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

1.     2. Site address (County / Province / District / City / Town / Village):

3. Name and address of principal:

4. Names and addresses of main contractors:

5. Names and addresses of subcontractors:

6. Name and address of consulting engineer:

7. Description of contract work (please give details of technical information such as dimensions (length, height, depth, span, number of floors), type of foundation and level of deepest excavation, construction method & construction materials:

8. Is the contractor experienced in this type of work or construction method?

    Yeso     Noo

9. Period of insurance:

commencement of work:

duration of construction & erection:          days          months          years

duration  of maintenance:          months

type of maintenance coverage required:     simple¨     extended¨

termination of work:

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10. What will be done by subcontractors?

11. Special risks?

fire, explosion:   Yes¨     No¨ - flood, inundation:   Yes¨     No¨

landslide, storm, cyclone:   Yes¨     No¨ - blasting work:   Yes¨     No¨

volcanism, tsunami:  Yes¨     No¨ - other risks (please specify):

have earthquakes been observed in this area:   Yes¨     No¨

if so, please state magnitude of intensity in Richter:

is the design of the structure to be insured based on                                                                        regulations for earthquake-resistant structures:   Yes¨     No¨

is the design standard higher than that stipulated in the relevant regulations:

Yes¨     No¨

12. Details of subsoil:   rocko     gravelo     sando     clayo     filled groundo other subsoil conditions:

do geological faults exist in the vicinity:     Yeso     Noo

13. Ground water?                     Level below grade:                  m

14. Name of nearest river, lake, sea, etc.?   

distance from site:

levels of Low water:          mean water:          highest level recorded:

debit of water (if so river):               width of water flow (if so river):           

mean level of site:

15. Meteorological  conditions?

rainy season from:                                      to:

max. rainfall in mm:               per houro            per dayo           per montho

Storm hazard:                         minoro                mediumo          higho

16. Are extra charges for overtime, night work, work on public holidays to be included?   Yeso        Noo

for airfreight:   Yeso        Noo

17. Is third party liability to be included?                               Yeso        Noo

has the contractor concluded a separate policy for T.P.L?   Yeso        Noo

If No, please give exact description of these buildings/structures and limits of indemnity:

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18. 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 as a direct or indirect consequence of the contract work (excavating, underpinning, piling, vibrating, ground water lowering, etc.)?     Yeso            Noo                                           

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

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

(If so, please attach list of them with breakdown values).

20. Is coverage construction / erection machineries (excavators, cranes, etc.) required?        Yeso             Noo                                           

(If so, please fill out questionnaire of CPM insurance).

21. State here the amounts you wish to insure and the limits of indemnity required:

Sum Insured

(currency:        )

Insured Items

Section I (Material Damages)

1. Contract price:

(cost of constructional & erection works)

2. Materials or items supplied by the principal:

3. Adjustment of the amount:

4. Construction plant and equipment (question 19):

5. Clearance of debris:

6. Existing properties (question 18):

7. Others:

Total sum insured under section I:

Limit of Indemnity¹

Requested Special Risks for Limit of Indemnity

(1) 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 & aggregate.

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Limit of Indemnity¹

Items to be Insured (question 17)

Section II (T.P.L)

Bodily injury for any one person:

1. Bodily injury for total person:

2. Property damage:

Total limits of indemnity under section II:

(1) 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 & aggregate.

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 & proposal forms the basis and is 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.

Date:

Signature and Seal: