1. Name and address of proposer :

Proposer is : Owner lessor lessee tenant of the cold-storage house

Name and address of tenant (if not yet stated) :

Name and address of cold- storage house :

Nearest railway station/airport :

2. Cold- storage house : in operation all the year round …… months in the year

Room No.

Area (m²)

Height(m)

Temperature (⁰ C)

Rel. air humidity (%)

CO₂(%)¹

O₂ (%)¹

Air pressure (bar)¹

Insulation: cork mineral wool foam plastics

date of last check :

date of last replacement :

Alternative storage facilities : yes No

If so, give name(s) and address(es) of alternative cold- storage house(s).²

distance : Km, percentage of goods which can be stored %

period : months

Have these facilities been used in earlier instances? Yes o No o

3. Refrigerating plant:

Does a Machinery Breakdown policy exist? Yes No

If so, since when?

With which company?

When was the refrigerating plant first put into operation?

Please complete specification of refrigerating plant (page 5).

Is switchover from one unit to the other possible? Yes No

If so, attach basic circuit diagram (sketch).

What refrigerating capacity remains when cold- storage rooms are fully stored? %

Refrigerant :

NH3 Freon 22 Freon 12 other

Pipes carrying refrigerant are: on the ceiling on the walls on the floor

Supervision :

by own staff o by governmento byo

Maintenance:

irregularo regular at intervals of o: 3 months o 6 months o other o

Maintenance is carried out by : manufacturer lessor

own staff maintenance firm

4.Control and alarm

system :

Please state total number of measuring devices for :

temperature rel. air humidity¹ CO₂ concentration¹

CO concentration¹ air pressure inside the rooms¹

Check intervals (hours) :

Is there also an independent calibrated reference

Thermometer in each cold-storage room? Yes No

temperature relative air humidity¹

CO₂ and CO concentration¹ air pressure¹

Are there different arrangements for Fridays and public holidays? Yes No

Signaling devices :

Installed to show disturbance or failure of the plant?

Yes No

If so, alarm is given : audibly visibly

If not, what is done to prevent losses?

Maintenance is carried out : irregularly

regularly at intervals of : months by

5. CA storage :

Can the cold-storage rooms be entered and inspected while in use? Yes No

Is the condition of the goods checked during storage? Yes No

(1) To be answered only in the case of CA storage.

"Page 3 of 5"

6. power supply :

Is failure of power supply to be insured? Yes No

Public power supply:

by ring main by single dead- end feeder

by double dead- end feeder laid

underground overhead

Own power supply

(please give details) :

Interruptions :

Of more than 2 hours in the last 2 years? Yes No

If so, number of interruptions: max. duration

Standby :

Is operational standby generating equipment available at any time, which can produce the electrical capacity, required when the cold- storage house is fully stocked? Yes No

If so, total capacity : KW, number of units:

7.Goods to

be insured :

The goods are :

Sortedo

Packedo

Type and grade of goods stored

Maximum quantity

Number of chambers

No-claims period (hours)^1,2

Sum to be insured³

Total Sum Insured: