ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED.

Regd. Office : ICICI Bank Towe!" Banda #$%a Co&'%e(" M$&)ai * +,, ,-.
Te%: /01. 223 4-5 .+.+ 6a( : /01. 223 4-5 .4-7
Make8ing Office:
Banc9 Adde!!:
P9one ::
B$!ine!! Sec8o: U)an R$a% Socia%
Po'o!a% 6o& No:
Go$' I.D.No:
C%ien8 I.D.No:
Mi!c 25 Page . of +
PROPOSAL 6ORM O6 PRO6ESSI ONAL INDEMNITY POLICY
(For Consulting Engineers, Architects and Interior Decorators)
GUIDELINES 6OR COMPLETION O6 T;E 6ORM
.. P%ea!e an!we a%% <$e!8ion! f$%%= and coec8%=. >9ee an= <$e!8ion doe! no8 a''%=" '%ea!e &en8ion c%ea%=
89a8 89e !a&e i! no8 a''%ica)%e.
2. In!$ance i! a con8ac8 of U8&o!8 Good 6ai89 e<$iing 89e In!$ed no8 on%= 8o di!c%o!e a%% &a8eia% fac8! )$8
a%!o no8 8o !$''e!! an= &a8eia% fac8! in e!'on!e 8o 89e <$e!8ion! in 89e 'o'o!a% fo&. If =o$ 89ink an=
fac8 i! &a8eia%" '%ea!e di!c%o!e i8.
5. T9e Po%ic= !9a%% )eco&e ?oida)%e a8 89e o'8ion of 89e In!$e" in 89e e?en8 of an= $n8$e o incoec8
!8a8e&en8" &i!e'e!en8a8ion" non@de!ci'8ion o on non@di!c%o!$e in an= &a8eia% 'a8ic$%a in 89e 'o'o!a%
fo&A'e!ona% !8a8e&en8" dec%aa8ion and connec8ed doc$&en8!" o an= &a8eia% info&a8ion 9a?ing )een
wi899e%d )= 89e 'o'o!e o an= one ac8ing on 9i! )e9a%f.
+. #ind%= con8ac8 89e Co&'an=B! Office! o Agen8! fo an= do$)8! o c%aifica8ion! on 89e 'o'o!a% fo&.

NOTE
T9e %ia)i%i8= of 89e Co&'an= doe! no8 co&&ence $n8i% 89i! 'o'o!a% 9a! )een acce'8ed )= 89e Co&'an= and
'e&i$& 'aid.
SCOPE O6 COCER
T9i! in!$ance Po%ic= inde&nifie! 89e In!$ed again!8 %ega% %ia)i%i8= ai!ing o$8 of an= )eac9 of 'ofe!!iona% d$8=
)= ea!on of an= neg%igen8 ac8" eo o o&i!!ion. I8 a%!o co?e! %ega% co!8! and e('en!e! inc$ed )= 89e
In!$ed" wi89 'io con!en8 of 89e Co&'an= and wi89in 89e %i&i8 of inde&ni8=" in 89e in?e!8iga8ion" defence o
!e88%e&en8 of !$c9 %ega% %ia)i%i8=.
SIGNI6ICANT EDCLUSI ONS
T9i! in!$ance Po%ic= doe! no8 co?e %ia)i%i8= fo infinge&en8 of '%an!" 'a8en8! o co'=ig98!. I8 a%!o doe! no8
co?e %ia)i%i8= fo '$e financia% %o!!" fine! and 'ena%8ie! /'$ni8i?e o e(e&'%a=3. 6o o89e e(c%$!ion! and
%i&i8a8ion!" kind%= efe 8o 89e Po%ic=.
NOTE
T9e foegoing i! on%= an indica8ion of 89e co?e offeed. 6o de8ai%!" '%ea!e efe 8o 89e Po%ic=.
DETAILS : P$8 a () &ak w9ee?e a''%ica)%e
.. CLIENT IN6ORMATION
/i3 Po'o!eB! na&e /'%ea!e %ea?e a !'ace af8e eac9 'a8 of na&e3:
/ii3 Po'o!eB! &ai%ing adde!! /'%ea!e %ea?e a !'ace af8e eac9 'a8 of adde!!3
/iii3 Po'o!eB! officeA'%ace of )$!ine!! adde!! / if an=3 /'%ea!e %ea?e a !'ace af8e eac9
'a8 of adde!!3
/i?3 ;ow %ong 9a?e =o$A89e fi& of w9ic9 =o$ ae a &e&)eA'a8ne" e8c. )een in 89e
)$!ine!! A'ofe!!ionE /in =ea!3
/?3 P%ea!e gi?e a )ief de!ci'8ion of =o$ )$!ine!!
