CONTRACTORS ALL RISK AND LIABILITY GENERAL PROPOSAL/QUESTIONNAIRE

Transcription

1 CONTACTOS ALL ISK AND LIABILITY GENEAL POPOSAL/QUESTIONNAIE IMPOTANT NOTICE Please answer all questions fully. If the space provided is insufficient, please attach a separate sheet. Attention is drawn to the fact that making untrue or false statements or withholding material facts will give underwriters the right to repudiate any claims made under the policy of insurance. This refers to facts which are likely to influence the acceptance of the risk by underwriters. A. BOKE DETAILS Broker Name Contact Person Tel Fax B. INSUED Name of Insured Postal Address VAT No Company egistration Tel Main Contractor Principal / Employer Complete either section C or D as well as section E and F C. OPEN ANNUAL POLICY Business Description Firedart Engineering Underwriting Managers (Pty) Ltd Directors Mike Tandy, Ian van Loggerenberg, George Parrott, Valerie Hayter T F E Company egistration Number 2008/009480/07 Vat egistration Number Block D, 1st Floor, Meyersdal Eco Office Park, cnr Michelle Avenue and Hennie Alberts oad, Meyersdal, Alberton PO Box 11653, andhart, 1457 FSP An authorised financial services provider Underwritten by Compass Insurance Company Limited (FSP 12148)

2 C. OPEN ANNUAL POLICY Estimated Annual Turnover Value Maximum Any One Contract Period months Note: The Annual Turnover Value must include the total costs of Materials, Labour, Free Issue Materials and any other Contractual Income + VAT. All in respect of Contracts Commencing during the period of Insurance (Definition of Free Issue Material: Material supplied by the purchaser/principal for incorporation into the contract works without charge to the Contractor). Building Work (Standard Construction) % Building Work (Non Standard Construction) % Civil Engineering % Trenching & Pipe Laying % oad Works % Mechanical / Electrical Contracts % Open Cast Mine Construction(Civil Infrastructure % Underground Mine Construction (Tunneling / Shaft sinking) % Underground Mine Equipping % Mechanical / Electrical contracts % Other (Please specify) % Maximum Value of any Contract Areas where Contracts will occur Section 1: Contract Works Extension equired (Yes / No) Limit Surrounding Property Damage (In respect of each and every occurrence) emoval of Debris (No damage to works) Claims Preparation Costs Maintenance Period Page 2

3 C. OPEN ANNUAL POLICY Section 2: Contract Works Extension equired (Yes / No) Limit Legal Defence Costs Arrest / Assault / Defamation Inception Date of Policy Maintenance Period equired months SASIA Yes No The following information must be supplied on all Coupons/Policies: isk address - top five (5) risks per highest sum insured isk Address 1 isk Address 2 isk Address 3 isk Address 4 isk Address 5 D. ONE OFF / SPECIFIC CONTACT Contract Value (The sum insured must be the total cost of the contract, i.e. the permanent and temporary works and all materials, including free issue material, labour costs etc.): Indicate if VAT incl. (Definition of Free Issue Material; Material supplied by the purchaser/principal for incorporation into the contract works without charge to the contractor) Full Description of Contract / Scope of Works Site Location: (Address) Main Contractor Cost Breakdown/Bill of Quantities Page 3

4 D. ONE OFF / SPECIFIC CONTACT Security Precautions (Give Details) Method Statement Contract Period From to Maintenance Period equired months Section 1: Contract Works Extension equired (Yes / No) Limit Surrounding Property Damage (In respect of each and every occurrence) emoval of Debris (No damage to works) Claims Preparation Costs Maintenance Period SASIA Yes No E. CONTACTOS PUBLIC LIABILITY Limit of Liability equired Section 2: Contract Works Extension equired (Yes / No) Limit Legal Defence Costs Arrest / Assault / Defamation Use of Explosives or Chemical Expansion Yes No If YES Please give details and advise of any third-party property and/or persons nearby) Page 4

5 E. CONTACTOS PUBLIC LIABILITY SITE SECUITY Adequately Fenced Off? Yes No Access control to Site? Yes No If NO please comment on the security measures being implemented at the Site Comment on Density of pedestrian and vehicle traffic in the immediate vicinity of the site, e.g. Shopping Mal EMOVAL OF LATEAL SUPPOT Should this cover be requested then the following information would be required 1. Description of the emoval of Support work 2. Engineers report, Method statement 3. Depending on the risk a Geotechnical eport may be required 4. Limit of Indemnity equired F. PEVIOUS INSUANCE Name of Insurer Claims Experience / Details G. GENEAL COMMENTS Note: Self-Propelled Plant, Tools and Equipment are not covered under this Policy and should be insured separately i.e. Business All isk or Plant All isk policies. DECLAATION I/We warrant the truth of the answers to the above questions and I/we declare that no information has been withheld. Signed by insured Date Page 5