IMPORTANT
An Insurance Agent who assists an applicant to complete an application or proposal form for insurance shall be deemed to have done so as the agent of the applicant – Section 54 (2) Insurance Act 2003.Please answer ALL questions in full. Use CAPITAL LETTERS.
DETAILS OF PROPOSER
Name of Proposer:
Address of Proposer (Not P.O. Box):
Phone (Office):
Phone (Mobile):
Email Address:
Website:
Date of Registration:
Incorporation No.:
Nature of Business:
Name of Bankers:
Address of Bankers:
Name of Auditors:
Address of Auditor:
Names/Addresses of Company Directors:
1.) Names:
Address
2.) Names:
Name of Chief Engineer/Plant Manager:
Type of Engineering Cover Required (Tick all that Apply):
Boiler & Pressure Vessel Insurance
Machinery Breakdown Insurance
Plant All-Risks Insurance
Contractors All Risk
Erection All-Risks
Computer All-Risks
Any Other Type (Please Specify)
Have the Boiler and Pressure Vessel Plants to be Insured been Covered under a Boiler/Engineering Insurance Policy by Another Company? Yes No
If Yes, Specify Items and Companies:
Commencement of Insurance:
Date:
Time:
Does the Specification Include all Other Boiler and Pressure Vessel Plants Coverable under a Boiler and Pressure Vessel Policy? Yes No
If No, Please Indicate the Excluded Items and Why?
Did any Accident Ever Occur to your Boiler and/or Pressure Vessel Policy? Yes No
If Yes, Give Full Details:
Are the Main Steam and Feed Water Piping Included? Yes No
Are All the Items in Good Condition? Yes No
If No, Give Particulars of Defects, if any:
Which Part of the Plant is Subject to Periodical Inspections?
By Whom was it Inspected & at What Intervals
What was the Last Date of Inspection?
What is the Maximum Load on Safety Value?
What Is the Working Pressure?
Item No.
Full Description of Item
Year of Manufacture
Remarks
Replacement Value
ON COMPUTER ITEMS:
Details of Operating Hours (Please Tick): 8 Hours A Day (5 Days A Week) 5 Hours A Day (6 Days A Week) 24 Hours A Day (7 Days A Week)
Measures To Maintain EDP Operations in case of Loss: Output Reduced by 20% Output Reduced by 50% Output Reduced by 80% or more
Indicate Name and Address of Company Which will Continue EDP Operations:
Name:
Address:
Indicate and Outline their Computer Configuration:
Test Runs Performance? Yes No
Software Compatible Without Notifications? Yes No
Indemnity Period, Time Excess and Insurance Period:
What is the Time Excess (Working Days)?
Indemnity Period (Months)?
Period of Insurance:
From:
To:
What Is the Cost & Expenses for Continuing EDP Operations?
Sum Insured:
Annual Sum Insured/Annual Aggregate Limit of Indemnity Should Correspond to Total Amount Per Working Year:
Maximum Indemnity Per Working Day:
Maximum Indemnity for Period of Indemnity:
Lay-out of Computer Room: Please Enclose Corresponding Lay-out, If Not Available Draw in Equipment to Proper Scale as Well as Windows, Doors, Wall thickness etc.
DOCUMENTS TO BE SUBMITTED * Please provide photocopies and also bring along original copies of the documents for confirmation.
1) Certificate of Incorporation/Registration
2) Memorandum & Article of Association
3) Form CO2
4) Form CO7
5) Copy of Authorization to Operate from Relevant Regulatory Bodies
DETAILS OF CONTACT PERSON
Name of Contact Person:
Email Address of Contact Person:
Phone Number(s) of Contact Person:
DECLARATION
I/We, hereby declare that the above particulars and answers are true and complete in every respect, and that no information has been suppressed or withheld. I/We further declare that if such statements and particulars are in the writing of any person other than myself/ourselves such person shall be deemed to have been my/our agent for the purpose of filling the form.
Signature:
Agent/Company Representative:
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