2. Ri!k De8ai%!
P%ea!e indica8e 89e %i&i8 of inde&ni8= e<$ied:
An= One Acciden8
1
/AOA3/R!.3
AOY R!.
P%ea!e !'ecif= Re8oac8i?e Da8e and E(ce!! De8ai%!
Retroactiv
e date
Compul sor
y eces s
(! o" A#A)
$oluntary
eces s (!
o" A#A)
%
Do =o$ e<$ie in!$ance co?eage fo Foin8 ?en8$e! wi89 do&e!8ic o
in8ena8iona% 'a8ne!
NO
If =e!" '%ea!e !'ecif= 89e de8ai%! of con8ac8! on w9ic9 =o$ 9a?e woked Foin8%= o
in 'a8ne!9i' in 89e 'a!8 fi?e =ea!
P%ea!e f$ni!9 89e fo%%owing de8ai%!
(a) No. of <$a%ified enginee!Aac9i8ec8!Ain8eio decoa8o! in =o$ ogani!a8ion :
1
AOA: An= One Acciden8 e%a8e! 8o %i&i8 of %ia)i%i8= in e!'ec8 of an= one acciden8
2
Co%$n8a= E(ce!!: 6i!8 'o8ion of an= %o!! 89a8 89e In!$ed wi%% )ea. P%ea!e indica8e 89e
?o%$n8a= e(ce!! a! 'ecen8age of %i&i8 of inde&ni8= 'e acciden8" w9ic9 wi%% en8i8%e =o$ 8o a
di!co$n8 in 'e&i$&.
Mi!c 25 Page 2 of 4 - -
/)3 No. of da$g98!&en :
/c3 No. of ad&ini!8a8i?e 'e!onne% :
inc%$ding c%ek!" 8='i!8!" office )o=!" e8c.
P%ea!e !'ecif= na8$e of !$'e?i!ion e(eci!ed o?e 89e e&'%o=ee!
P%ea!e 'o?ide de8ai%! a! $nde fo 89e 'e?io$! fi?e financia% =ea!
&ear 'ast &ear (et
&ear
)ross "ees earned
P%ea!e gi?e 89e 'oFec8ed 8$no?e fo 89e 'o'o!ed 'eiod of in!$ance a! $nde
P%ea!e indica8e 89e a''o(i&a8e 'ecen8age of =o$ 8o8a% go!! fee! dei?ed fo&
eac9 of 89e fo%%owing ca8egoie! of con8ac8!
C9e&ica% engineeing
Con!8$c8ion A'oFec8 &anage&en8
S8$c8$a% engineeing
Do =o$ engage 'e!on! o$8!ide =o$ oganiGa8ionE
Ye! No
If =e!" !'ecif= 89e de8ai%! of '$'o!e of !$c9 engage&en8 and na8$e of con8o%
e(eci!ed /!'eci&en con8ac8 of engage&en8 8o )e enc%o!ed3.
Ac9i8ec8$a% de!igning and da$g8!&an!9i'
Doe! =o$ fi& en8e in8o wi88en con8ac8! on e?e= 'oFec8 E
P%ea!e !8a8e 89e - %age!8 'oFec8!Acon8ac8!" and in e!'ec8 of w9ic9 con!8$c8ion 9a!
co&&enced" d$ing 89e 'a!8 4 =ea! *
P%ea!e !8a8e w9e89e =o$ $nde8ake !$'e?i!ion of con8ac8 wok! )eing e(ec$8edE
Ye! No
If =e!" '%ea!e !'ecif= 'eiodici8= of in!'ec8ion wi89 de8ai%!. A! 'e 'oFec8
!'ecifica8ion! anging fo& dai%= 8o fo8nig9%=

;a! an= in!$ance Co&'an= dec%ined =o$ 'o'o!a% No Ye! Re<$ied an
incea!ed 'e&i$& No Ye!
Ref$!ed 8o enew =o$ 'o%ic= No Ye!
Cance%ed !$c9 a 'o%ic= N, Ye!
