CONTRACTORS ALL RISK

1

Name of insured

2

Insured VAT No

3

Insured Company Reg No

4

Postal Address

5

Insured Telephone No.

6

Insured Cell No

7

Insured email address

example@example.com

8

Name of Main Contractor

9

Name of Principal Employer

10

Name of sub contractors

11

Name of broker

12

Contract Value Including free issue material R

13

Contract Title Full Description of Contract

14

What work will be done by Sub Contractors

15

Site Location

16

Close proximity to rivers, dams, watercourses?

YESNO

17

Close proximity to highway, motorways or airport?

YESNO

18

Contract period required?

19

Maintenance Period Required?

20

Surrounding property /Property under custody and control (not part of works)

21

Limit of indemnity required

22

SASRIA required?

YESNO

23

Contractors Public Liability: Limit of Indemnity Required

24

Use of explosives?

YESNO

25

Removal of support (lateral support)?

YESNO

26

Claims Experience DetailsIf no claims, state no claims

27

Any notes to add at end of form?

28

SIGNED BY INSURED

Clear

29

DATE

Date