1.
Others Insureds (Principal, Contractor or Owner Builder):
2.
Construction Period:
months
OR Period of Insurance:
to
3.
Full Description / Nature of Contract Works:
4.
Full Address of Contract Site:
5.
Maintenance Period (nil months if owner builder):
6.
Construction Material:
7.
Ground Conditions:
8.
Maximum Number of Floors:
9.
Maximum Depth of Excavation:
meters
10a.
Contract Value:
$
10b.
Principal Suppled Materials:
$
10c.
Total Contract Value (10a + 10b):
$
10d.
Escalation Allowance (up to 15%):
%
11a.
Removal of Debris?
11b.
Professional Fees?
11c.
Expediting Expenses?
12a.
Pre-existing Property:
$
12b.
Details of Pre-existing Property (Please supply additional information such as age and condition of existing structure;
any load bearing walls affected; restumping):
13.
Mitigation Costs:
$
14.
Material in Transit:
$
15.
Material in Storage Off-Site:
$
16.
Plant and Machinery:
$
17.
Employee Effects:
$
18.
Temporary Buildings, Fencing, Scaffolding Tools of Trade:
$
19.
Excess Options (minimum excess may apply depending on Contract Value):
20.
Number of years client has been in business:
21.
Does insured carry out any of the following: use of explosives, bridge construction/maintenance, demolition only activities
(incidental demolition to ground +1 storey and excavation work to single basement depth allowed), construction or maintenance work
involving chemical works, underground mines, offshore platforms, aircraft, petrochemical plants, power stations, ships?
22.
If contractors/sub-contractors are included, are their policies policed?
23.
Are contractors/sub-contractors required to carry their own liability insurance?
24.
Are contractors/sub-contractors covered under this Insured's Workers Compensation Policy?
25.
Does the insured have hot works permit system in place (N/A for owner builder)?
26.
Excess Options (minimum excess may apply depending on Contract Value):
27.
Additional Information / Covers Required:
28.
Have the Insured had any Material Damage or Third Party Liability Claims in the past 5 years? If Yes , please provide details below.
29.
Have you ever alone or in partnership or jointly with any other party, or if a corporation, any of its directors:
a.
Suffered any loss(es) (insured or otherwise) totalling more than $5,000 in the last 12 months or totalling more than $20,000 in the last three (3) years or suffered two (2) or more bodily injury claims in any one period of insurance in the last three (3) years?
If Yes , please provide details:
b.
In the last five (5) years had any insurer decline any claim or proposal, cancel or refuse to renew a policy or increase the premium or impose special conditions?
If Yes , please provide details:
c.
In the last five (5) years ever been placed in receivership or liquidation or declared bankrupt?
If Yes , please provide details:
d.
In the last ten (10) years been convicted of or had any fines or penalties imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property?
If Yes , please provide details: