ERECTION ALL RISKS INSURANCE

PROPOSAL FORM

This proposal is to be completed by the Proposer or an Authorized Representative of the proposer. As the answers will form
the basis of any insured issued, they should be complete and accurate. Attention is also drawn to Proposer’s obligations by
law,to disclose all material facts which would affect the issuance of the proposed insurance.
If there is insufficient space to complete the proposal, please attach additional sheets.

1. Details of Proposer

1. Name

2. Mailing Address PO Box: City: Emirates:

3. Contact Number Mobile: Tel: Fax:

4. Business of the Insured

2. Contract Details

Please clearly indicate in the list below, the “Proposer” of the insurance, and those to be declared as “Insured” in the Policy.

1. Title of Contract

2. Principal Name:

Proposer Insured Address:

3. Main Contractor (s) Name:

Proposer Insured Address:

4. Sub Contractor (s) Name:

Proposer Insured Address:

5. Manufacturers of main items Name:

Proposer Insured Address:

6. Firm supervising erection Name:

Proposer Insured Address:

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2. Contract Details (continued)

Name:
7. Consulting Engineer
Address:
Proposer Insured

3. Site Details

1. Location/s to be insured Plot No.: Area:

Town: City/Emirates:

2. Geo Coordinates Longitude: Latitude:

4. Erection Details

1. Exact description of the property to

be erected (if second hand items are Plot No.: Area:
to be erected, please state) In case
of machines: manufacturer’s name, Town: City/Emirates:
number, type, size, capacity, weight,
pressure, temperature, revolutions; Longitude: Latitude:
year of construction of major units.
In case of complete factories:
general drawing of plant, nature of civil
engineering work (if any)

2. Period of Insurance Commencement of Insurance

Duration of pre-storage Months

Commencement of erection work

Duration of erection / construction Months

Duration if testing Weeks

3. If maintenance coverage is required Duration of Maintenance Months

Type of coverage required

Termination of Insurance

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4. Erection Details (continued)

4. Have plans, designs and materials Previous Constructions Yes No

of the kind used in this project been
Previous Constructions by the
used and / or tested in – Yes No
contractor

*Please give details of similar projects carried out by the Contractor(s)

5. Is this an extension of an existing Yes No

plant?

6. If yes, will operation of the existing

plant continue during the erection Yes No
period? (Enclose plans where available).

7. Have the building and civil

engineering works already been Yes No
completed?

Please list the work to be carried out by subcontractors

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5. Site Information

1. Is there any aggravated risk of Fire Yes No

Explosion
Yes No

2. If so, give details

3. Ground Water level

4. Nearest river, lake, sea, etc. levels of

Name Distance from site
such river, lake, sea, etc.
Low water Mean water Highest level recorded

Mean level of site

5. Meteorological Information Monsoon from To

Max. rainfall (mm) Per hour Per day

Max. wind Storm

LOW MED HIGH
velocity frequency

6. History of Natural Disasters Has the site experienced any natural disasters like
Yes No
volcanoes or tsunamis, for example?

Have any earthquakes been observed in the area? Yes No

If yes, please state the intensity and magnitude

Is the design of the structure to be insured based on

Yes No
regulations regarding earthquake resistant structures?

Do geological faults exist in the vicinity? Yes No

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5. Site Information (continued)

7. Subsoil conditions Rock Gravel Sand Clay Filled site

8. Estimate, if possible, the probable a) due to earthquake b) due to fire
maximum loss, expressed as a
percentage of the sum insured, c) due to other cause (please specify)
in a single occurrence

6. Insurance Covers

1. Is coverage of Construction / Yes. Please give brief description and state value under Sum Insured
Erection equipment (scaffolding, huts, Section I, point 3
tools, etc.) required?

No
2. Is coverage of Construction / Yes. (Please attach list of major machines showing individual new
Erection machinery (excavators, replacement values and state total value under Material Damage Sum
cranes, etc.) required? Insured Section I, point 4.)

No

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6. Insurance Covers (continued)

3. Are existing buildings and / or Yes* (Please state the limit under Material Damage Sum Insured Section
structures on or adjacent to the site, I, point 6)
owned by or held in care, custody
or control of the Contractor(s) or the
Principal, to be insured against loss or
damage arising out of or in connection
with the contract works?

No
4. Is Third Party Liability to be Yes. (Give brief description of surrounding and existing buildings and / or
included? structures not belonging to the Principal or Contractors (enclose maps, if
possible) State limits under Limits of Indemnity, Section II TPL)

No

5. Do you wish to cover to include express freight, overtime, night work,

Yes No
extra charges (in case of loss) for: work on public holidays
air freight Yes No

Give details of any special extension of cover required:

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7. Sum Insured & Limits of Indemnity - Section 1 Material Damage

Please state hereunder the amounts you wish to insure or where applicable, the limits of indemnity that are required
Items to be insured Sum Insured
(Please state the amount for each item separately).
Currency:
1. Erection works, split up as follows:
1.1. Item to be erected
1.2. Freight
1.3. Customer Duties and Dues
1.4. Cost of Erection
2. Civil Engineering Works
3. Construction Erection Equipment/Machinery
4. Temporary Facilities
5. Clearance of Debris (Limit of Indemnity)
6. Property located on the Principal’s Premises or on the
site, belonging to the Principal or held in care custody or
control (Limit of indemnity - see Memo 4 of Policy)
Total sum to be insured under Section 1
Please indicate limits of indemnity required for the following
perils:
Risk Limits of Indemnity1
1. Earthquake, Volcanism, Tsunami

2. Storm, Cyclone, Flood, Inundation, Landslide

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Limit of Indemnity in respect of each and every loss or damage and / or series or losses or damage arising out of any one
event.

8. Limits of Indemnity - Section 2 Third Party Liability

Items to be insured Limits of Indemnity2

Currency

1. Bodily Injury – any one person

2. Bodily Injury – total

3. Property Damage

Or alternatively, Combined Single Limit

2
Limit of Indemnity in respect of any one accident or series of accidents arising out of one event.

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9. Declaration

I/we declare the above particulars to be true and correct and shall form the basis of contract between Oman Insurance
Company P.S.C. (hereinafter referred to as “Sukoon”) and me/us.

The Insured undertakes to inform the insurer of any material alteration whereby the risk is increased, and the insurers reserve
the right to modify any quotation made in the light of such alteration.

I/we agree that any information collected or held by Sukoon (whether contained in application or obtained otherwise)
may be used or disclosed by Sukoon to its associate individuals/companies or any independent third parties (within or
outside UAE) for any matters related to this application, any policy issued and to provide advice information concerning
products and services, which Sukoon believes may be of interests to the proposer and to communicate with the
proposer for any purposes.

Proposers Signature

Company Stamp

Date