1. Title of contract (If project consists of several sections, specify section(s) to be insured):

2. Location of erection site :

Country :

City/ Town/ Village :

3. Name and address of principal:

4. Name(s) and address(es) of main contractor(s) :

5. Name(s) and address(es) of subcontractor(s) :

6. Name(s) and address(es) of manufacturer(s) of main items:

7. Name and address of firm supervising erection:

8. Name and address of consulting engineer :

9. Proposer:

Please indicate which of the parties Nos 3 to 8 above is the proposer of the insurance and which parties are to be declared as insured in the policy:

Proposer No: Insured No(s):

10. Exact 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):

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11. Period of insurance :

Commencement of insurance:

Duration of pre-storage: months prior to beginning of erection work

Commencement of erection work:

Duration of erection/ construction : months

Duration of testing:

If maintenance coverage required :

Duration of maintenance: months

Type of coverage required:

Termination of insurance:

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

A) previous constructions? Yes o No o

B) previous constructions by the contractor(s)? Yes o No o

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

13. Is this an extension of an existing plant? Yes o No o

If so, will operation of existing plant continue during erection period? Enclose plans. Yes o No o

14. Have the buildings and civil engineering work already been completed?

Yes o No o

15. Work to be carried out by subcontractors:

Please also give answers to Nos 16 to 21 as far as information obtainable :

16. Is there any aggravated risk of :

Fire? Yes o No o

Explosion? Yes o No o

If so, give details:

17. Ground water level :

18. Nearest river, lake, sea, etc. : Name : distance from site:

Levels of such river, lake, sea, etc.

Low water : mean water: highest level recorded:

Mean level of site :

19. Meteorological conditions : Rainy seasons from : to :

Max rainfall (mm) : per hour o per day o per month o

Max wind velocity: storm frequency: low o medium o high o

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20. Hazards of earthquake, volcanism, tsunami:

Is there a history of volcanism, tsunami at the site? Yes o No o

Have earthquakes, etc. been observed in this area? Yes o No o

If so, please state intensity : magnitude:

Is the design of the structures to be insured based on regulations regarding earthquake resistant structures? Yes o No o

Subsoil conditions:

Rock o gravel o sand o clay o filled site o

Other types:

Do geological faults exist in the vicinity? Yes o No o

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

A due to earthquake :

B due to fire :

C due to other causes (please specify) :

22. Is coverage of construction/ erection equipment(scaffolding, huts, tools, etc) required? Yes o No o

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

23. Is coverage of construction/ erection machinery (excavators, cranes, etc) required? Yes o No o

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

24. 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 28.9)

Yes o No o

If so , give exact description of these buildings/ structures:

25. Is third party liability to be included? Yes o No o

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 and state limits under No28, section II) :

26. Do you wish cover to include extra charges (in case of loss) for :

Express freight, overtime, night work, work on public holidays?

Yes o No o

Air freight? Yes o No o

27. Give details of any special extension of cover required :

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28. Please state hereunder the amounts you wish to insure or where applicable the limits of indemnity required :

Items to be insured

Sums to be insured (State below separately)

Section I

1.Total price of items to be erected :

(attach separate sheet if necessary)

(Material

Damage)

2. Freight :

3. Customs duties and dues :

4. Cost of erection :

5.Civil engineering works :¹

6. Adjustment of the amount :¹

7.Construction plant & equipment :

8.Clearance of debris :

9. Property located on the principal’s premises or on the site, belonging to the principal or held in care custody or control :

10. Others :

Total sum to be insured under section I:

Risk

Limits of indemnity ²

Section II

Items to be insured

Limits of indemnity ²

(Third Party

Liability)

1. Physical injury

1.1 Any one person

1.2 Total :

2. Property damage :

Total limits of indemnity under section II:

(1) In case the details of the amounts of No.5&6 mentioned above in the cost of erection , please state the amount of each one separately in the above table but subtract the total sum of these items from the cost of erection amount (item No.4)

(2)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

Remarks :

We hereby declare that the statements made by us in this questionnaire and proposal are, to the best of our knowledge and belief, complete and true, and we hereby agree that this questionnaire and proposal form the basis and are part of any policy issued in connection with the above risk .

It is agreed that the insurers are liable in accordance with the terms of the policy only and that the insured will not lodge any other claims of whatever nature.

The insurers undertake to deal with this information in strict confidence.

Signature and Seal : Date :