2. Period of Insurance:

3. Total Sum Insured

4. a) Boiler and Pressure Plant -

D D M M Y Y Y YToD D M M Y Y Y Y

Mr. / Mrs. / Ms. / Dr. / M/s.1. a) Name

b) Work Address (Site of the Property to be Insured)

Pin code State

Pin code State

Office +91Mobile No.Contact Nos.

Address

Bharti AXA General Insurance Company Limited

(

: customer.service@bharti-axagi.co.in SMS < > to 5667700: www.bharti-axagi.co.in

1800-103-2292

SERVICE

Boiler and pressure plant insurance policy Proposal Form- PEB

Important Note

Please fill this form in Block Letters and Tick the Boxes where appropriate

1 Intermediary details

1 of 4Bharti AXA General Insurance Company Limited, 1st Floor, The Ferns Icon, Survey No. 28, Next to Akme Ballet,Doddanekundi, Off Outer Ring Road, Bangalore 560037.ST Registration No.: AADCB2008DST001 Co. Registration No.: U66030KA2007PLC043362

Please answer all questions completely. This policy commences only after the proposal is accepted and subject to realisation of premium.

Indemnity under the Workmen's Compensation Act 1923 and subsequent amendments of the said Act prior to the date of the issue of the Policy; the Fatal Accidents Act, 1855; and at Common Law.

2 Proposers details

From

Sl. No. LocationDescription - Makers name,

Makers No., CapacityRegistration

NumberYear ofMake

SumInsured

b) Surrounding Property of the Insured including Property held in trust or on commission

Intermediary/Sales OfficerName Code

Branch Name Code

Sales Manager's Name Code

Campaign Name Code

Business Indicator Rural Indicator Yes No

2 of 4

c) Legal liabilities to third parties

a) Personal Injury Rs.

b) Property Damage Rs.

d ) On payment of additionalpremium do you wish to cover the following?

a) Express freight (excluding Air Freight), Overtime and Holiday rates of wages.

b) Air freight

c) Owner's Surrounding Property

d) Third Party Liability

i) Any One Accident

ii)Any One Year

e) Additional Customs Duty

If Yes, provide Limits of Indemnity

Rs.

Rs.

Rs.

Rs.

Rs.

Rs.

Rs.

If No, please tick the boxes given below

No

No

No

No

No

No

No

5.

7.

8.

9.

10.

6.

a) In case of Boiler, state if it is Water tube type?

b) If so, what is the evaporative capacity per hour

a) Do you wish to include the main steam piping?

b) If so, state whether cover required within 20 meters or 100 meters radius of the Boiler

a) Are all the items in good condition?

b) Give particulars of any defects.

a) Which items of Plant are subject to periodical inspection?

b) By whom are they inspected, and at what intervals?

c) Date of last inspection, working pressure approved, and period of such approval (attach copy of last report).

a) What is the maximum load on safety valve per square inch?

b) What is the working pressure?

State how Boiler is fired, e.g. Oil, Gas, Coal or Pulverized fuel.

a) Yes No

b)

a) Yes No

b) 20 m 100 m

a) Yes No

b)

a)

b)

c)

a)

b)

3 of 4

11. a) Are the Boiler Attendants solely employed on the Boiler Plant?

b) What are their qualifications?

c) What proportion of their time is given to other duties, if not solely employed on the Boiler Plant?

a) Yes No

b)

c)

12.

13.

15.

17.

18.

16.

14.

a) Is the Boiler Plant now Insured?

b) If so, state name of Insurer, and date policy expires.

a) Has the Boiler Plant at any time been insured by you?

b) If so, state name of Insurer, and date of policy expired?

a) Have you ever had an accident to your Boiler Plant?

b) If so, give full particulars on separate sheet.

a) Are any of the Boilers shown in the proposal automatically controlled?

b) If so, which ones?

a) Is any of the automatically controlled Boilers not under continuous supervision by person competent to operate it?

b) If so, which ones?

Have your any Boiler Plant in use other than that specified in this schedule?

In respect of Boiler Insurance, has any Insurer -

a) Permitted withdrawal of or declined any proposal from you?

OR

b) Cancelled or refused to renew your policy?

Note: Name of Insurer to be stated.

a) Yes No

b)

a) Yes No

b)

a) Yes No

a) Yes No

b)

a) Yes No

b)

a) Yes No

b) Yes No

a) Yes No

b)

4 of 4

19. Is Boiler under regular and frequent supervision whilst working?

Yes No

PF/

BP

P/O

RI/

10-0

9

3 Declaration

I/We hereby declare that the statements, answers and particulars are true to my/our knowledge and belief. It is hereby understood and agreed that the statements, answers and particulars provided are the basis on which the insurance is being granted and that if, after the insurance is effected is found that any of the above statements, answers or particulars are incorrect or untrue in any respect, then Bharti AXA General Insurance Co. Ltd., the Insurers, shall have no liability under the insurance.

If any additions/alterations are carried out in the risk proposed after the submission of this Proposal form then the same should be conveyed to the Insurers immediately.

Place:

Date:

1. No person shall allow or offer, 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 or 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 rebate as may be allowed in accordance with the published prospectuses or tables of the Insurer.

2. Any person making default in complying with the provisions of this section shall be punishable with fine, which may extend to five hundred rupees.

Note: i) The term 'Boiler' where used in the above schedule includes fittings, integral super heaters and integral economisers but does not include steam or feed water piping, separate super heaters, separate economisers, such items being covered by the Policy only is specifically listed in the schedule.

ii)Value of the Boiler and/or Pressure Plant older than 20 years must be indicated separately.

Insurance is the subject matter of the solicitation.

Proposer's Signature

4 Prohibition of rebates (section 41) of the Insurance Act 1938