Proposal PRLEI0004932

Royal Sundaram General Insurance Co.
Limited
Corporate Office: Vishranti Melaram Towers, 2/319
Rajiv Gandhi Salai (OMR), Karapakkam, Chennai 600097
EMPLOYEES COMPENSATION INSURANCE
PROPOSAL FORM
If at any time during the Period of Insurance any Employee of the Insured so declared shall sustain injury by
accident arising out of and in the course of his employment in the Business, Indemnity shall be under Law(s)
opted for, subject to the terms, exceptions and conditions contained in the Policy wordings or endorsed hereon,
upto the Limit of Indemnity against all sums for which the Insured shall be so liable which is agreed by the Insurer
and mentioned on the Policy Schedule
Proposer’s name in full: Rakhoh Industries Private Limited

Proposer’s business (Correspondence) address:
MIDC S 11 T BLOCK,Bhosari,,PUNE,Maharashtra,411026
Proposer’s trade or occupation: Engineering and fabrication
Risk Location Address(s): All Over India
Period of Insurance: From 01/06/2024 To 31/05/2025

COVERAGE REQUIRED
COVERAGE
COVERAGE SCOPE OF COVERAGE AGGREGATE LIMIT OF INDEMNITY
OPTION(YES/NO)
Subject otherwise to the

terms, conditions and
Employees
exclusions of the Policy, Limit: As per Employees Compensation Act Yes
Compensation
the amount of liability
incurred by the Insured
Subject otherwise to the

Fatal terms, conditions and
Accidents Act, exclusions of the Policy, As per Fatal Accident Act, 1855 Yes
1855 the amount of liability
incurred by the Insured
1. Limit per Employee for any number of

accidents during Period of Insurance as
mentioned in Endorsement No.LW10 attached
to this Policy
2. Limit per Accident for any number of

Employees Subject to Company’s maximum
Subject otherwise to the terms, conditions and liability under all the Laws covered as
Common
exclusions of the Policy, the amount of liability mentioned in Endorsement No.LW9 attached Yes
Law
incurred by the Insured, but not exceeding:- to this Policy.
3. Aggregate limit for all accidents and claims

arising therefrom during the Period of
Insurance Subject to Company’s maximum
liability under all the Laws covered as
mentioned in Endorsement No.LW9 attached
to this Policy.
coverage for workmen of contractors - Yes
Employees Compensation Insurance Policy – Proposal Form

UIN: IRDAN102CP0001V01201920
IRDA Regn No.102
Page 1 / 2
Royal Sundaram General Insurance Co. Limited
Corporate Office: Vishranti Melaram Towers, 2/319
Rajiv Gandhi Salai (OMR), Karapakkam, Chennai 600097
Whether Market renewal - No
In case of market renewal, loss in the past details are shown as below:
Sl.No UW Year Total Wages Premium Claims
1. 2023-2024 0 0 0
2. 2022-2023 0 0 0
3. 2021-2022 0 0 0
I/We, the undersigned this ………………. Day of …………… 20 desire to effect an insurance in terms of the Policy to
be issued by the Company against my/our Statutory and Common Law liability as above-mentioned. I/We agree to
render, at the end of each period of insurance, a statement in the form required by the Company of all wages
actually paid, and to pay premium on any wages paid in excess of the amount estimated above, I/We hereby
declare that all the above statements and particulars, which I/We have read over checked, are true that I/We have
not suppressed misrepresented or mis-stated any material fact, that I/We fairly estimated my/our total wages and
salaries expenditure and I/We agree that this declaration shall be the basis of the contract between me/us and the
ROYAL SUNDARAM GENERAL INSURANCE CO. LIMITED.
Date …………………….
Signature of Proposer …………………………..
Section 41 of 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 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 shown on the policy; nor shall any
person taking out or renewing or continuing a policy accept any rebate, except as may be allowed in accordance
with the published prospectuses or tables of the Insurer.
(2) Any person making default in complying with the provisions of this section shall be punishable with fine which
may extend upto Ten lac rupees.
Employees Compensation Insurance Policy – Proposal Form

UIN: IRDAN102CP0001V01201920
IRDA Regn No.102
Page 2 / 2

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Royal Sundaram General Insurance Co.

EMPLOYEES COMPENSATION INSURANCE

Proposer’s name in full: Rakhoh Industries Private Limited

Proposer’s trade or occupation: Engineering and fabrication

Risk Location Address(s): All Over India

Period of Insurance: From 01/06/2024 To 31/05/2025

Subject otherwise to the

Subject otherwise to the

1. Limit per Employee for any number of

2. Limit per Accident for any number of

3. Aggregate limit for all accidents and claims

coverage for workmen of contractors - Yes

Employees Compensation Insurance Policy – Proposal Form

Whether Market renewal - No

Sl.No UW Year Total Wages Premium Claims

Employees Compensation Insurance Policy – Proposal Form

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