NATIONAL INSURANCE COMPANY LIMITED
(Subsidiary of General Insurance Corporation of India )
Regd. Office : 3, MIDDLETON STREET, CALCUTTA – 700 071

Code
DEV. OFFICER AGENT

PROPOSAL FORM FOR MONEY INSURANCE

This insurance Policy provides cover against loss of money in transit, by the insured or insured’s authorised employee
(s) occasioned by robbery, theft or any other fortuitous cause.
This Insurance Policy also covers loss by Burglary or house breaking whilst money is retained at Insured’s premises, in
safe (s) or strong room.
EXCLUSIONS
This Insurance Policy does not cover loss or damage due to Flood, Cyclone, Earthquake and other Convulsions of
nature, War and Warlike Operations, Civil Commotion, Riot and Strikes & Terrorists Activities, Shortage due to error
or omission, by use of keys to safe (s) or strong room, unless such keys are obtained by force or threat, whilst being
carried under contract of affreighment, theft from unattended vehicle and consequential loss.
DEFINITION
Money shall mean and include Cash, Bank Drafts, Currency Notes, Cheques, Postal Orders a Money Order and Current
Postage Stamps.
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NOTE :
a. THE FOREGOING IS ONLY A BROAD INDICATION OR THE COVER OFFERED, FOR DETAILS
PLEASE REFER TO ANY OFFICE OF THE COMPANY.
b. Ensure that the sum fixed as limit of the Company’s liability in respect of any loss is adequate to get full
protection.
c. This type of Insurance is also available in Shopkeeper’s Policy.
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NOTE : PLEASE ANSWER EVERY QUESTION AND FULLY.
1. Name of Proposer (in full) (IN BLOCK LETTER)
2. Business Address :
FOR OFFICE USE ONLY
ACCEPTED BY ...............................................
DATE & TIME .................................................
ROLL ...............................................................
REMARKS .....................................................
POLICY NO....................................................
COLLECTION/SCROLL NO.........................
3. Business or Trade :
4. DESCRIPTION OF MONEY TO BE INSURED . ( IF NO INSURANCE IS REQUIRED FOR ANY ITEM,
INSERT “NIL”)
Section Money
No.
Estimated annual amount sof Money
in transit, which will be the basis on
which the provisional premium will
be charged
Rs.
Highest amount in transit at any one
time which will be limit of the
company’s liability for any one loss.
Rs.
(I) A. Money for payment sof wages,
salaries & other earning or for petty
cash, in direct transit from the Bank
to the Insured’s premises, from the
time the money is received at the
Bank by the insured or authorised
employees of the Insured, until
delivered at the premises or other
place sof disbursement, and whilst
there until paid out, provided that
outside business hours, money shall
be secured in locked safe (s) or
locked strong room on the premises,
cheques drafts by the insured to
provide for such Money are also
covered whilst in transit, from the
premises to the Bank.
B. Money (other than described in
item A above), in transit from to
Insured’s Premises/Bank/P.O. / Any
other specified premises.
C. Money (other than described in
items A & B) collected by and in the
personal custody of the Insured or the
authorised employees of the Insured,
whilst in transit to the premises or
Bank, within a period not exceeding
48 hours, from the time of collection.
ESTIMATED TOTAL ANNUAL
AMOUNT OF MONEY IN
TRANSIT
(II) Money (other than described in
Section IA above) whilst on the
premises during the Business hours
or whilst secured in locked safe (s) or
strong room, on the Insured’s
Premises, outside business hours,
against in risks of Burglary,
Housebreaking, Dacoity Robbery and
Hold up.
MAXIMUM AMOUNT OF
MONEY HELD AT ANY ONE
TIME :
5. a)What is the maximum distance
over which the money will be
conveyed ?
b) Addresses of premises
between which money will
be carried.
6. Are employees authorised to
handle/carry money covered
under Fidelity guarantee Policy
? If yes, give details.
7. How is the money carried ?
Give whether in bags, trunks etc.
?
8. What means of transport do the persons carrying the
money use i.e. own car/ public transport etc. ?
9. Are the persons carrying the money accompanied by
an armed guard/s ? If not, state protection if any, is
provided for them.
10. Do you need to cover against Riot and Strike and
Terrorist activities on payment of Additional
Premium.
a. Do you wish to insure the Employees whilst carrying
and/or accompanying cash against bodily injury
inflicted during hold up ?
11. a. State following particulars of safe(s) and/or strong
room in which money will be kept outside business
hours.
Maker’s Name
Weight
Dimensions
Identification Number
b. Address of premises where rack is kept.
c. Is it fixed to the walls or floor ?
d. By whom are the keys of the safe(s) and/or strong
room held ?
e. Are all such keys removed from the premises outside
business hours ?
f. Will the premises be guarded whilst they are closed
for business ?
12. Have you ever sustained any loss of money whilst in
transit or whilst on your premises ? If so, give full
particulars.
13. Has any Company in respect of Money insurance
a. Declined your proposal ?
b. Accepted your proposal on special terms and
conditions.
c. Cancelled or refused to renew your Policy.
(a)
(b)
(c)
14. Has the risk been previously Insured ? If so.
a. The name of the Insurance Company.
b. Policy No.
c. Period
d. Rate charged
e. Any special terms and conditions imposed.
15. Period of Insurance :
From.....................................To ..........................................
I/We hereby declare and warrant that the above statements are true and complete. I/We agree that this proposal and the
declarations shall be the basis of the contract between me/us and the company and I/We agree to accept a Policy.
Subject to the conditions prescribed by the Company and to renew at the end of each period of Insurance a Statement in
the form required by the Company of all money conveyed and to pay premium on the amount in excess of the amount
estimated above.
Date : ............................. 20 Proposer’s Signature .................................
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Development Officer’s Report
D.O.’s Report. : The Proposer is know to me/my agent for .......................years and I
............................................................................ Recommend acceptance of this proposal.
Date : ........................... 20 Signature D.O. ................................................................................
Place ...................................... Name & Code No ..........................................................................
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PROHIBITION OF REBATES
Section 41, of insurance Act 1938
(1) No persons shall allow or offer to allow, 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 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 provision of the Section shall be punishable with fine
which may extend to five hundred rupees.
Skd./ money insurance proposal