Bajaj Allianz General Insurance Company Limited

Regd. Office & Head Office : GE Plaza, Airport Road, Yerawada, Pune - 411 006.
CIN: U66010PN2000PLC015329

Marine Cargo Proposal Form

Important: This proposal for Insurance will be the basis of any subsequent Insurance Policy that we issue to you. It is essen al that
you answer fully and accurately all of the ques ons contained in this proposal, and that you provide us with any and all addi onal
informa on relevant to the risk to be insured or our decision as to the acceptance of the risk or the terms upon which it sh ould be
accepted. Your failure to comply with this obliga on now may result in the rejec on of your claim and the avoidance of your policy
when a claim is made. If you are in any doubt about the informa on to be given, please seek the advice or guidance of your
insurance advisor or agent. If there is insufficient space in this proposa l for you to provide relevant informa on, whether as
requested or otherwise, please a ach a separate sheet to this proposal and return it to us.

1) PERSONAL DETAILS
a) Proposer’s Name & Address
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
b) Customer ID, if any: _________________________ Pincode: ___________________________________
c) Contact Person, if any: __________________________________________________________________________________
d) Telephone: ________________________________ E-mail ID:___________________________________
2) CARGO DETAILS
a) Goods Proposed for Insurance _________________________________________________________
b) Specify whether New or Secondhand _________________________________________________________
c) Nature of Packing used _________________________________________________________
d) Conveyance(s) and/or shipping _________________________________________________________
e) Containeriza on Details _________________________________________________________
f) Terms of Sale, whether FOB or CIF or similar terms _________________________________________________________
g) RR/GR/BL/AWB No., and date if any _________________________________________________________
h) Details of the carrying vessel/vehicle _________________________________________________________
such as name/no. and name of the transporter
i) Value of Cargo (for specific voyage) _________________________________________________________
j) Basis of Valua on _________________________________________________________
k) Sum Proposed for insurance (for specific voyage) _________________________________________________________
l) Annual Turnover (other than specific voyage) _________________________________________________________
m) Limit per Sending (other than specific voyage) _________________________________________________________
n) Limit per Loca on (other than specific voyage) _________________________________________________________
3) COVER DETAILS
a) Type of Policy required (please ck whichever is applicable)
i) Inland Transit □
ii) Inland Transit plus FOB □
iii) Overseas Transit □
iv) Specific Policy/ Declara on Policy/ Open Cover/ Open Policy □
v) Others (please specify): _____________________________________________________________________________
_________________________________________________________________________________________________
b) Voyage Details From ________________ To ________________
c) Distance less than 100 kms Yes □/No □
d) Period of Insurance From ________________ a.m./p.m. To____________ midnight
e) Mul transit involved Yes □/ □
No
(if yes, please state whether cover for intermediate processing is required) _______________________________________
_____________________________________________________________________________________________________
f) Transhipment, if any with details Yes □/No □
If Yes, specify the Place :_____________________
No. of weeks : ____________________
g) Is Storage cover required? Yes □/No □
1
 Bajaj Allianz General Insurance Company Limited
Regd. Office & Head Office: GE Plaza, Airport Road, Yerwada, Pune- 411 006.

h) Periodicity of Declara on (other than specific voyage)

Specific / Weekly / Fortnightly / Monthly / Others_______________________ _____
i) Type of Cover (please ck whichever is applicable)
i) Inland Transit (Rail/Road) Clauses A / B / C
ii) Ins tute Cargo Clauses A / B / C
iii) War and / or Strikes Clause
iv) Ins tute Cargo Clauses (Air)
v) Post Parcel Clause
vi) Duty Insurance Clauses
vii) Increased Value Insurance Clauses
viii) Ins tute The , Pilferage and Non Delivery Clause
ix) Others (please specify) ______________________________________________________________________________
_________________________________________________________________________________________________
j) Do you want to take on part of every loss: Yes □/No □
If yes, please specify the % of loss _____________________________________________
4) CLAIM EXPERIENCE (For last Three years excluding current year)

Claims (Rs.)
Department Year Premium (Rs.)
Paid Outstanding
MARINE

OTHER THAN MARINE

5) OTHERS
Has any other insurer refused to accept this insurance or imposed condi ons to accept the same? Yes No □/ □
If Yes, give details _________________________________________________________________________________________
________________________________________________________________________________________________________
Rate of premium charged by previous insurer, if any ______________________________________________________________

I/WE hereby declare and warrant that the above statements are true and complete in all respects and that there is no other
informa on which is relevant to my applica on for Insurance that ha s not been disclosed to you. I/We agree that this proposal
and the declara ons shall be the basis of the contract between me/us and Bajaj Allianz and I/We agree to accept a policy,
subject to the condi ons prescribed by Bajaj Allianz and to pay premiums on the amount es mated above at the start of each
policy period. I/We undertake to exercise all ordinary and reasonable precau ons for safety of the property as if it were
uninsured.

I/we have read and understood the Privacy Policy of your Company and I hereby uncondi onally agree and bind myself to all
terms and condi ons of your Privacy Policy, as amended, from me to me.

____________________________
SIGNATURE OF THE PROPOSER
(WITH OFFICIAL SEAL,IF ANY)
SECTION 41 OF INSURANCE ACT, 1938
No person shall allow or offer to allow either directly or indirectly as an inducement to any person to take out or renew or con nue
an insurance in respect of any kind of risk rela ng to lives or property in India, any rebate of 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 con nuing a policy accept
any rebate except such rebate as may be allowed in accordance with t he published prospectuses or tables of the Insurer.
Any person making default in complying with the provisions of this sec on shall be punishable with fine, which may extend to Five
Hundred Rupees.