Contractor

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ALLRI SKSI NSURANCE ( Thel i abi l i t yoft heCompanydoesnotcommenceunt i lt hi spr oposalhasbeen accept edbyt heCom mp panyandt hepr em mi i um pai d) I nf or ma t i ongi v enhe r e i nw wi i l lbet r e at e di nst r i c tConfide nc e. Puta( )ma r kwhe r e v e r appl i cabl e 1 .( a ) )N Na m me e&Ad dr e s so ft h ePr i n c i p al ( a )_ __ __ _ __ __ __ __ _ __ __ __ __ __ _ __ __ Tr adeorBusi ness__________________________  ( b) )N Nam me e&Addr essoft heCont r act or( b)____________________________ Tr adeorBusi ness __________________  ( c ) )N Na m me e&Ad dr e s so ft h eSu bCo nt r a c t o r ,( c )_ __ __ __ __ __ __ __ __ __ __ _ _ i fany . ___________________________________________ T r ad eo rBus i n es s

THEI NSUREDI NTERESTS 2.Wh os ei nt er es t sar et obeI ns ur ed?Pr i nc i palCont r ac t or SubCo nt r ac t or

3.THECON ONTRACTW WO ORKS   ( a)Ful l des cr i pt i onoft heCont r ac t   ( b)Pl eas egi v edet ai l s:   ( i )   ( i i )   ( i i i )   ( i v )   ( v)   ( v i )   ( v i i )

Bui l di n g( t y peofc ons t r uc t i on, numberofs t or e yset c . ) Bl a s t i n go pe r a t i o n Ex c a v a t i o nwo r k Pi l er i v i ng Tunnel l i ng Da m Co ns t r u c t i o no rd i v e r s i o n ofwat er Ot her s( Spec i f y )

 

Not e:As i t epl anofc ont r ac twor km ma a ybeenc l os ed.

4.( i )I st hi sac ont r ac t / Subc ont r ac tf or mi ngpar t   ofanov eral l c ons t r uc t i onpr oj ec tofv al ue ( i )   e x c eedi ngRs .5c r or es .  ( i i )I fyesgi vet henam me eoft hePr oj ect

( i i )

5.( a)Wi l l t heCons t r uc t i onbec ar r i edoutby y o uro wnp er s o na l? ( a )

Ye s

 ( b)I fnot ,bywhom ?

( b)

 ( c )Pa ste x pe r i e nc eo ft hec o nt ac t o r

( c )

6 .( a ) )W Wi l l a nys ub c o nt r ac t or sbet a k i n gp ar t i nt hewor kofc ons t r uc t i on?

( a )

 ( b)I fy es ,whati st hei rpos i t i onasr egar ds   t hi si ns ur anc e?

( b)

7 .( a ) )L L oc a t i o no fCo nt r a c ts i t e

( a )

 ( b ) )N Ne ar e s tPo r ta nd / o rRa i l wa ySt a t i o na nd di s t anc e

( b )

( Not e:Ac ompl e t el a youtoft hes i t ema ybeenc l os ed)

 

t hef ol l owi ngi nv ol v ed?

( a)

No.

No .

Yes

THECONTRACTSI TE

8 .( a )Ar ea nySpe c i al Ri s k so fo neo rmor eo f

Yes

No .

 

( i )Ear t hquak eFi r e&Shoc k ( i i )Lands l i de/ Roc ks l i de/ Subs i denc e ( i i i )Fl ood/ I nundat i on ( i v ) St or m/ T empes t / Hur r i c ane/ T y phoon/   Cy c l o ne ( v )Col l aps e ( v i )Wat erDamagef or‘ Wet ’ r i s ki . e. c ont r ac ti nv ol v i ngc ons t r uc t i oni n r i v er s ,c anal s ,l ak esors ea. ( b)

Di st ancef r om near estr i ver ,l ake,r eser voi r ( b) ors eat henamesandp ar t i c ul ar st obegi v e n.

( c)

El ev at i onofcons t r uct i onSi t eabovenor mal r i v er ,l ak er es er v oi rors eal ev el .

( c)

( d)

I st her eanyr ecor doft heconst r uct i onsi t e e v erh av i n gbe ene ffec t e db ya nyoft h e maj orper i l sspec i fi edi n( a)abov e.

( d)

9 .

Gi v ef u l l d et a i l sr e ga r d i n gg eo l o gi c a l c ondi t i oni nc l udi ngs ubs oi l .

1 0. ( a )Br i e fd es c r i p t i o no ft h ea r r a ng eme nt sm ma a de f ors t or ageofc ons t r uc t i onmat er i al sand e qu i p m me e nt s whe t h eri no peno rc l o s ed p r e m mi i s e s .  

( b)( i )Wi l l t her ebeawat chandwar dr ound   c l oc k

 

( i i )I fnot ,whatpr ec aut i onswi l l bet ak en   agai nst t hef tmal i ci ousdam ma ageet c.

