ENGINEERING INSURANCE PROPOSAL/KYC FORM

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:

Address

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.

Name of Proposer:

Signature:

Date:

Agent/Company Representative: