KERALA STATE INSURANCE DEPARTMENT, THIRUVANANTHAPURAM ................................................................................................................................................ Proposal and Questionnaire for Erection all Risks/ Marine-cum-Erection Insurance (The liability of the Department does not commence until this proposal has been accepted by the Department and the premium paid.) Information given herein will be treated in strict confidence Put a (3 ) mark wherever applicable 1. (a) (b) (c) Name and address of the Principal Trade or Business............................................ Name & address of the Contractor Trade or Business Name & address of the Sub-Contractor if anyTrade or Business (a) (b) (c) THE INSURED INTERESTS 2. Whose interests are to be insured? Principal Contractor Sub-Contractor THE CONTRACT WORKS 3. Full description of the Plant & Machinery to be erected , including capacity. (Please attach separate sheet if necessary) 4. (i) Is this a contract/sub contract forming (i) Yes No part of an over all erection project of value exceeding Rs. 5 crores (ii) It yes give name of the project (ii) 5. (a) Have the Plans, Designs and Materials been already tested in any previous erection? (b) Is the installation or part thereof built for the first time (c) Are you manufacturer importer buyer or contractor of the installation? (d) Is the property brand new or is it second hand and used one? (e) If second hand or used, state age (a) (b) (c) (d) (e) Yes Yes Manu- Brand New No No Imorter Conractor Secnd Hand Usedone 6. (a) Will the erection be carried out by your own personnel? (a) Yes No (b) If not by whom? (b) (c) Past experience of the erectors (c) 7. (a) Will any sub contractors be taking part (a) Yes No in the work of erection (b) If yes, what is their position as regards this insurance? (b) THE CONTRACT SITE 8. (a) Location of site where the Plant is to (a) be erected ? (b) Nearest Port and/or Railway Station and (b) distance (NOTE:-A complete lay out of the Factory and site may be enclosed). 9. (a) (i) Are any special risks of floods, fire (a) (i) Yes No or explosion involved? (ii) If yes, give details (ii) (b) Distance from nearest river or sea-the (b) names and particulars to be given (c) Elevation of erection site above normal (c) river or sea level (d) Is their any record of the erection site ever (d) Yes No having been submerged during floods? 10. (a) Brief description of the arrangements made (a) for storage of equipments-whether in open or closed premises. (b) (i) Will there be a watchman on duty (b) (i) round the clock? (ii) If not, what precautions will be taken (ii) against theft, malicious damage etc. ? THE INSURANCE 11. (a) Probable date of first shipment or despatch (a) (b) Expected date of first arrival at site (b) (c) Expected date of last arrival at site (c) (d) Probable date of commencement of erection of plant & machinery . (d) (e) Probable date on which erection of plant & (e) machinery is expected to be completed finally. (f) Duration of testing period (including in 'g' below) (f) ............... ....Months,.......................... (g) Period of Insurance required including test run. (g) ...............Months, From.........To......... 12. Sum Insured I (a) On landed cost of imported machinery ..................................................Rs as at factory site i.e, @ Exchange rate(sub divided as under) (i) Invoice Cost Rs (ii) Freight ,Insurance, Handliong Clearing and Transportation charges upto Factory site Rs (iii) Customs duty Rs (b) On Machinery fabricated or manufactured in ..................................................Rs India (subdivided as under) (i) Invoice Cost including insurance handling Rs and clearing and transporting upto factory site. (ii) Freight Rs (c) On Cost of Erection including salaries of al ..................................................Rs Foreign and Indian Technicians and wages ofall skilled and unskilled labour employed atFactory Site during erection. (d) On building in which the above Plant and Machinery is to be erected. (i) Permanent Civil Engineering Works ..................................................Rs (ii) Temporary works ..................................................Rs Completely Erected Value Rs. II Clearance and Removal of Debris Rs III Construction Plant and Machinery to be Rs used at the Project Site. Details as perattached list IV Insured's own Surrounding Property Rs V (a) On increased replacement value (including .....................% Rs duty on such additional replacement value) which may have to be paid on replacement of imported Plant and Machinery as per item I -(a) above (b) On increase replacement value which may .....................% Rs Have to be paid on replacement of indigenous plant and Machinery as per item 1(b) above VI Extra charges for Express Freight (excluding Rs air freight) Overtime , Sunday and Holiday ratesof wages. VII Third party Liability : (a) For any one accident . Rs (b) For all accidents during the period Rs Total sum insured Rs 13. (a) Have you approached any other InsuranceCo. for insurance cover in respect of thisproposal (a) Yes No (b) If yes? please state name of the insurance Co. 14. Has any such proposal been (a) Yes No (a) declined ? (b) Yes No (b) withdrawn ? (c) accepted subject to an increased rate (c) Yes No or special conditions? The following questions are to be answered if Marine /Transit Insurance cover is required (a) Yes15. (a) Are there any fragile items like refractorymaterials Asbestos Cement Sheets, Porcelain materials, Glass equipments, FireBricks Graphite Electrode etc. No (b) If yes, please give their value descriptionand mode of packing (whether packed incases or loose) 16. (a) (b) Do you want cement to be covered ?If yes give its value and mode of packing(whether packed in gunny bags or paper bags) (a) (b) Yes No 17. Please give particulars of voyage for imports. 18. What is the limit required (a) Per any one shipment ? (in case of imports) (b) Per any one despatch? (in case of indigenous materials ) 19. Please state (for Inland Transit ) (a) How the goods will be transported to site of erection? (a)(b) (a) (b) How many Transhipments will be there? (c) Special hazards, if any in transporting goodsfrom nearest Station/ Port to erection site. 20. Do you require War & S.R.C.C risk to be covered during overseas/ inland transits? (b) (c) Yes Cuntry Craft No I / We the undersigned hereby declare that the above statements and particulars are true and completeand I / We declare and agree that this declaration and the answers given above shall be held to be promissoryand shall be the basis of the contract between me/us and Department. Place......................... Dated......................... Proposer's Signature.............................. Section 41 Insurance Act 1938. PROHIBITION OF REBATES (1) No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of whole or part of the commission payable or any rebate of the premium shown in the policy; nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables of the Insurer. (2) Any person making default incomplying with the provisions of this Section shall punishable with fine which may extend to five hundred rupees.
