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
Period of insurance
If so please state
Nearest river, lake, sea, etc
An extra charges for overtime, night work, work on public holidays to be included?
State the amounts you wish to insure and the limits of indemnity
Items to be insured: (Material damage)
Special risk to be insured
Items to be insured: (Third party liability)
- 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
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.