MONEY INSURANCE PROPOSAL FORM
 

1.

      Contact Information

Name of Proposer

Contact Name (inc Title)

Business/Occupation

Premises where safe is kept ?

Current Address:
 

Contact Phone

Fax

P.O.Box
Email Address

Address

2.

 Money In transit:

 

Describe fully Money in transit to be Insured
   

The expression “MONEY”  means Cash, Bank Notes, Cheques, Money Orders, Postal Orders, Bills of Exchange and Postage and other Stamps having a monetary value.

 

(a)
Bank to Premises
Money for payment of wages in direct transit from Bank to Insured / Authorized Employee (s) until delivered at Premises

 

Limit of Liability Maximum amount carried any one Time

Cash  

Cheques

Estimated Annual Carrying

Cash  
Cheques

Maximum distance involved in transit

Maximum Amount Retained In Locked Safe (if none, state "NIL")

If wages and salaries are not paid away on the day drawn from the Bank,state maximum amount of such moneys held in locked safe or strong room out of business hours

maximum amount Retained in locked safe
Cash  

Cheques

maximum period kept in locked safe

Remarks.............

 

 

 (b)

Premises to Bank

Money other than (a) above in transit from premises to Bank or other places  and vice versa,

(please specify)

 

Limit of Liability Maximum amount carried any one Time
Cash  
Cheques

Estimated Annual Carrying

Cash  
Cheques

Maximum distance involved in transit

 

(c)

Travelers and Collectors

Money (other than A and B above) collected by employees for delivery to Proposer's Premises or Bank subject to delivery being made on the same day as received

 
Limit of Liability Maximum amount carried any one Time
Cash  

Cheques

Estimated Annual Carrying

Cash  

Cheques

Maximum distance involved in transit

 

 

 (d)

 

Others: (if none, state "NIL")

(please describe fully such transit)

 

Limit of Liability Maximum amount carried any one Time

Estimated Annual Carrying

Maximum distance involved in transit

 

 

  please give details of security arrangements in force to  protect money

 

 

 

 

i-

How will the money be conveyed?

 

 

 

ii-

How is money protected?

 

iii-

How often journeys made ?

 

 

 

iv-

Are journeys made only during business hours ?

 

 

 

v-

Number of employees engaged in carrying cash ?

 

vi-

Are employee (s) engaged in carrying cash covered under Fidelity Guarantee Policy.

 

 

If So, with whom ?

 

  

if not,

 

 

vii-

Do you wish to extend  Insurance to include this cover?

 

 

This insurance covers losses arising from fraud or dishonesty of employees engaged in carrying cash.

 

 

viii-

Will such employees  be armed or accompanied by armed guard ?

 

 

 

  

If armed guards do not accompany,

 what precautions are provided ?

 

 

3.

 

Cash In Safe:

Money on the Premises (other than under A)

 

 

 

State whether you wish to insure against loss of money by housebreaking or burglary from locked safe or strongroom

or by hold-up while on the premises including damage to any safe or strongroom. 

Remarks

 

  

 

 

Please give particulars of safe and strong rooms in

which money is contained out of business hours.

(if not Required, state "NIL")

 

i)

 

Mark&No

Dimensions

HxWxD

Weight

 

Thief Resisting

fixed to floor/wall
1-
2-
3-

Situation

/Floor

 Value of Safe Itself

Maximum Limit

Of Cash In safe

 

 ii)

 How many keys, with whom & where kept ?
       

4.

    Do u keep regular Books of Accounts and

 

 

 

(a)

record of all such Cash in Transit ?

 

 

(b)

record of all such Cash in Safe ?

 

 

(c)

Give other information material to risk.

 

 5.

 

 

 

 

 

(A)

Have you ever proposed for similar insurance?

 

 

  

If so, state name of Insurer.

 

 

(B)

 Have you ever sustained the loss of any money?

 

 

 

If so, please give details.

 

 

(C)

Has an Insurance Company declined Proposal, Cancelled Policy/ required special terms for renewal ?

 

 

  

If so, give details.

 

 6.

 

 Period of Insurance

 

 

 

 

          

From 

To 

 

 

 

 I/We Declare that foregoing statement are true to best of my/our knowledge and belief:

Place

Date