MACHINERY BREAKDOWN INSURANCE PROPOSAL FORM





Has any of the Machinery to be insured, been insured previously by other insurance companies? YesNo
If yes, mention the items of the specification and the name of Insurance Company

CLAIMS HISTORY FOR THE PAST (3) YEARS







YesNo

YesNo

YesNo
YesNo

YesNo


MAINTENANCE OF MACHINERY



Is the last statutory report / certificate up-to-date and satisfactory?
(Please attach copies) Only PDF, Excel, Word & JPG Files are accepted.


Please ATTACH document of all items to be Insured, in the below format:

Item No. | Description of Items | Year of Manufacture | Remarks | Replacement Value

NOTES:
1. Please give full description of all machines in column No. 2 including name of manufacturer, type, capacity, speed, load, weight, voltage, amperage, cycles, fuel, pressure, temperature, etc.
2. Replacement value in column No. 4 must be calculated on the current cost of replacing the machine by new machinery of same kind and capacity (inclusive of oil in the case of transformers and other electrical equipment) plus freight charges, custom duties, cost of erection,
3. If you also wish to cover the foundations, declare the value of foundations separately for each machine.
4. If any of the machines is a “stand-by”, the same should be identified in the following schedule.


Only PDF, Excel, Word & JPG Files are accepted.

DECLARATION:
We hereby declare that the statements made by us in this Proposal are, to the best of our knowledge and belief, complete and true, and we hereby agree that this Proposal forms the basis and is part of any policy issued in connection with the above risk(s).

Important: No insurance is in force until this Proposal has been accepted by the Company