PROPOSAL FOR ERECTION ALL RISK INSURANCE

Title of contract (if project consists of several Sections, specify section(s) To be insured)

Location of erection site

Country

City, town village

Principal Name and address

Email Address

Main contractor(s)

Name(s) and address(es)

Email Address

Subcontractors Name(s) and address(es)

Email Address

Manufacturers of main items

Name(s) and address(es) E-mail Address:

Firm supervising erection

Name and address

Consulting engineer Name and address

Please state previous works successfully executed by Main Contractor and Subcontractors

Exaction description of the property to be erected (if second-hand items are to be erected, please state In case of machines: manufacturer's name, number, type, size, capacity, weight, pressure, temperature, revolutions, year of construction of major units. In case of complete factories: general drawing of plant, nature of civil engineering work (if any)

Commencement of insurance

Date

Commencement of erection work

Type of coverage required

Termination of insurance

previous construction?

YesNo

previous construction by the contractor(s)?

YesNo

If so, please give details of similar projects carried out by contractor(s)

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

Fire?

YesNo

Explosion

YesNo

If so give details

Ground water level

Name

distance from site

Low water

mean water

highest level recorded

Rainy seasons from

to

Max rainfall (mm)

per hour

per day

per month

Max wind velocity

Storm frequency

LowMediumHigh

Is there a history of volcanism, tsunami at the site?

YesNo

Have earthquakes, etc. been observed in this area?

YesNo

If so please state intensity

magnitude

Is the design of the structures to be insured based on Regulations regarding earthquake resistant structures?

YesNo

Subsoil conditions

Other types

Do geological faults exist in the vicinity?

YesNo

due to earthquake

due to fire

due to other cause (please specify)

Is coverage of construction/erection equipment (scaffolding, huts, tools, etc) required?

YesNo

Please give brief description and state new replacement value under No. 28.3

Is coverage of construction/erection machinery (excavators, cranes, etc) required?

YesNo

Please attach list of major machines showing individual new replacement values and state total value

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 out of or in connection with the contract works? State limit under No.28.5

YesNo

If so, give exact description of these buildings/structures

Is third party liability to be included?

YesNo

If so, give brief description of surrounding and existing buildings and/or structures not belonging to the principal or contractor(s) (enclose maps, If possible State limits under No 28, section II

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

Give details of any special extension of cover required

Amount

Section I

Please indicate limits of indemnity required for the following perils:

Section II-Third party liability

DECLARATION

It is the duty of the proposer to disclose all material facts relevant to the risk. A material fact is one that is likely to influence our judgment and acceptance of your proposal. If your proposal is a renewal, it should include any change in facts previously advised to us. If you are in any doubt about facts considered material, disclose them. Please note that failure to disclose a material fact or if any information provided proves to be incorrect, we may void your policy and decline to pay any claim.

I/We declare that the statements and particulars made by me/us in this proposal are, to the best of my/our belief, complete and true and I/we agree that this proposal, together with any other information supplied by me/us, shall form the basis of the contract of insurance effected thereon. I further declare and agree that if the statement and particulars above have been completed in the handwriting of any other person other than the undersigned, such person is deemed to be the representative of the proposer for the purpose of completing this proposal.

Signing this proposal form does not bind the proposer or underwriter to complete this insurance.

Date

Signature

AgentBroker

PROPOSAL FOR ERECTION ALL RISK INSURANCE

Experience of Main Contractors and Subcontractors

Period of insurance

Duration of pre-storage Months prior to beginning of erection work

Duration of erection/construction Months

If maintenance coverage required

Have plans, designs and materials of the kind used in this project been used and/or tested in

Is there any aggravated risk of

Nearer river, lake, sea etc

Hazards of earthquake, volcanisms, Tsunami

Estimate, if possible, the probable maximum loss, expressed as a percentage of the sum insured, in a single occurrence

Please state hereunder the amounts to be insured or where applicable the limits of indemnity required (see Policy wording, Section I, memo 1 and Section II):