1. Subject to be insured :

2. Name and address of proposer :

Type of business :

Location of equipment to be insured (address of building, storey):

Structure of building: steel skeleton o brickwork o concrete o wood o

3. Has any of the equipment insured previously been covered by other insurance companies? Yes o No o

If so, which item(s) of the specification and by which companies?

Period that had been insured : from to

4. Is all the equipment to be insured new? Yes o No o

If not, which items of the specification are second- hand?

What equipment can still be obtained ex works? ( state items of the specification )

5. Condition of equipment.

Is the equipment maintained in accordance with the manufacturers’ instructions?

Yes o No o

6. Quality of staff.

Have operators been trained with the manufacturer? Yes o No o

7. Is there a risk of flood and inundation?

Yes o No o If so, by bodies of water o torrential rainfall o

Sewer back flow o other o (please state) :

8. Are dangerous materials used in the vicinity?

Yes o No o If so, specify acids o or sensitized papers o

lyes o test solutions o developers o explosives o isotopes o others o

(Please state) :

"page 2 of 3"

9. Give details of any special cover that to be required?

10. Has there been any previous loss or damage to the machinery insured ? (if so please explain)

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 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.

Signature and Seal : Date :

Item No.

Description of Items ¹

Year of

Man

Remarks²

Qty.

Replacement Value³

Total Sum Insured :