Contractors All Risk Insurance Proposal

1. if necessary on a spread sheet

2. For harbors piers, docks, tunnels, galleries, dams, roads, airports, railway facilities, sewerage and water supply systems and bridges, see additional questionnaires
Is the contractor experienced in this type of work or construction method?
YesNo

Period of insurance

Date of completion

Speical risks

Fire, explosion?
YesNo
Flood, inudation?
YesNo
landslide, storm, cyclone?
YesNo
Blasting work?
YesNo
Other risks?
Volcanic activity, tsunami
YesNo
Have earthquake been observed in this area?
YesNo

If so please state

Is the design of the structure to be insured based on regulations for earthquake-resistant structures?
YesNo
Is the design standard higher than that stipulated in the relevant regulations?
YesNo
Details of subsoil
Rockgravelsandclayfilled ground
Do geological faults exist in the vicinity?
YesNo

Ground water

Nearest river, lake, sea, etc

Meteorological conditions

Rainy seasons

Storm hazard
minormediumhigh
An extra charges for overtime, night work, work on public holidays to be included?
YesNo
Is third party liability to be included?
YesNo
Has the contractor concluded a separate policy for TPL?
YesNo

Are existing buildings and/or structures on or adjacent to the site, owned by or held in care, custody or control of the contractor(s) or the principal, to be insured against loss or damage arising as a direct or indirect consequence of the contract work?
YesNo

State the amounts you wish to insure and the limits of indemnity

Items to be insured: (Material damage)

1. Contract work (permanent and temporary work including all materials to be incorporated)
1.1. Contract price
1.2. Materials or items supplied by the principal(s)
2. Construction plant and equipment
3. Construction machinery (please attach list)
4.Clearance of debris
Total sum to be insured

Special risk to be insured

Earthquake, volcanism, tsunami
Storm, cyclone, flood, inundation, landside

Items to be insured: (Third party liability)

1. Bodily injury
1.1. Any one person
1.2. Total
2. Property damage
Total limit
- Limit of indemnity in respect of each and every loss or damage and/or series of losses arising out of any one event.
- Limit of indemnity in respect of any one accident or series of accidents arising out of any one event.

We hereby declare that the statements made by us in this Questionnaire and proposal are to the best of our knowledge and belief, complete
and true, and we hereby agree that this questionnaire and Proposal forms the basis and is part of any policy issued in connection with the
above risk,
It is agreed that the insurers are liable in accordance with the terms of the Policy only and that the insured will not
lodge any other claims of whatever nature,
The insurers undertake to deal with this information in strict confidence.