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NAME OF THE PROPOSER

ADDRESS

CONTACT NUMBER

EMAIL ADDRESS

DATE OF ESTABLISHMENT AND DATE OF COMMENCEMENT OF OPERATIONS

WHAT IS THE EXACT NATURE OF THE WORK TO BE DONE OR BEING CARRIED OUT? GIVE FULL PARTICULARS

COMPANY WEBSITE

REQUIRED PERIOD OF INSURANCE (FROM) (YYYY-MM-DD)

DATE OF EXPIRY (TO) (YYYY-MM-DD)

EXPERIENCE YOU HAVE FOR THIS KIND OF WORK

WHERE IS THE LOCATION OF WORK OR BEING CARRIED OUT. PLEASE PROVIDE EXACT LOCATION

WHAT IS THE NATURE OF THE SITE AND ITS SURROUNDINGS? PLEASE PROVIDE DETAILS INCLUDING DESCRIPTION OF THE NEAREST BUILDINGS AND THE LIKE

CAN THE GENERAL PUBLIC OBTAIN ACCESS TO THE SITE?

YES NO

WHAT IS THE APPROXIMATE AREA THE WORK OCCUPY?

WHAT WILL BE OR IS THE NUMBER OF WORKMEN EMPLOYED?

WHAT IS THE ESTIMATED AMOUNT OF WAGES TO BE PAID TO SUCH WORKMEN DURING THE PERIOD OF WORK?

GIVE FULL DESCRIPTION OF ALL THE MACHINERY AND PLANT THAT WILL BE OR IS USED.

DETAILS OF FIRE FIGHTING EQUIPMENTS AVAILABLE IN THE PREMISES

ARE SUCH MACHINERY AND PLANT IN GOOD ORDER AND CONDITION?

YES NO

HOW ARE THEY FENCED AND GUARDED?

WILL ANY ACIDS, GASES, CHEMICALS OR EXPLOSIVE BE USED? IF SO, GIVE PARTICULARS OR KINDS, QUANTITIES AND FREQUENCIES.

YES NO

IF YES, PLEASE PROVIDE DETAILS

IS THE WORK CARRIED OUT BY YOU AS PRINCIPAL OR CONTRACTOR?

WHAT IS THE AMOUNT OF CONTRACT(S)?

REQUIRED LIMIT OF INDEMNITY PER OCCURRENCE

REQUIRED LIMIT OF INDEMNITY IN THE AGGREGATE

GIVE PARTICULARS OF ALL CLAIMS MADE UPON YOU IN RESPECT OF ACCIDENTS DURING THE PAST THREE YEARS

HAVE YOU PROPOSED FOR THIS OR ANY SIMILAR RISK TO ANY INSURANCE COMPANY OR UNDERWRITER?

YES NO

IF YES, PLEASE PROVIDE NAMES

ARE YOU AT PRESENT INSURED WITH ANY OTHER COMPANY?(required)

YES NO

IF YES, PLEASE STATE THE NAME OF INSURER

HAS ANY INSURER EVER DECLINED OR CANCELLED YOUR INSURANCE POLICIES(required)

YES NO

IF YES, PLEASE CLARIFY

ANY ADDITIONAL REQUIREMENTS, PLEASE SPECIFY

We hereby declare that the statements made by us in this online questionnaire are, to the best of our knowledge and belief, complete and true and we hereby agree that this online questionnaire forms the basis and is part of any policy issued in connection with the above proposed risks.