Professional Indemnity Insurance Architects and Consulting Engineers Single Project Cover

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1 Professional Indemnity Insurance Architects and Consulting Engineers Single Project Cover Proposal Form ADNIC is a Public Joint Stock Company incorporated in the United Arab Emirates by Law No. (4) of 1972, and it is governed by the provisions of the UAE Federal Law No. (6) of 2007 Establishment of the Insurance Authority & Organization of its Operations, with Registration No. (1). Completing this form In order to apply for this insurance, please complete all parts of this proposal form and the annexures, if any. You must provide full, accurate, and true answers to all questions listed below. Material facts which you know or ought to know should be fully and accurately disclosed. Failure to do so may result in rejecting your claim and/or terminating the insurance policy from inception. If you are in any doubt about what you should disclose, please do not hesitate to contact us. A material fact is one that would influence our decision whether to offer you insurance or the terms which we offer. If the space provided is inadequate, please provide details using an additional information sheet, signed and dated. Your insurance does not commence when you sign the proposal. Your cover will only commence once we have reviewed the proposal form and confirmed cover in writing. Please keep a copy of this proposal form for your record along with any correspondence/ information provided to us and policies/endorsements that are issued to you subsequently. 1/8

Completing this form In order to apply for this insurance, please complete all parts of this proposal form and the annexures, if any.

2 1. General information a. Name of the firm: b. Address of head office: (Please show the address required on the policy) Contact person s name: P.O. Box: Country: Phone number: Fax number: City: Mobile number: address: Website address: c. Address of branch office(s) and name(s) of resident partner(s): P.O. Box: Country: Phone number: Fax number: City: Mobile number: address: Website address: d. When was the firm established? e. Details of all practising principals or partners Names Qualifications, dates qualified/total duration of professional experience Position held in company and for how long 2/8

Address of branch office(s) and name(s) of resident partner(s): P.O.

3 1. General information (continued) f. Total number of principals, partners and staff Technical: Principals, partners, or officers Other qualified engineers Qualified architects Surveyors Draughtsmen Other qualified staff (please specify) Trainee staff (please specify Total non-technical/administration staff Number g. Do you give work to independent firms (sub-contractors) and/or specialists? Yes No If so, please state kind of work and percentage of fees: (The professional liability of such independent firm is not covered under the proposed policy.) h. Are you financially connected with the principal of the project and/or with contractor(s)? Yes No 2. Nature of your activities a. In which of the following professions is your firm engaged? i) Civil engineering ii) Structural engineering iii) Mechanical engineering iv) Electrical engineering v) Heating and ventilating engineering vi) Chemical engineering vii) Soil engineering viii) Others not shown, please specify: b. In what type of projects is your firm specialized? Please specify: 3/8

Trainee staff (please specify Total non-technical/administration staff Number g. Do you give work to independent firms (sub-contractors) and/or specialists?

4 2. Nature of your activities (continued) c. List some of the largest and typical jobs performed by your firm during the last five years (brief description including values and fees): 3. General questions regarding the project a. Principal: b. Main contractor/consortium: c. Nature and purpose of project: d. Location of project (place, country): e. i) Total contract value: ii) How much of total sum refers to building structure? f. Your fees: 4. Nature of your work/responsibility/period a. Nature of your work (detailed description including special techniques and hazardous factors): 4/8

General questions regarding the project a. Principal: b. Main contractor/consortium: c. Nature and purpose of project: d.

5 4. Nature of your work/responsibility/period (continued) b. Your responsibility (e.g. design and/or supervision): c. Commencement and duration of your work: d. Commencement and duration of construction work: e. Probable date of handing over: f. Period of your liability/statutory limitation: 5. Technical details a. Soil conditions: b. Groundwater conditions: c. Nature of foundations: 6. Surrounding property Please give a description of the neighborhood of the site (details of existing buildings or surrounding property possibly affected by contract works such as excavation, underpinning, piling, vibration or groundwater lowering). 5/8

Soil conditions: b. Groundwater conditions: c. Nature of foundations: 6.

6 7. Insurance/claims experience a. Are you protected by an annual professional indemnity insurance policy? Yes No If so, please advise: i) Insurance company: ii) Limit of indemnity: b. Number of claims, amount of paid claims and background of each claims during last 5 years 8. Indemnity required a. Limit any one accident: b. Limit in the annual aggregate: c. Deductible (each and every) claim to be borne by insured: 9. Scope of coverage a. Design only Yes No b. Supervision only Yes No c. Design and supervision Yes No d. Loss of documents Yes No Limit 6/8

Number of claims, amount of paid claims and background of each claims during last 5 years 8. Indemnity required a.

7 9. Scope of coverage (continued) e. Dishonesty of employees Yes No If so, please answer the following questions: i) Has the firm sustained any loss through the fraud or dishonesty of any employee? Yes No ii) Is any employee allowed to sign cheques without counter signature by a partner? Yes No If so, up to what amount? f. Libel and slander Yes No 7/8

firm sustained any loss through the fraud or dishonesty of any employee?

8 Declaration I/We hereby declare that the statements/information given by me/us in the Proposal Form are full, accurate and true. It is hereby understood and agreed that the statements, answers and particulars provided in this Proposal Form and as per the attachments are the basis on which the insurance policy is being issued/effected. If after the insurance policy is effected, it is found that any fact in the statements, answers or particulars in this Proposal Form is incorrect, untrue, inaccurate, misrepresented or non-disclosed in any material respect, ADNIC shall have no liability under the insurance policy and/or shall have the right to terminate the insurance policy from inception. Name of Proposer: Title: Signature: Stamp: Date: Note: Please note that each page of the proposal form should be signed by the Proposer or its legal representative 8/8

Professional Indemnity Insurance Architects and Consulting Engineers - Annual Cover

Professional Indemnity Insurance Architects and Consulting Engineers - Annual Cover Proposal Form ADNIC is a Public Joint Stock Company incorporated in the United Arab Emirates by Law No. (4) of 1972,