Document Sample
It is your duty to disclose all material facts to insurers before the start of the policy, and to keep them informed of any such facts or changes to such facts throughout the duration of the policy, and at renewal of the policy. All material information concerning the risk, including any losses or claims information, should be accurate and kept up to date at all times. A material fact is a fact that may influence an insurers decision as to whether to accept a risk or not, and if so, on what terms. If you are in any doubt as to whether a fact is material or not, you should disclose it. Failure to disclose material facts may entitle insurers to avoid the policy from inception. 1. General - The Proposed Insured   Name: Date Established:

2. Main address of the Proposer and any overseas addresses (specifying the name and position of the individual responsible at each location including web and e mail addresses: Address:  First Line:    3. 4. Town: Country: Post Code:

How long has the Proposer been conduction business: In what territories is the equipment to be used?

5. Please confirm the purpose for which equipment is to be used: 6. i. Please confirm the location to which equipment is returned when not in use:


Is the equipment housed? (If so, estimate maximum declared value at any one time)


Is the equipment in the open? If so estimate maximum value at any one time


iv. v. vi.

What precautions have been taken with regard to site security i.e. 24hr watch, fencing? Please give details: Give details of type of sites the equipment/ plant will operate: What steps have been taken to protect plant from natural peril hazards?:

7. Does Proposer do any dynamiting or work at job sites where others might do dynamiting work? 8. Has the Proposer sustained any losses during the past five years which would have been covered under this form of insurance if the Proposer had carried a policy? Yes No 9. Please give full details/circumstances of losses and when they occurred ie causes, items involved, and costings: 10. Was insurance in force? No Yes

11. Who previously Insured the Proposer's equipment? State the name of the Insurer: 12. Has the Proposer ever had insurance cancelled or refused? Yes No

13. Please give full details of why insurance was cancelled or refused: 14. Please enter details of items requiring cover:


Description: ie Type, manufacture, capacity and Serial No

Year of manufacture

New replacement value

Current Value


15. i. ii. iii. Is any equipment to be hired out to third parties? No If so how much and under what are the: Yes

Is there any plant hired in by the proposer: if so please give details of types of plant, values and estimated hiring in charges per annum

16. Please give details of repair, spare, maintenance and servicing facilities:


17. Please confirm if there are any hire purchase or loan agreements on any of the items listed. Please give details: 18. Please enter details of items working underground or in hazardous locations i.e. bridgework, dams, tunnels: sea defence work and similar operations: Details of Plant Values

19. Please give details of any statutory inspection programmes in place: 20. Is there any risk management programme in place? If so please give details: Yes No

21. What does the Proposer perceive as the maximum at risk to be in respect of any one accident or series of accidents arising out of any one occurrence? 22. Is all plant and equipment operated and maintained in accordance with manufacturers recommendations? Yes No 23. Are all operators licensed to operate plant in accordance with statutory regulations: Yes No 24. i. ii. Is plant fitted with immobiliser? No Are there additional sets of keys? Yes Yes No

25. Please confirm the lifting capacity for cranes to be Insured: i. Please advise full details as to where crane will operate i.e. types of site & location, and who is responsible for ground conditions

26. The following warranties will be imposed by Insurers. By signing the declaration at the end of this proposal form you accept that you have understood these warranties and will comply with them i. ii. iii. All Plant and equipment is operated and maintained in accordance with manufacturers' recommendations: All Cranes are fitted with operational overload alarms and wind speed indicators: All operators of die plant must be licensed to operate such plant in accordance with statutory regulations In areas where there is no statutory requirement the operators must have completed the Insured's internal training programme and in all cases have sufficient practical experience and proof of same being supplies to insurers/reinsurers:


iv. v.

All Cranes must be used on firm and level ground and be in a blocked /stabilized position when undertaking lifting operations: Jibs/Booms to be lowered to ground level at the end of each working day and or/when cranes are not in use: If you are unable to comply with any of the above warranties please give full details as to why you cannot comply with them:

27. The following exclusions are contained in the policy wording. Full details of the exclusions are specified in the policy wording. This is not an exhaustive list of exclusions and there may be some others which will be enclosed in the policy wording. By signing this proposal form you accept that you have understood these exclusions and will comply with them: i. ii. iii. Liability/ Third Party Liability/ Employers Liability: Abandonment howsoever occurring and from any cause whatsoever: Loss or damage to any item by its own explosion, mechanical or electrical breakdown failure, breakage or derangement and any resultant loss or damage arising there from in respect of jibs, booms on cranes or similar lifting appliances: Dual and or tandem lifting operations: Goods being lifted and any contents contained therein: Offshore operations: Sabotage and Terrorism: Loss or damage occasioned by the weight of a registered lifting capacity of any machine: load exceeding the

iv. v. vi. vii. viii. ix.

Plant/Equipment: Underground unless such plant or equipment can be repaired underground or brought back to the surface for repair carried out at the Insured's own expense: Business: Interruption/Consequential Loss / Increased costs of Working unless specifically accepted by the insurer:


28. Please note that there is no automatic period of extension and a Premium payment warranty will apply:


DECLARATION I/we declare that the whole of the statements & particulars made by me/us in this proposal are true and that I/we have not mis-stated or suppressed any material facts. I/we agree that this proposal together with other information supplied by me/us shall form the basis of any contract of insurance effected upon. I/we undertake to inform Insurers of any material alteration to these facts occurring before completion of the contract of insurance. However the duty to disclose material facts from and throughout completion of this proposal form and throughout any period of insurance and any extension, upon which this proposal form was used as the basis of the contract of insurance Signing this Proposal does not bind the Proposer to complete this insurance Signature:



E-mail address:

For a full Quotation please contact: AAI Insurance Brokers Tel. +962 (0)6 550 3222 Fax. +962 (0)6 550 3223


Shared By: