UNITED INDIA INSURANCE CO.

LTD
(Regd H.O. : No.24, Whites Road, Chennai – 600 014.)

BRANCH / DIVISIONAL OFFICE ……………………………

PROPOSAL FORM FOR FIDELITY GUARANTEE INSURANCE (EMPLOYER)

SCOPE OF COVER
This Insurance Policy provides indemnity to Employees against any direct financial loss, including loss of
goods, caused by fraud or/of employees.

EXCLUSIONS
The insurance policy does not cover loss:
(a) Discovered more than 12 months after the termination either of the guarantee or of the service of
employee concerned.
(b) When there has been any change in the agreed system of check of accounting precautions without the
Insurer’s prior consent.
(c) Caused by an employee after discovery of his previous fraud or dishonesty.
(d) Such as stock taking shortages, trading losses not caused by fraud or dishonesty.

Basis of Insurance
Named employees can be selected and guaranteed for specified amounts. Employees can be guaranteed for
a total amount overall or for separate amounts in respect of different categories.

NOTE:
1. THE FOREGOING IS ONLY A BROAD INDICATION OF THE COVER OFFERED.FOR
DETAILS PLEASE REFER TO ANY OFFICE OF THE COMPANY.

Please reply fully to all the following questions. If the answer to any question is none state ‘NONE’

1. (a) Name and address of the Employer

(b) Description of Business

(c) Since when established

2. Details of Employees to be guaranteed

Names Duties Since when Place of Total Amount to be Any other

in service Employment remuneration guaranteed security
taken
3. Is there a system to obtain references from
previous employers?
If not, specify practice followed.

4. State the estimate amount held by any employee at any one time and for how long?
(a) Money : Amount : ________________ (b) Stock: Amount: ________________
Period : ________________ Period : ________________

5. Has there been any occasion to question

honesty or conduct of any person proposed for guarantee
(a) How often are the employees required
to account for money?
(b) What independent system is there to
check that all sums received by employees are accounted for?

6.
(a) Do employees pay out of money or draw
cash from Employer’s account?
(b) System of operation of Bank Account and
precautions taken
(c) Whether such payments/withdrawals are
authorised by a senior employee and compared
with supporting documents?

7. How often the cash book is balanced, the entities

checked with vouchers and Bank’s Pass Book and
with counterfoils of receipt books?

8. How often are the Proposer’s books balanced?

9.
(a) System followed for purchase of goods
and recording deliveries
(b) System followed for authorising despatch
of goods and ensuring that despatch is
recorded and charged to the customer?

10. How often and by whom stock verification

is done?

11. System for collecting outstanding accounts

12. How often will statements of account be

furnished by the proposer direct to Customer’s?

13. What’s the extent and frequency of audit?

14. Details of losses suffered on account of infidelity

of any employees during last 5 years and steps
taken to prevent recurrence

15. Has any company in respect of any fidelity

guarantee insurance declined your proposal?
Cancelled or refused to renew policy?
Accepted your proposal on special terms and conditions.
 I/We do hereby declare and warrant that the above statements and answers are true and that I/We
have not withheld any information whatsoever regarding this proposal. I/We agree that this proposal and
declarations shall be the basis of the contract between me/us and United India Insurance Company Ltd.
Whose policy for this insurance is acceptable to me/us. I/We undertake to exercise all ordinary and
reasonable precautions for safety of the property as if it were uninsured.
Place : Proposer’s Signature

Date :

NOTE: 1. The liability of the Company does not commence until the proposal has been accepted and
premium paid.
2. Premium will be quoted on application
3. To obtain full indemnity insure for adequate guarantee for each employee.

Development Officers Report

The proposer is known to me/my agent for ………………………….. years and I recommend acceptance of
this proposal.

Place:

Date : Signature of Development Officer

Name and Code No of Development Officer

PROHIBITION OF REBATES
The following is the copy of section 41 of the Insurance Act, 1938.
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 or risk relating to lives or property in
India any rebate of the whole or part of commission payable or any rebate or the premium- shown on
the policy not shall any person taking out or renewing continuing a policy except any rebate as may be
allowed in accordance with the published prospectuses or tables of the insurer.
2) Any person making default in complying with the provision of this section shall be punishable with
fine which may extend to five hundred rupees.
 PROPOSAL FORM FOR FIDELITY GUARANTEE INSURANCE (EMPLOYEE)
NOTE : PLEASE ANSWER EVERY QUESTION AND FULLY

1. Write your full name, address and nationality

(a) Age

2. Are you single, married or a widower?

3. (a) Have you a family?

