PROPOSAL FORM FOR PUBLIC LIABILITY INSURANCE
(For Non-Industrial Risks)
Liability of the company does not commense until this Proposal has been accepted and premium paid. Territorial limit as applicable to policy is anywhere in Nepal.
All questions should be answered with respect to each unit/establishment.
1. Name of the Proposer (IN FULL)  
2. Address of Proposer  
3. Address and Full description of each of premises and/or chain of establishments to be insured  
  Current Address:    
  Contact Phone  
  Email Address  
  Address  
 
4. (a) Are Premises/ Equipment/ Machineries in sound condition of repair.  
(b) In so far surounding Areas/Property, have you complied with all Statutory Rules/ Regulations pertaining to permises and business activities :  
   
5. (a) Does the Premises have Boundary Fencing ?  
(b) Security/Safety arrangements ?  
(c) Details of systems provided for prevention of fire explosion etc.  
(d) Details of Emergency Plan  
         
6 Do you handle or use or Store Gases/ Hazardous /Toxic/Radioactive Materials and/or equipments in premises. If yes, please give details of max capacity stored/ used/ handled at one time.
7. Please give claims history for last three years  
  Year
  No.of claims
  Total amount paid
  Bodily Injury
  Property damage
  Cost of defence actions
  Total amount of pending claims
  Bodily Injury
         
8. Has your proposal or renewal been declined or premium been increased or special terms has been imposed by any insurer in past ?  
9. Please indicate limit of indemnity required    
  (a) Any Person  
  (b) Any one accident  
  (c) Any one year  
       
10. Policy Period required From  
To  
11. Do you need cover against risks associated with food and beverages served in your establishment  
       
I/We desire to effect an insurance in terms of the Public Liability Policy of the company against the limits of indemnity specified above. I/We hereby declare that all statutory provisions relating to may/our premises proposed for insurance are complied with. I/We further declare that the above statements and particulars are true, and I/We have not omitted, suppressed, misrepresented or misstated any material fact and I/We agree that this declaration shall be the basis of the contract between me/us and the company and incorporated therein.
 
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