Marine Marine Insurance Questionnaire Form

IME GENERALINSURANCE.,.N"'frrdEEf ffirtrrffiilmffiF

Head Office: Narayan Chaur, Naxal, P.O. 3ox21746, Kathmandu, NepalTel : +977 - 1 - 441 1 51 0, 441 1 52O, 441 1 7 35, F ax: +97 7 - 1 - 441 1 7 g6E-mail: info@iginepal.com, Web: www.iginepal.com

MARINE INSURANCE QUESTIONNAIRE FORM

Date:

Name of office:

Agency:

ALL QUESTIONSARE TO BE ANSWERED

1. Name of Proposer

Address

2. Description of goods to be insured:

3. Details of Packing:

4. Details of Voyage or Transit:

a) From:

b) To:

c) Mode of transit (by Sea /Air / Rait / Road):

d) ln case of Sea Voyage, name of the vessel:

e) lnvoice No & Date:

f) L/C No.& Date:

g) B/L No./C/N No./AWB No.iRlR No.& Date:

5. Estimated Date of Departure:

6. Sum lnsured

a) lnvoice value:

b) Tolerance Limit (lf any):

c) lncremental Costs (Expressed as a percentage of lnvoice value):

d) Duty (Duty amount payable on arrival):

7. Type of lnsurance cover required (All Risk / Basic Risk / Minimum Risk):

8. Additional Cover required:

9. How long has proposer previously been handling this type of business:

PROPOSER'S S/GNAIUFE

PAN No.:

lr

FOR OFFICE USE:

Entered in Premium Register .... Entered in Statistics Register

PREMIUM CALCULATION SHEET

Specified Premium Rate (as per S.N....... ....of Schedule 6) (ln decimal) (A)

Air Transit Discount (20% ol A)

or

lnland Transit within Nepal (limited distance) discount (30% of A)

or

lnland Transit within Nepal discount (25/, of A)

Inland Transit Discount (20% ot A) (B)

( A-B) (c)

Container Discount (10% of C) (D)

(c-D) (E)

Additional Premium Rate for:

a) W & SRCC or SRGC (as per S.N.....of Schedule 7)

b) Other (specify)

i) ................ (as per S.N'... of Schedule 7)

ii) ............... (as per S'N.... of Schedule 7)

(F)

(G)

(H)

Applicable Premium Rate (E+F+G+H) (t)

Premium for other than Duty lnsurance

{(lnvoice value + incremental cost) x Applicable premium ratei (ln Rs') (J)

Premium for Duty lnsurance

(Duty in amount x Applicable premium rate) (K)

(J+K) (L)

Direct Business Discount (10% of L) (M)

Premium after direct discount (L-M) (N)

Large Sum lnsured Discount (20% of N) (o)

Premium

Stamp Duty

13% VAT

Total Rs.