________________________

Place: ___________  					Signature of the Proposer