Download Proposal for Fire Insurance

* This form consists of 4 pages Fire Branch Policy No .............................. KERALA STATE INSURANCE DEPARTMENT TRIVANDRUM PROPOSAL FOR FIRE INSURANCE Name of Proposer ............................................................................................................................. (In case of mortgage or other interest, the names of all parties should be given) Name of the Mill or Factory ............................................................................................................... Nature of Manufacture carried on ..................................................................................................... Period of Insurance from .............................................................................. to ............................... Number on Plan Description Amount to be Insured On the Building (Excluding plinths & foundation) On Machineryand Accessories On Stock in Process Total Note :- Detached buildings which adjoin but do not communicate with each other internally, must have a separate sum insured on each, and if stock or other effects are lodged into or more distinct buildings the sum to be insured thereon in each building must be specified. Perfect Party Wall :- A "perfect party wall" is a solid wall of concrete and/or stone or burnt brick properly bounded in cement, lime or mortar not less than 18 inches in thickness at any part and carried through and at least 18 inches above the roof, having no openings therein except such as are protected by fireproof doors and/or shutters or such as are used for shifts, straps and steam, gas or water pipes, these openings not being of more than sufficient size for the purpose and in no case exceeding 4 square feet in area. 1. When, where the premises erected? 2. Where is the building situate? Give the Municipal number and the name of the street and town where it is situated. East West South North 3. If the building bears no Municipal number, state the boundaries 4. What is the power used for driving the Machinery­(a) Oil Engine? (b) Steam Engine? (c) Electricity? 5. If steam power is used, is the Boiler in a detached building or in a fire-proof compartment within the Mill or Factory? 6. If the Oil Engine or the Boiler is in an adjoining or fire­proof compartment, what is the nature of the communication, (if any) with the Mill or Factory proper­(a) If there is any communicating doorway, how is it constructed and is it fire proof? (b) How is the wall, dividing the Engine or Boiler House and the Mill, constructed? (c) Is it not less than 18 inches in thickness? (d) Is there any opening excepting for shafts, straps and steam, gas or water pipes? (See note on page1) (e) If the roof is tiled, is the dividing wall carried through the roof to the extent of at least one foot? 7. How is the factory, lighted? By electric, gas, candles, kerosene or vegetable oil light? 8. Is any night work carried on between the hours of 9 p.m. and 5 a.m. 9. Where are the godowns situate? Are they clearly separated from the factory or adjoining the factory ? 10.If clearly separated, what is the distance from the nearest portion of the mill to the nearest portion of the godowns. Are they beyond or within 100 feet? (a) If adjoining, are they divided by perfect party walls? 11 Are there stocks in the open within 100 feet of godowns ? Described what kind of stocks will be stored in the open? 12. Describe the nature of process or processes carried on in the mill: (a) Rice hulling? (b) Groundnut decorticating? (c) Oil extracting? (d) Cotton ginning? (e) Cotton pressing? Note :- If any one or more process or processes are carried on state clearly. 13. If oil extraction is done state whether fire heat or steam heat is used for extraction of oil. Note:- The steam heat mentioned above has no reference to the use of steam or other engine in the engine house used for driving machinery in the mill. It refers only to that process whereby the extraction of oil is promoted by the application of steam heat by conducting steam, generated in a separate boiler house by suitable pipes to the stock in process in the mill proper. 14. How are the Buildings constructed? No. on plan Description of property Construction of Buildings Height of Building i.e, Number of Building includingbasement and attic Purpose for which the building is used External walls Floor Roof Engine House .. Boiler House .. Mill Hall .. Huller Hall .. Decoricator Hall .. Husk House .. Ginning Hall .. Pressing Hall .. Storage Godowns .. 15 Are there any Insurances in force on stock or on the Mill Buildings with other Offices? If so, please give particulars of same, i.e., amount insured and name of Company or Companies insuring. 16. Has the Insurance been proposed to this or any other office and declined? 17. Has this or any other Office declined to renew an Insurance on the properties? 18. If there are other premises adjoining or in close proximity (i.e., within 50 feet) to the Mill or Factory buildings, please describe particularly the construction and occupancy of such premises 19. State the nearest Railway Station with its approximate distance from the premises to be insured 20 (a) Do you take stock at least once a year? (b) Keep a proper set of account books? (c) Keep the said account books in a fire proof safe. 21. Have you suffered any loss by fire on the same property during previous years? 22 Please state precisely what fire extinguishing appliances are there? 23 Is cover required in respect of other perils in addition to fire or lightning such as riot and strike damage risks Earthquake, Explosion, Storm Tempest, Flood, Aircraft damage etc.? Please specify perils for which cover is required. GROUND PLAN AND DESCRIPTION OF THE PREMISES Note :- When the plan is not drawn to scale, it will be necessary to mark the dimension of the buildings and the distance separating each from the others. Internal communications between adjoining Buildings should be clearly shown on the Plan and care should be taken to describe fully the nature of the Division walls between Buildings which adjoin but do not communicate. Note :- If there are any insurances on the same property in force with this or other companies please supply a copy of the written portion of the Policy or Policies as it is important that all specifications of various Insurances covering the same property should be exactly similar in wording so as to prevent the possibility of inconve­nience or delay in the settlement of any loss. DECLARATION I, the undersigned hereby declare that the above statements and particulars are true, and I hereby agree that this declaration shall be held to be promissory and shall be the basis of the contract between me and the Kerala State Insurance Department and I am willing to accept a policy subject to the terms and conditions prescribed by the Department. ................................................................. (Signature of proposer) Date ............................ Address ......................................................... ......................................................... .........................................................