* This form consists of two pages KERALA STATE GOVERNMENT INSURANCE DEPARTMENT PROPOSAL FOR GOVERNMENT FIDELITY BONDS STATE : KERALA Questions to be answered by the Employee 1. Your full Name and Address 2. Age and place of birth 3. Whether Single, Married or Widower 4. What is the Amount of Guarantee required. Date of commencement of risk. 5. In what capacity are you working and in which Department 6. What salary and other allowance you receive in respect of this appointment. 7. State the Designation and Address of the Officer in whose name Bond is required. 8. State designation and address of your immediate superior to whom the renewal notice should be sent. I hereby declare that the above answers are correct without any reservation whatsoever on my part. Date: Signature of the Employee Counter signature of Superior Officer Designation INSURANCE ACT, 1938 (Section 41- Prohibition of Rebates) Your attention is drawn to Section 41 of the Insurance Act, which reads as under : 1. No person 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 show on the policy, nor shall any person taking or renewing a policy accept any rebate as may be allowed in accordance with the published prospectuses or table of the insurers. 2. Any person making default in complying with provisions of this section shall be punishable with fine which may extend to five hundred rupees. KERALA STATE GOVERNMENT INSURANCE DEPARTMENT Annexure to the Proposal for Government Fidelity Bonds. 1. Is the applicant required to handle cash and / or stock as part of his/her duties. 2. Is the applicant in permanent service ? If not, State the tenure of his/her service. 3. (a) If the applicant is required to handle cash please state whether the books are balanced daily. (b) Is the applicant permitted to retain cash overnight? If so, what is the maximum amount so permitted to be retained at any one time? How the cash is secured during night ? 4. If the applicant is in charge of stock, lace state the nature and value of the stock and whether they are physically verified periodically. 5. Is the applicant authorised to issue receipts on behalf of the employer? If so, Please state 6. (a) Whether a printed serially numbered receipts book with counterfoils is used. (b) Whether his/her work is supervised by any superior. 7. Is the applicant covered under any previous policy issued by the Corporation? If so, Please state the number of policy and the period of Insurance. I hereby declare that the foregoing answers are correct without any reservation whatsoever on my part. Date: Signature of Employee Counter signature of Superior Officer Designation
