CONTRACTORS ALL RISKS INSURANCE

PROPOSAL FORM

EVANS KIRERA 26223

Agency / Broker Code

PIN Number: A003355653W

PARTICULARS OF PROPOSER
OYARO EDWIN ONYIEGO
Name of Proposer (in full)
Surname First name Other names
3342 40200 KISII
Postal Address: P. O. Box Postal Code Town
0716167199 oyaroedwin8@[Link]
Telephone Number(s) Email Address:
Home Office
ID Number / Passport / Business Reg. No (Tick) 27156854 Pin No (KRA) (Mandatory) A005572400H

35 BUSINESSMAN
Age Profession / Occupation

Period of insurance: From MARCH 4, 2024 To OCTOBER 4, 2024 (both dates inclusive)

1. Title of contract (if CONSTRUCTION OF KEGOGI HEALTH CENTRE MATERNITY BLOCK, ABLUTION BLOCK AND SEPTIC

project consists of MOTHER CHILD HOSPITAL BLOCK, SEPTIC TANK AND ABLUTION BLOCK
several section(s)
specify section(s)
to be insured.)

Country KENYA Province NYANZA District KISII CENTRAL

2. Site
City KEGOGI Town KEGOGI
Village OMORAA

3. Name and address of EDWIN ONYIEGO OYARO

principal
Postal Address P. O. Box: 3342 Code: 40200 Town: KISII

4. Name(s) and NEVYLYNK FIRST (K) LIMITED

address(es) of P. O. Box: 3342 Code: 40200 Town: KISII
Contractor(s)

5. Name(s) and CHARLES ALAL

address(es) of P. O. Box: 3000 Code: 40100 Town: KISUMU

Contractor(s) (I)

6. Name(s) and ENG. JOSEPHAT SIMBA

address(es) of P. O. Box: 1516 Code: 40200 Town: KISII

consulting engineer(s)
7. Description of contract (If necessary on separate sheet.)
work (Please give 1. Dimensions (length, height, depth, spans, number of floors)
detailed technical 14.7M BY 12.6M
information.)
 2. For harbours, piers, docks, tunnels, galleries, dams, roads, airports, railway facilities,
sewerage and water supply systems and bridges see additional questionnaires.
N/A

3. Type of foundation and level of deepest excavation.

NORMAL FOUNDATION WITH 4 METRES DEEP EXCAVATION

4. Construction method.
LABOUR AND MACHINE BASED

5. Construction materials.
MACHINE CUT NATURAL STONES

8. Is the contractor experienced in this type of

YES Yes No
work or construction method?

9. Period of insurance 1. Commencement of work. MARCH 23, 2024

2. Duration of construction months. 4 MONTHS

3. Date of completion. 25/5/2024

4. Maintenance period. 2 MONTHS

10. What work will be done

by subcontractors? ELECTRICAL AND MECHANICAL FITTINGS

11. Special risks Yes No NO

1. Fire, explosions?

2. Flood, explosions? Yes No NO

3. Landslide, storm, cyclone? Yes No NO

4. Blasting work? Yes No NO

5. Volcanism, tsunami? Yes No NO

6. Other risks? FALLING OBJECTS

Have earthquakes been observed in this area? Yes No NO

If so please state the intensity (metrical) N/A Magnitude (Richter) N/A

Is the design of the structure to be insured based on regulations for earthquake-resistant

structure? Yes No NO

Is the design standard higher than that stipulated in the relevant regulations?
Yes No YES

Rock Gravel Sand Clay Filled ground

GOOD
Other subsoil conditions?

12. Ground water level FAR BELOW THE FOUNDATION

below grade

13. Nearest river, lake, Name LAKE VICTORIA

sea, etc. Distance 120KM

Levels Low water Mean water
Highest ever record Date:
14. Meteorological Rainy season from to

conditions Max rainfall: Per hour Par day Par month

Storm hazard: Minor Medium High

15. Are extra charges for Yes No

overtime charges for
night work, work on Limit of indemnity Kshs
public holidays to be
included
16. Is third party liability to Yes No
be included

Has the contractor

concluded a separate Yes No

policy for third party

Limit of indemnity Kshs
liability

17. Details of existing

buildings or
surrounding property
possibly affected by the
contract work(excavating)
underpinning, billing,
vibrating, ground water
lowering, etc)

18. Are existing buildings

Yes No
and/or structures on or
adjacent to the site, Exact description of the buildings/structures
owned by or held in care
custody of or control of
the contractor(s) or
principal to be insured
against loss or damage
arising as a direct or
indirect consequence of
of the contract work?
Limit of indemnity Kshs

19. State hereunder the

amounts you wish to
insure and the limits
of indemnity required
( see policy, wording,
section I, memo I,
and section II)
 Items to be insured Sums to be insured

Section I 1. Contract work (permanent and temporary work, including

material damage all material to incorporated here in)

1.1 Contract price

1.2 Material or items supplied by the principal(s)

2. Construction plant and equipment

3. Construction machinery (please attach list)

4. Clearance of debris

Total sum to be insured under section I

Special risk to be insured Limit of indemnity 3

Earthquake, Volcanism, Tsunami, Storm, Cyclone, Flood,

Inundation, Landslide

Item to be insured Limit of indemnity 4

Section II 1. Bodily

Third Party liability

1.1 Any one person

1.2 Total

2. Property damage

Total limit under section II

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

3 Limit of indemnity in respect of any one accident or series of accidents arising out of any one
event.
Credit Reference Bureau
I confirm that I have authorized Madison General Insurance Kenya Limited to share my credit information, and to access my
credit profile from Credit Reference Bureau.

Premium Payment.
All premiums shall be paid directly to Madison General Insurance Kenya Limited. Madison General Insurance Kenya Limited
will not assume the risk proposed for, unless and until the full premium payable is received by them.

DECLARATION
We warrant that all the above statements and particulars are true and We hereby agree that this declaration shall be
held to be promissory and shall form the basis of the contract between we and Madison General Insurance Kenya Limited
and us. We are willing to accept the policy subject to the terms, exceptions and conditions prescribed by the company
therein.
MAY 7, 2024
SIGNATURE AND STAMP OF PROPOSER DATE

MGIK UW PPF 201 001 2019