Machinery Breakdown Insurance Proposal Form Please select the country/city where the form is to be submitted -Select Country- (Kuwait Lebenon Saudi Arabia U.A.E  1. Name of the Proposer  Address of Proposer Telephone No Fax No: E-mail  Address of plant  Nature of business  Name of business  Name of chief engineer or plant manager  Nearest railway station / airport  2. Has any of the machinery to be insured previously been covered by  other  companies? select Yes No  If so, which items of the specification by what companies?  State when the insurance is to  commence. Date: Time:  Period of insurance to expire at the  same date and time next year           3. Do you wish to insure the foundations of the machinery If so, please state the  relevant items of the specification. select Yes No  4.Does the specification include all the machinery coverable under a Machinery  policy? select Yes No  5.If not, does the machinery to be insured represent all the machinery coverable in  one Plant section? select Yes No  express freight, overtime, nighttime, night work, work on public holidays? select Yes No  air freight? select Yes No  Limit of indemnity for air freight:      6.Give details of any special extension of cover required.   We hereby declare that the statements made by us in this Questionnaire and Proposal , to the best of our Proposal are, to the best of our knowledge and belief, complete and true, 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. Specification of Items to be Insured Item No Description of Items Please give full and exact description of all machines, including name of manufacturer, type, output, capacity, speed, load, weight, voltage, amperage, cycles, fuel, pressure, temperature, etc. Year of manufacture Remarks Give particulars of any part of the machinery to be insured, which has had a breakdown, or failure during the last three years, which shows any signs of repair, or which is exposed to any special risk. 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 and also value of foundations, if the latter are to be insured. 1 2 3 4     [ To download the form please right click the Download button and select "Save target as" and Save.]  Download the Form              Download Acrobat Reader Top