Allied Cooperative Insurance Group (ACIG) شركة املجموعة املتحدة للتاأمني التعاوين ) أ سيج( CONTRACTORS ALL RISKS INSURANCE Call us: 920012331 www.acig.com.sa CONTRACTORS ALL RISKS INSURANCE
UCONTRACTORS ALL RISKS INSURANCE When completing this Proposal Form... - Please answer all questions giving full and complete answers. - If the space provided on the Proposal Form is insufficient, please use a separate signed and dated sheet in order to provide a complete answer to any question. - Please ensure that the Proposal Form is properly signed and dated. 1 Title of contract (if project consists of several sections, specify sections(s) to be Insured) 2 Location of Site Country/province/district City/town/village 3 Proposer Please indicate below which of the Nos. 4 to 7 below is the Proposer of the insurance and which of the parties are to be declared as Insured in the Policy. Proposer No : Insured No(s) : 4 Name and address of Principal 5 Names(s) and address(es) of Contractor(s) 6 Name(s) and address(es) of Subcontractor(s) 7 Name and address of Consulting Engineer 8 Description of contract work (please give detailed technical Information) Dimensions (length, height, depth. Spans, number of floors) Foundation (method, level of Deepest excavation) Construction methods Construction materials 9 Is the Contractor experienced in this type Page 1 of 5 ص.ب 3515 الخبر 31481 المملكة العربية السعودية
of work or construction methods? 10 Period of Insurance Commencement of work Duration of construction months 11 Work to be carried out by Subcontractors? Date of completion Maintenance period months 12 Special risks *If necessary use a separate sheet. For harbours, piers, docks, tunnels, galleries, dams, roads, airports, railways facilities, sewerage and water supply systems, bridges and structures in earthquake zones also see special questionnaires. Fire, explosion? Flood, inundation? Landslide, storm, cyclone? Blasting work? Other risks Volcanism, tsunami? Have earthquakes been observed in this area? If so, please state intensity Is the design of the structures to be insured based on regulations regarding earthquake resistance structures? Magnitude Is the design standard higher than that stipulated in the relevant regulations? 13 Details of Subsoil rock gravel sand clay filled ground 14 Ground water level Other sub-soil conditions Do geological faults exist in the vicinity? Page 2 of 5 ص.ب 3515 الخبر 31481 المملكة العربية السعودية
15 Nearest river, lake, sea, etc. Name Distance Levels Low water Mean water 16 Meteorological conditions 17 Are extra charges for overtime, night work, work on public holidays to be included? 18 Is Third Party Liability to be Included? Has the Contractor concluded a separate policy for TPL? 19 Details of existing buildings or surrounding property possibly affected by the contract work, such as by excavating, underpinning, piling, vibration, groundwater lowering, etc. 20 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? Highest ever recorded Date Rainy season from to Max. rainfall (mm) per hour per day per month Storm hazard minor medium high Limit of indemnity Limit of Indemnity limit of indemnity Exact description of these buildings/structures 21 Please indicate the previous loss experience Date of Loss Amount of Loss Cause of Loss Page 3 of 5 ص.ب 3515 الخبر 31481 المملكة العربية السعودية
during the past three (3) years 22 Has any insurance Proposal ever been declined or has such Insurance been cancelled or refused or special terms imposed? If yes, please give details. 23 Please state hereunder the amounts you wish to insure and the limits of indemnity required (see Policy Wording, Section I, Memo 1, and Section II) Section I Material Damage Currency: Items to be Insured 1 Contract work (permanent and temporary work, including all materials to be incorporated herein) Sums to be Insured 1.1 Contract price 1.2 Materials or Items Supplied by the Principal(s) 2 Construction plant and equipment 3 Construction machinery (please attach list showing replacement values of new items) 4 Clearance of debris (Insured only up to the amount indicated) Total sum to be insured under Section I: Special risks to be insured Limits of Indemnity 3 Earthquake, volcanism, tsunami Storm, cyclone, flood inundation, landslide Section II Third Party Liability Page 4 of 5 ص.ب 3515 الخبر 31481 المملكة العربية السعودية Items to be insured Limits of Indemnity 4
1 Bodily injury 1.1 Any one person 1.2 Total 2 Property damage Total limit to be applied under Section II 3 4 Limit of indemnity in respect of each and every loss or damage and/or series of losses or damages arising out of any one event Limit of indemnity in respect of any one accident or series of accidents arising out of any one event Declaration I/ We declare that the information given in this proposal and any attachment to it are true and correct and all information relevant to the decision and terms of insurance has been given. I /We hereby authorized the underwriter to give to or obtain from other insurers any information relating to insurance held by me/us or any claim in relation thereto. I/We agree that this proposal, together with any other information supplied by us shall from the basis of the insurance contract between us and Allied Cooperative Insurance Group (ACIG) The Allied Cooperative Insurance Group (ACIG) undertakes to deal with this information in strict confidence. Note: Completing this proposal form does not mean acceptance of this risk unless approved by Allied Cooperative Group ACIG- Signature: Date: Call ص.ب 40523 920012331 الرياض us: 11511 www.acig.com.sa المملكة العربية السعودية Page 5 of 5 ص.ب 3515 الخبر 31481 المملكة العربية السعودية
Allied Cooperative Insurance Group (ACIG) شركة شركة شركة املجموعة املتحدة للتاأمني التعاوين ) أ سيج( ) أ سيج( ) أ سيج( CONTRACTORS ALL RISKS INSURANCE