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Questionnaire and Proposal for Constructors All Risks Insurance

GSIS questionnaire and proposal for constructors all risks insurance

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN
(GOVERNMENT SERVICE INSURANCE SYSTEM)
Financial Center, Pasay City, Metro Manila

Questionnaire and Proposal for
Contractors’ All Risks Insurance
1. Title of Contract (if project consists of several sections, specify section(s) to be
insured)

______________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
2. Location of site
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Country/province/district

______________________________________________________________________________
City/Town/Village

______________________________________________________________________________
3. Name and address of Principal
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4. Name(s) and address(es) of Contractor(s) 1
______________________________________________________________________________
___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

5. Name(s) and address(es) of Subcontractor(s) 1
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
6. Name and address of Consulting Engineer
______________________________________________________________________________
7. Description of Contract Work (please give detailed technical information)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Government Service Insurance System
Contractor’s All Risks Insurance Application Form
Page 2 of 4

______________________________________________________________________________
1

If necessary on a separate sheet

2

For harbours, piers, docks, tunnels, galleries, dams, roads, airports, railway facilities, sewerage and
water supply systems, bridges and structures in earthquake zones. Also see special questionnaires.

8. Is the Contractor experienced in this type of work or construction method?
□ yes

□ no

9. Period of Insurance
Commencement of work

______________________________________________________________________________
Duration of construction

months

______________________________________________________________________________
Date of Completion

______________________________________________________________________________
Maintenance Period

months

______________________________________________________________________________
10. Work to be carried out by Subcontractors
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
11. Special Risks

Fire, Explosion

□ yes

□ no

Flood, inundation

□ yes

□ no

Landslide, storm, cyclone

□ yes

□ no

Blasting

□ yes

□ no

Others:
Volcanism, Tsunami

□ yes

□ no

□ yes

□ no

Have earthquakes been observed in this area?
If so, please sate intensity ___________________

magnitude ___________________

Is the design of the structure to be insured based on
regulations regarding
earthquake-resistant structures?
□ yes □ no
12. Subsoil conditions

□ rock
□ sand

□ gravel
□ clay

□ filled ground

Others __________________________________________________________
Do geological faults exist in the vicinity?

□ yes

□ no

13. Ground-water level
______________________________________________________________________________
14. Nearest River, lake, sea, etc.
Name_________________________________________________________________
Distance ______________________________________________________________
Levels _____________ Low water _____________ Mean water_____________

Government Service Insurance System
Contractor’s All Risks Insurance Application Form
Page 3 of 4

Highest level recorded _________________________________________________
15. Meteorological conditions
Rainy season from ______________________

to _________________________

______________________________________________________________________________
Max. Rainfall (mm)
per hour
per day
per month
______________________________________________________________________________
Storm Hazard
□ minor
□ medium
□ high
16. Are extra charges for overtime, night work, work on public, holidays to be
Included?
□ yes
□ no
Limit of indemnity

______________________________________________________________________________
17. Is Third Party Liability to be included?

□ yes

□ no

Has the Contractor concluded a separate policy for TPL?

□ yes

□ no

Limit of Liability ___________________________________________________________
18. Details of existing buildings or surrounding property possibly affected by the
contract work, such as by excavating, underpinning, piling, vibration, ground
water lowering, etc.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
19. Are existing buildings and/or structures on or adjacent to the site, 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?
□ yes
□ no
Limit of Liability

______________________________________________________________________________
Exact description of these buildings/structures

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
20. Please state the amount you wish to insure and the limits of indemnity
required
Currency:
______________________________________________________________________________

Government Service Insurance System
Contractor’s All Risks Insurance Application Form
Page 4 of 4

Section I
Material Damage
Items to be insured

Sums to be insured

1. Contract work
(Permanent and temporary work, including
all materials to be incorporated herein)

1.1 Contract Price
1.2 Materials or items supplied
by the Principal(s)
2. Construction plant and
Equipment
3. Construction machinery
(please attach list showing replacement
values of new items)

4. Clearance of debris
(insured only up to the amount indicated)

Special risks to be insured

Limits of indemnity

Earthquake, volcanism, tsunami
Storm, cyclone, flood,
inundation, landslide
Section II
Third Party Liability
Items to be insured

Limits of indemnity

1. Bodily injury
1.1 any one person
1.2 total
2. Property damage
Total limit to be applied under
Section II
3 Limit of indemnity in respect of each and every loss or damage and/or series of losses or damages

arising out of any one event.
4 Limit of indemnity in respect of any one accident or series of accidents arising out of any one event.

We hereby declare that the statements made by us in this Questionnaire and Proposal
are complete and true to the best of our knowledge and belief, and we hereby agree
that this Questionnaire and Proposal shall form the basis and be part of any policy issued
in connection with the above risk or risks. It is agreed that the Insurers shall not be liable in
accordance with the terms of the Policy only and that the Insured will not lodge any
other claims of whatever nature.
The Insurers undertake to deal with this information in strict confidence.
Executed at _______________________________ this _____day of __________________ 20_____
Signature
Name and Designation
Date

: __________________________________________
: __________________________________________
: __________________________________________
 
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