THE ORIENTAL INSURANCE CO LTD 

PROPOSAL FORM FOR PLATE GLASS INSURANCE

Proposer’s Name__________________________________________________________
Address________________________________________________________________

1.	Situation of the Premises in which the glass is contained.		
2.	Name of the Business carried on in the premises		
3.	Are the Premises situated at the corner of a street or exposed to any special risk ?
		
4.	Are you Proprietor or Tenant ?		
5.	Is there any glass in the Premises not included in the Schedule?  If so, specify it.		
6.	Is there at present any broken or damaged glass. If so, described its position and size.		
7.	Have there been any previous Breakages ? If so, give particulars.		
8.	Has the risk been previously insured? If so,
a)	The Name of the Insurance Company___________________________
a)	Policy No.__________________________
b)	Period _________________________
c)	Rate Charged________________________
d)	Any special terms and conditions imposed _________________________________________________
	
9.	Has any Company refused to accept or continue your insurance or increased the premium thereof ?		
PARTICULARS OF GLASS TO BE INSURED
Position of each square of pane of glass	Size of each square of pane	Description of glass: state whether plain plate or Plain Sheet painted Rough silvered Embosed Stained Bent or ornamental	Value	Premium	
	Height in Cms.	Width Cms.				

Date:______________		Proposer’s Signature_________________________