UNITED INDIA INSURANCE COMPANY LIMITED
PROPOSAL FOR CIVIL ENGINEERING COMPLETED RISKS INSURANCE

1. Title of project - _______________________________________
(If Projects consists of several
sections, Please specify
Section(s) to be insured)
_______________________________________
_______________________________________
2. Location of project -
a) Country/province/district _______________________________________
b) City/town/village _______________________________________
3. Name and address of owner _______________________________________
4. Name(s) and address (es) of
Contractor(s)` who has (have)
executed the
project
_______________________________________
5. *Name(s) and address (es) of
Subcontractor(s)
_______________________________________
6. ’work to be carried out by
Subcontractor(s)`
7. Name and address of consulting
engineer
________________________________________
8. Description of each section of
project (please give detailed
technical information) -
________________________________________
____
________________________________________
____
________________________________________
____
a) Dimensions (length, height, depth,
spans, number of floors, diameter,
inclination)
b) Foundation (type, method and
level of each section)
c) Construction methods applied
d) Construction materials used
9 Period of construction -
a) Commencement of work
b) Duration of construction ______________ months
c) Date of completion ________________________
d) Maintenance period _________________ months
10. Has the project been
insured? -
a) during the construction period? Yes No
b) after the construction period? Yes No
11. Has there been any accident,
loss or damage? -
a) during the construction period? Yes No
If so, please give details of
cause and amount.
________________________________________
_
b) after the construction period? Yes No
If so, please give details of
cause and amount.
________________________________________
__
12. Does any special risk
or exposure exist? -
a) Fire, Explosion Yes No
b) Flood, Inundation Yes No
c) Landslide Yes No
d) Strom, Cyclone Yes No
e) Blasting Yes No
f) Collision by traffic on roads or
water
Yes No
g) Other risks Yes No
h) Volcanism, tsunami Yes No
i) Have earthquakes been
observed in this area?
Yes No
If so, please state intensity Magnitude_______________________________
_
j) Is the design of the structures to
be insured based on
regulations regarding earthquake
-resistant structures?
Yes No
k) Is the design standard higher
than that stipulated in the
relevant regulations? Yes No
13. Subsoil conditions - Rock Gravel
Sand Filled ground
clay
a) Other sub-soil conditions ________________________________________
b) Do geological faults exist in the
vicinity?
Yes No
14. Topographical conditions and
configuration of ground (eg
angles of slopes). Please attach
plans or photographs
________________________________________
____
15. Ground-water level ___________________
16. Nearest river, lake, sea, etc.
a) Name - __________________________
b) Distance - _____________
c) Levels - ______ Low water _____ Mean water
______ Highest level recorded
17. Does a warning system exist for
flood and inundation? (Please
give details) ________________________________________
__
18. Meteorological conditions -
From ________ To ____________
a) Rainy season -
b) Maximum rainfall (mm) - ____ per hour____ per day_____ per month
c) Storm hazard Minor Medium High
19. Is there any regular
maintenance work?
Yes No
If so, please give details of such
maintenance work
20 a) Do a time schedule and a
checklist exist for
maintenance work (eg.
cleaning of culverts, bridges,
under and overpasses,
painting work)?
b) Who is in charge of
maintenance work?
c) Are staff being specially
trained for maintenance
work?
21. a) Is the project observed or
occupied full time by own staff
Number of staff permanently on
site?
Yes No
(b) ____________________
22. Has major repair work taken
place since completion of
original construction? Yes No
If so, please give details
23. Is there any construction work in
the vicinity, which would affect
the project during the insurance
period?
Yes No
If so, please give details
24. What was the amount of the
original costs of constructing.
(eg for bridges: foundation,
column, abutment, superstructure)
25. Please state the amounts to
be Insured (mention currency)
and the limit of indemnity
required -
a) Items to be insured –
i) New replacement value of
whole project
(breakdown as under 24)
ii) Clearance of debris (insured
only up to amount indicated)
b) Total sum to be insured*
c) Special risks to be insured -
i) Earthquake, Volcanism,
Tsunami.
ii) Storm, Cyclone, Flood,
Inundation, Landslide
d) *Limit of indemnity in respect
of each and every loss or
damage and/or series of losses
arising out of any one event
We hereby declare that the statements made by us in this Questionnaire and proposal are
complete and true to the best of our knowledge and belief, and we hereby agree that this
Questionnaire and proposal forms the basis and is part of any policy issued in connection with the
above risk(s). 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.
Executed at _____ ___________ this ___________ day
of
20 _____
Signature
* * * * * * * * * * * * * * * *