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| Please
select the country/city where the form is
to be submitted |
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| 1 |
Name
of the Principal. |
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Address.
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Telephone
No: |
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Fax
No. |
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E-mail
Address. |
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| 2 |
Title
of contract (If Project consists of several
sections, specify section(s) to be insured) |
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| 3 |
Site.
Country/Province/District
City/Town/Village |
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| 4 |
Name
of the Contractor(s) |
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Address |
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| 5 |
Name
of the Subcontractor(s) |
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Address |
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| 6 |
Name
of the Consulting Engineer |
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Address |
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| 7 |
Description
of contract work (Please give detailed technical
information)
(a) Dimensions (length, height, depth, spans,
number of floors)
(please
put a comma after each filed)
(b) Type of foundation and level of deepest
excavation
(c) Construction Method
(d) Construction materials |
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| 8 |
Is
the contractor experienced in this type
of work or construction method? |
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| 9 |
Period
of Insurance
(a) Commencement of work
(b) Duration of construction (months)
(c) Date of completion
(d) Maintenance Period (months) |
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| 10 |
What
work will be done by subcontractors? |
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| 11 |
Special
risks |
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Fire
Explosion? |
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Flood,inundation?
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Landslide,storm,
cyclone? |
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Blasting
work? |
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Other
risks |
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Volcanism,tsunami? |
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Have
earthquakes been observed in this area
If so please state intensity (Mercalli)
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magnitude(Richter) |
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Is
the design of the structure to be insured
based on regulations for earthquake-resistant
structure? |
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Is
the design standard higher than that stipulated
in the relevant regulations? |
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| 12 |
Details
of subsoil
rock
gravel
sand
clay
filled ground
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Other
subsoil conditions |
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Do
geological faults exist in the vicinity? |
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| 13 |
Ground
water Level below grade |
meters |
| 14 |
Nearest
river, lake, sea, etc. |
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Name
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Distance
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Levels
Low
water
Mean Water
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Highest
ever recorded
Date
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| 15 |
Meteorological
conditions |
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| 16 |
Are
extra charges for overtime, night work,
work on public holidays to be included?
Level of Indemnity |
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| 17 |
Is
third party liability to be included?
Has the contractor concluded a separate
policy for TPL
Level of Indemnity |
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| 18 |
Details
of existing buildings or surrounding property
possibly affected by the contract work (excavating,
underpinning, piling, vibrating, ground
water lowering, etc. |
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| 19 |
Are
exiting buildings and/or structures on or
adjacent to the site owned by or held in
care, custody or control of the contractor(s)
or the principal, to damage arising as a
direct or indirect consequence of contract
work? |
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| 20 |
State
here under the amounts you wish to insure
and the limits to indemnity required (see
policy wording, section l memo l and section
ll)
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Section
l
Material Damage |
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Items
to be Insured |
Sum
to be insured |
| 1 |
Contract work
(Permanent and temporary work, including
all materials to be incorporated herein)
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| 1.1 |
Contract
price |
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| 1.2 |
Materials
or items supplied by the principal(s) |
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| 2 |
Construction
plant and equipment |
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| 3 |
Construction
machinery |
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| 4 |
Clearance
of debris |
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Total
sum to be insured under Section I: |
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Special
risk to be insured |
Limit
of indemnity |
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Earthquake,
volcanism, tsunami |
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Storm,
cyclone, flood, inundation, landslide |
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Section
lI
Third party liability |
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Item
to be insured |
Limit
of indemnity |
| 1 |
Bodily
injury |
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| 1.1 |
Any
one person |
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| 1.2 |
Total |
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| 2 |
Property
damage |
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Total
limit under Section ll: |
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