For download this form, Please click on bellow link :
http://www.iraninsuranceint.com/files/requests/questionnaireE-CPM.doc
"Page 1 of 3"
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1. 1.Name and address of proposer :
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2. 2.Insurance :
On annual basis o
For months o Years (specify period) o
Geographical scope of cover :
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3.Has there been any previous CPM insurance? Yes o No o
If so, for which item(s) of the specification and by what companies?
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4.Have the plant and machinery which are going to be insured (partly or in total)been hired?
Yes o No o
If so, please specify the owner’s name and address:
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5.Are the plant and machinery highly exposed to special hazards?
Fire, explosion o Earthquake,volcanic activity, tsunami o
Storm, cyclone o Flood, inundation o
Landslide o Blasting o
Employment in mountainous terrain o Employment underground o
Other o please explain :
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6.Do you wish the cover to include extra charges for :
Overtime, night work, work on public holidays ? Yes o No o
Limit of indemnity for such extra charges :
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7.Do you wish the cover to include inland transport? Yes o No o
If so, please specify maximum value transported by one means of transport :
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8. Do you wish any the extra cover?
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"Page 2 of 3"
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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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"Page 3 of 3"
Specifications of Plant and Machinery to Be Insured
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Item No.
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Description of Items
(Please give full and exact description of all plant and machinery)
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Year of
Manufacture
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High Exposure to Special Hazards
(please specify hazards of item 5 overleaf)
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Replacement Value
(please state current cost of replacing the machine by new machinery of the same kind and capacity including oil in the case of transformers and switches plus freight charges, customs duties, costs of erection)
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Name of manufacturer
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Type and serial number
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Output
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Total Sum Insured :
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Signature & Seal : Date :