CONTRACTORS ALL RISK INSURANCE QUESTIONNAIRE & PROPOSAL FORM

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0912 222 2200

wecare@heirsgeneralinsurance.com

HEIRS INSURANCE CONTRACTORS' ALL RISK INSURANCE QUESTIONNAIRE & PROPOSAL FORM

Please answer ALL questions in full. Use CAPITAL LETTERS.

Title of Contract (If Project consists of several sections, specify section(s) to be insured.) (*)

Site Country/Province/District (*)

Site City/Town/Village (*)

Name of Principal (*)

Address of Principal (*)

Name(s) of Contractor(s) (*)

Address(es) of Contractor(s) (*)

Name(s) of Sub-Contractor(s)(*)

Address(es) of Sub-Contractor(s)(*)

Name of Consulting Engineer(*)

Address of Consulting Engineer(*)

Description of Contract Work (Please give detailed technical information.) (*) Dimensions (length, height, depth, spans, number of floors)

Is the Contractor experienced in this type of work or construction method? (*)
YesNo

Period of Insurance

Commencement of Work (*)

Duration of Work (*)

Date of Completion (*)

Maintenance Period (*)

What work will be done by subcontractors? (*)

Special Risk

Volcanism, Tsunami (*)
YesNo

Have earthquakes been observed in this area? (*)
YesNo

If so, please state intensity (Mercalli) - Magnitude Ritcher (*)

Is the design of the structure to be insured based on regulations for earthquake-resistant structures? (*)
YesNo

Is the design higher than that stipulated in the relevant regulations? (*)
YesNo

Details of Subsoil

Do geological faults exist in the vicinity?
YesNo

Ground Water

level below grade (m)

level below grade (ft.)

Nearest river, lake, sea, etc.

Name

Distance

Low Water Levels

Mean Water Levels

Highest ever recorded

Date

Meteorological Conditions

Rainy Season from

(mm) (in) per hour

per day

per month

Storm Hazard
MinorMediumHigh

Are extra charges for overtime, night work, work on public holidays to be included?
YesNo

Limit of Indemnity (% of Claim Amount)

Is Third Party Liability to be included?
YesNo

Has the contractor concluded a separate policy for TPL?
YesNo

Limit of Indemnity

Details of existing buildings of surrounding property possibly affected by the contract work (excavating, underpinning, piling, vibrating, ground water lowering, etc…)

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

Limit of Indemnity

Exact description of these buildings/structures.

State hereunder the amounts you wish to insure limits of indemnity required (see policy wording, Section I, Memo 1 and Section II)

Section 1 | Material Damage

Contract Work (Permanent and temporary work including all materials to be incorporated herein)

Sums to be Insured

Contract Price

Sums to be Insured

Materials or Items supplied by the Principal(s)

Sums to be Insured

Construction Plant and Equipment

Sums to be Insured

Construction Machinery (please attach list)

Sums to be Insured

Clearance of Debris

Sums to be Insured

Total Sum Insured Under Section 1

Sums to be Insured

Special Risk to be Insured: Earthquake, volcanism, tsunami, Storm, cyclone, flood, inundation, landslide

Limit of Indemnity

Section 2 | Third Party Liability

Bodily Injury

Limit of Indemnity

Any one person

Limit of Indemnity

Total

Limit of Indemnity

Property Damage

Limit of Indemnity

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.

Executed at: (*)

Date: (*)

Signature: (*)