11 .THEI NSURANCE   ( a)Es t i mat edc ons t r uc t i onper i odex c l udi ng

( i )

( i i )

( a) . . . . . . . . . . . . . . . . . . . . . . . mont hs

 

  ma i n t e na nc ep er i o d( c o v e rt oc o m mm me nc e f r om t hedat eoffi r s tar r i v al ofc ons i gnment Fr om. . . . . . . . . . . . . . . t o. . . . . . . . . . . . . .   mat ma er i al sats i t e,or ,c ommenc ementofwor k whi c hev eri sear l i er ) .   ( b)Cov err equi r eddur i ngm ma ai nt enanc eper i od, ( b) . . . . . . . . . . . . . . . . . . . . . . . mont hs i fany dat eonwhi chcons t r uct i oni s  e x pe ct e dt ob ec omp l e t ed .

Fr om. . . . . . . . . . . . . . . . t o. . . . . . . . . . . . . . . .( c ) Pr obabl e c)

  ( d) Per i odofI ns ur anc er equi r ed

( d) . . . . . . . . . . . . . . . . . . . . . . . . . mont hs   Fr om. . . . . . . . . . . . . . . . . t o. . . . . . . . . . . . . . .

1 2.( a ) Ha v ey o ua pp r o ac h eda nyo t h erI n s ur a nc e( a ) Ye s Co.f orI ns ur anc eCov eri nr es pec toft hi s

No

Pr o pos a l?   ( b) I fy e s,pl eas es t at enameoft heI ns ur anc eCo. ( b)

13.Hasanys uc hpr opos al been

( a)

Yes

No

( b)

Yes

No

( a)Dec l i ned? ( b)wi t hdr awn?

( c )ac c ept eds u bj ec tt oa ni nc r eas edr at eo r( c ) Yes No  s pec i al c ondi t i ons? 14. SUMI NSURED: I .Cont r ac tWor k s  ( Pe r ma ne nt&T e mp mp or a r ywo r k si n c l u di n g   al l mat er i al st oi nc or por at edt her ei n) ( a)Cont r ac tPr i c e

Rs.

( b) Mat er i al sorI t em ms ssuppl i edbyt hePr i nci pal

Rs.

 

( c ) Anyaddi t i onal i t em ms snot i nc l udi ngi n( a)& ( b)abov e

Rs.

( d)Landedc os tofi mpor t edi t emsasat c ons t r uc t i ons i t e[ Pl eas es pec i f ywher e i nc l udedi n[ a]and/ or( b)abov e] @ Ex c hangeRat e. . . . . T ot al Val ueo fc ont r ac twor k s .

Rs . ________ Rs . ___ ___ __

I I .

Const r uct i onPl ant&Machi ner yt obeused att hec ons t r uc t i ons i t e( Det ai l sasper at t ac heds hee t )

I I I .

Cl ear anc e&Remo v al ofDebr i s

Rs .

I V.

I ns ur ed’ sowns ur r oundi ngpr oper t y .

Rs

V.

Ext r ac ha r ge sf orExp r es sFr ei gh t( ex c l ud i ng ) Ai rFr ei ght )o v er t i meSunda y&Hol i da y r at esofwages ,i fr equi r ed

Rs .

VI .

OnI nc r eas edRepl ac ementv al uef orI t em I( a)( b)&( d)abov e,i fr equi r ed

Rs . ( . . . . . . . %)

VI I . Thi r dPar t yLi abi l i t y ( a) Foranyoneac c i dent

Rs .

( b) Foral l Acc i de nt sdu r i ngt hep er i od

Rs .

15 . Doy ouwi s ht oop tf orhi gh eramoun t ofDeduc t i bl eEx c es s?

I fy es ,whet her

( i ) ( i i )

2t i mes 5t i mes

Yes

No.

 

( i i i )

10t i mes

I/ We the undersigned hereby declare that the above statements and particulars are true and complete and I/We declare and agree that this declaration and the answers given above shall be held to be promissory and shall be the basis of the contract  between me/us and the Company. Company.

Pl ac e. . . . . . . . . . . . . . . . . . . . . . . . . Dat e. . . . . . . . . . . . . . . . . . . . . . . . . .

SI GNATUREOFPROPOSER

PROHI BI TI ONOFREBATES Thef ol l owi ngi st hec op yofSec t i on41oft heI ns ur anc eAc t1938. 1.Noper s ons hal l al l oworoffert oal l ow,ei t herdi r ec t l yori ndi r ec t l y ,asani nduc ementt oany  per s ont ot ak eoutorr eneworc ont i nueanI ns ur anc ei nr es pec tofanyk i ndofr i s kr el at i ng t ol i v eorpr oper t yi nI ndi a,an yr ebat eoft hewhol eorpar toft hec ommi s s i onpa y abl eor a ny r e ba t eo ft h ep r e m mi i u m s h o wn i nt h ep ol i c y ;n ors h a l la ny p er s o nt a k i n go uto r r ene wi ngc ont i nui ngap ol i c yac c eptan yr ebat e,e x c ep ts uc hr ebat ea sma ybeal l o wedi n ac c or danc ewi t ht hepubl i s hedpr os pec t us esofr ebat esoft heI ns ur er .  2.Any per s on mak i ng def aul ti nc ompl y i ng wi t ht he pr ov i s i ons oft hi ss ec t i on s hal lbe  puni s habl ewi t hfi newhi c hma ye x t endt ofi v ehundr edr upees .

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