For download this form, Please click on bellow link :
http://www.iraninsuranceint.com/files/requests/questionnaireCECR.doc
1. 1.Title of structure (If the structure consists of several sections, please specify section(s) to be insured):
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2.Location of structure( country / province / district / city / town / village ):
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3.Name and address of owner:
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4.Name(s) and address(es) of contractor(s)1 who has (have) built the structure :
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5.Name(s) and address(es) of subcontractor(s)[1] :
Work carried out by subcontractor(s):
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6.Name and address of consulting engineer:
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7.Description of each section of structure:
Dimensions (length, height, depth, spans, number of floors, diameter, inclination):
(please give detailed technical information) 1:
Foundation (type, method and level of each section):
Construction methods applied:
Construction materials used :
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"Page 2 of 4"
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8.Period of construction :
Commencement of work :
Duration of construction : months
Date of completion :
Maintenance period : months
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9.Has the structure been insured :
during the construction period? Yes o No o
after the construction period ? Yes o No o
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10.Has there been any accident, loss or damage:
during the construction period?(If so, please give details of cause and amount):Yeso No o
after the construction period?(If so, please give the details of cause and amount):Yes o No o
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11.Does any special risk or exposure exist?
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Fire, explosion
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Yes o No o
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Flood, inundation
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Yes o No o
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Landslide
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Yes o No o
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Storm, cyclone
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Yes o No o
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Blasting
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Yes o No o
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Collision by traffic on roads or water
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Yes o No o
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Other risks :
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Volcanism, tsunami
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Yes o No o
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Have earthquakes been observed in this area?
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Yes o No o
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If so, please state: intensity (Mercalli): magnitude (Richter):
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should the design of the structure be insured based on regulations regarding earthquake- resistant structures?
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Yes o No o
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Is the design standard higher than that stipulated in the relevant regulations?
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Yes o No o
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12.Subsoil conditions:
rock o gravel o sand o clay o filled ground o
Other subsoil conditions:
Do geological faults exist in the vicinity? Yes o No o
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13.Topographical conditions and configuration of ground (e.g. angles of slopes) (please attach plans or photographs):
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14.Ground- water level :
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15.Nearest river, lake, sea, etc :
Name :
Distance :
Levels: low water mean water Highest level recorded
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"Page 3 of 4"
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16.Does a warning system exist for flood and inundation ?(please give details)
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17.Meteorological conditions :
Rainy season from to
Maximum rainfall (mm) per hour per day per month
Storm hazard o minor o medium o high
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18.Is there any regular maintenance work? Yes o No o
(If so, please give details of such maintenance work):
Do a time schedule and a check list exist for maintenance work (e.g. clearing of culverts, bridges, under and overpasses, painting work)?
Who is in charge of maintenance work?
Are staffs being specially trained for maintenance work?
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19.Is the structure observed or occupied full time :
by own staff?Yes o No o
If so, please indicate number of staff permanently present:
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20.Has major repair work taken place since completion of original construction?
Yes o No o (If so, please give details):
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21.Is there any construction work in the vicinity which would affect the structure during the insurance period? Yes o No o (If so, please give details):
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22.What was the amount of the original costs for building the whole structure?
Please give breakdown of original costs for major sections of the structure (e.g. for bridges: foundation, column, abutment & superstructure).
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"Page 4 of 4"
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23.Please state the amounts to be insured and the limits of indemnity required:
( Currency : )
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Items to be insured
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Sums to Be Insured(state below separately)
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1.New replacement value of whole structure (breakdown as under 22):
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2.Clearance of debris (insured only up to amount indicated):
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Total Sum to be insured :
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Requested Special Risks for Limit of Indemnity
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Limit of Indemnity 1
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(1) Limit of indemnity in respect of each and every loss or damage and/or series of losses arising out of any one event.
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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 :
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