Installation All Risk Insurance

Proposer name
Proposer E-mail
Title of contract
Location of erection site

Country
City, Town, Village
Principal

Country
Address
Main contractor(s)

Names
Addresses
Manufacturer(s) of main items

Names
Addresses
Firm supervising erection

Name
Address
Consulting engineer

Names
Address
Proposer

Proposer is
Proposer No.
Insured No(s)

Period of insurance

Commencement of insurance
Duration of pre-storage
Commencement of erection work
Duration of erection/construction
Duration of testing
Duration of maintenance
Type of coverage required
Termination of insurance
(Optional) Have plans, designs and materials of the kind used in this project been used and/or tested in.
a previous construction
YesNo
a previous construction by the contractor(s)
YesNo

Is this an extension of an existing plant?
YesNo
If so, will operation of existing plant continue during erection period? Enclose plans.
YesNo
Have the buildings and civil engineering works already been completed?
YesNo
Work to be carried out by subcontractors
Please Answer the following as far as information obtainable:-
Is there any aggravated risk of fire?
YesNo
Is there any aggravated risk of explosion?
YesNo
Nearest river, lake, sea, etc..

Level of river, lake, sea, etc..

Meteorological Conditions

Rainy seasons

Max rainfall (mm)

Hazards of earthquake, volcanism, tsunami

Is there a history of voloanism, tsunami at this site?
YesNo
Have earthquakes, etc been observed in this area?
YesNo
Is the design of the structures to the insured based on regulations regarding earthquake resistant structures
YesNo

RockGravelSandClayFilled siteOther types
Do geological faults exist in the vicinity?
YesNo
Estimate, if possible, the probable maximum loss, expressed as a percentage of the sum insured, in a single occurrence.

Is coverage of construction/erection equipment (scaffolding, hits, tools, etc) required?
YesNo
Are existing buildings and/or structures on or adjacent to the site, owned by or held in care, custody or control of the constractor(s) or the principal, to be insured against loss or damage arising out of or in connection with the contract works?
YesNo
Is third party liability to be included?
YesNo

Do you wish cover to include extra charges (in case of loss) for

express freight, overtime, night work, work on public holidays?
YesNo
air freight?
YesNo
Please state here the amounts you wish to insure or where applicable the limits of indemnity required
Currency

Items to be insured

Erection works, split up as follows:

Civil engineering works

Construction/erection equipment

Clearance of debris

Property located on the principal's premises or on the site, belonging to the principal or held in care, custody or control


Total sum to be insured under section !

Please indicate limits of indemnity required for the following perils:

1. Limit of indemnity in respect of each and every loss damage and/or series of losses or damage arising out of any one event.

2. Limit of indemnity in respect of any one accident or series of accidents arising out of one event.
Name:
Date:
Risk
Limits of indemnity (1)
Insured items
Limits of indemnity(2)
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 policy issued in connection with
above risk it is agreed that the insurers are liable in accordance with the terms of Policy only and that the Insured will not
lodge any other claims of what ever nature.
the Insurers undertake to deal with this information in strict confidence.