Mi!c 25 Page 3 of 4 - -
Declaration
IA>e a$89oi!e 89e Co&'an= and a%% o89e go$' co&'anie! of ICICI Bank Go$' and 89ei
agen8! 8o e(c9ange" !9ae o 'a8 wi89 a%% 89e info&a8ion e%a8ing 8o &= 'e!ona% and financia%
de8ai%! and info&a8ion 8o o89e ICICI Bank Go$' co&'anie!A Bank!A 6inancia% In!8i8$8ion!A
Cedi8 B$ea$A Agencie!A S8a8$8o= Bodie! a! &a= )e e<$ied and IA>e wi%% no8 9o%d 89e
Co&'an= and a%% o89e go$' co&'anie! of ICICI Bank Go$' and 89ei agen8! %ia)%e fo $!e
of 89i! info&a8ion.
IA>e agee 89a8 89e Po%ic= !9a%% )eco&e ?oida)%e a8 89e o'8ion of 89e Co&'an=" in 89e e?en8
of an= $n8$e o incoec8 !8a8e&en8" &i!e'e!en8a8ion" non@de!ci'8ion o non@di!c%o!$e in
an= &a8eia% 'a8ic$%a in 89e 'o'o!a% fo&A'e!ona% !8a8e&en8" dec%aa8ion and connec8ed
doc$&en8!" o an= &a8eia% info&a8ion 9a! )een wi899e%d )= &eA$! o an=one ac8ing on
&=Ao$ )e9a%f 8o o)8ain an= )enefi8 $nde 89i! Po%ic=.
IA>e" 89e $nde!igned 9ee)= dec%ae and waan8 89a8 89e a)o?e !8a8e&en8! ae 8$e"
acc$a8e and co&'%e8e. IA>e de!ie 8o effec8 an in!$ance a! de!ci)ed 9eein wi89 89e
Co&'an= and IA>e agee 89a8 89i! 'o'o!a% and dec%aa8ion! 9ee8o !9a%% )e 89e )a!i! of
con8ac8 )e8ween &eA$! and 89e Co&'an= and IA>e agee 8o acce'8 a Po%ic= !$)Fec8 8o 89e
condi8ion! 'e!ci)ed )= 89e Co&'an=.
IA>e agee 89a8 89e i!!$ance of Po%ic=ACo?e No8e !9a%% )e !$)Fec8 8o ea%i!a8ion of 'e&i$&
c9e<$e.
IA>e 9ee)= agee and confi& 89a8 if 89e a&o$n8 co%%ec8ed i! %e!! 89an 89e 'e&i$& <$o8ed
o e?i!ed a! 'e c9ange! in !$& 'o'o!ed fo in!$ance o !co'e of co?e de!ied )= &eA$!"
89e 'o'o!a% !9a%% )e con!ideed fo acce'8ance fo a ed$ced !$& a''o'ia8e 8o 89e
'e&i$& co%%ec8ed and 89e Po%ic= !9a%% )e fina%i!ed accoding%=.
P%ace: Po'o!eH! Signa8$eIIIIIIIIIIIIIIIIIIIIIIIIII
Da8e: Na&e: IIIIIIIIIIIIIII De!igna8ion IIIIIIIIII
/DDMMYYYY3
STATUTORY >ARNING
PRO;IBITION O6 REBATES
/Unde Sec8ion +. of In!$ance Ac8 .15J3
.. No 'e!on !9a%% a%%ow o offe 8o a%%ow" ei89e diec8%= o indiec8%= a! an ind$ce&en8 8o an=
'e!on 8o 8ake o$8 o enew o con8in$e an in!$ance in e!'ec8 of an= kind of i!k e%a8ing
8o %i?e! o 'o'e8=" in India" an= e)a8e of 89e w9o%e o 'a8 of 89e co&&i!!ion 'a=a)%e o
an= e)a8e of 89e 'e&i$& !9own on 89e 'o%ic=" no !9a%% an= 'e!on 8aking o$8 o
enewing o con8in$ing a 'o%ic= acce'8 an= e)a8e" e(ce'8 !$c9 e)a8e a! &a= )e a%%owed
in accodance wi89 89e '$)%i!9ed 'o!'ec8$!e! o 8a)%e! of 89e In!$e.

2. An= 'e!on &aking defa$%8 in co&'%=ing wi89 89e 'o?i!ion! of 89i! !ec8ion !9a%% )e
'$ni!9a)%e wi89 fine" w9ic9 &a= e(8end 8o fi?e 9$nded $'ee!.
Mi!c 25 Page 4 of 4 - -