(b) If so, state number of children?
4. How many persons in all, are dependent on you?

5. Give name, address and occupation of your father or nearest relative.

6. Are you a house holder?

(a) If not do you reside with your relatives?

7. At what addresses have you resided during the last three years?

8. Amount of security required?

9. Nature of duties in respect of which this guarantee is required?
10. Full Name and address and business of employer for whom this guarantee is required

11. State salary and give full particulars of any other remuneration from the employment.

12. State clearly and separately how and Full name and address Reason for
where you have been occupied during of the Employer Leaving
the last seven years, given full names
and addresses of all employers, your
period of service and reasons of leaving,
in each case please note the whole period
of seven years must be accounted for.

From …………. To ………………

as …………… with ……………
From …………. To ………………
as …………… with ……………
From …………. To ………………
as …………… with ……………
From …………. To ………………
as …………… with ……………
From …………. To ………………
as …………… with ……………

13. Have you any private or business liabilities? If so state the amount?
14. Were you ever bankrupt or insolvent or did you
ever arrange with your creditors? If so, please
state the circumstances which led to your financial
difficulties, the name and address of the Trustee,
and whether you are now free of all liability.

15. Is your life insured? If so, please state for what

amount, where and whether the policy is in your possession

16. Do you possess any property, are you entitled to

any in reversion?
If so, state generally its nature and whether encumbered?

17. Have you any source of income besides the remuneration

derived from the employment for which the guarantee
is required? If so, give particulars.

18. Are you surety for anyone? If so, give particulars:

19. Have you ever applied for a Guarantee to this

or any other insurer?
If with, what company and at what date?
Whether the application accepted or declined?

19. Give the names of two or more persons(not relatives)

who have known you intimately for some time and to
whom reference may be made.

Name of referees (Block Letters) Occupation Full Postal Address

I hereby declare that in all my replies on this proposal form I have stated the truth without any
reservation.

Place :

Date : Signature of Proposer

 UNITED INDIA INSURANCE CO. LTD
(Regd H.O. : No.24, Whites Road, Chennai – 600 014.)

BRANCH / DIVISIONAL OFFICE ……………………………

PROPOSAL FORM FOR FIDELITY GUARANTEE POLICY FOR GOVERNMENT SERVANTS

QUESTIONS TO BE ANSWERED BY THE EMPLOYEE

1. Full Name and address of the applicant

2. Age of the applicant

3. Marital Status and the number of persons

Dependant on the applicant

4. (a) Amount of Insurance required

(b) Period for which cover is required

5. (a) In what capacity is the applicant

working and in which department?

(b) Is the applicant required to handle

cash and or stock as part of his/her
duties?

6. (a) Is the applicant in permanent service?

If not state the tenure of his/her service?
(b) Salary and other allowances the applicant
draws in respect of this appointment

7.
(a) If the applicant is required to handle
cash please state whether the books
balanced daily?
(b) Is the applicant permitted to retain
cash overnight? If so, what is the
maximum amount so permitted to be
retained any one time? How the cash is
secured during night?

8. If the applicant is in charge of stock please

state the nature and value of stock and whether
they are physically verified periodically.

9. Is the applicant authorised to issue receipts

on behalf of the employer? If so please state
(a) Whether a printed serially numbered receipt
Book with counterfoils is used
(b) Whether his/her work is supervised by any
other superior?

10. State the designation and address of the Officer

to whom the policy is required to be issued.

11. State the designation and address of the Applicant’s

 immediate superior to whom the policy should be sent?

12. Has any insurer previously granted a cover in respect

of the risk proposed for insurance? If so please state
(a) Name of the insurer
(b) The period of insurance

13. Please give the names and addresses of 2 persons 1.

who are not related to the applicant but who are
known to the applicant for at least 3 years to whom 2.
the company may refer if necessary

14. Premium remitted by cheque/DD/Money order No …………………..

Date …………………

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 …………………

PROHIBITION OF REBATES
The following is the copy of section 41 of the Insurance Act, 1938.
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 or risk relating to lives or property in
India any rebate of the whole or part of commission payable or any rebate or the premium- shown on
the policy not shall any person taking out or renewing continuing a policy except any rebate as may be
allowed in accordance with the published prospectuses or tables of the insurer.
2) Any person making default in complying with the provision of this section shall be punishable with
fine which may extend to five hundred rupees.