ERECTION ALL RISKS INSURANCE PROPOSAL FORM

1. Title of contract & reference number (if project consist of several sections, specify section(s) to be insured)

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2. Location of erection siteCountry (within GCC) Province/DistrictCity/Town/Village

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3. Principal’sName & address.

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4. Main Contractor(s) Name(s) & address (es).

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5. Subcontractor(s) Name(s) & address (es).

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6. Manufacture(s) of main items

Name(s) & address (es).

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7. Firms Supervising ErectionName(s) and address (es).

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8. Consulting Engineering Name & address.

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9. Proposer Please indicate which of the parries Nos. 3 to 8 above is the Proposer of the Insurance and which parties are to be declared as Co-Insureds in the Policy.

Proposer No.: ------------------ C.R./ID No: ----------------------

Co - Insured No(s): ------------------------------------------------------------

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10. Description of the Property to be erected, please state:- In case of major machines:

the manufacture’s name, number, type, size, capacity, weight, pressure, temperature, revolution and year of construction of major units.

- In case of complete Factories:General drawing of plant, nature of civil engineering work (if any)

- If any second hand items are to be erected, please state the details.

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For Pipe Laying on Land and Turbine-Generator Sets additional questionnaire supplied may be filled up

11. Is the Contractor experienced in this type of work?

Yes No

12. Period of Insurance

If Maintenance Cover Required

Commencement of Insurance: … … … … … … … … … … … … … …

Duration of pre-storage … … … … months prior to beginning of contract work

Commencement of Erection Work … … … … … … … … … … … …

Duration of Erection/Construction … … … … … … … … … … … months

Duration of Testing … … … … … … … … … … … … … … … weeks

Duration of Maintenance … … … … … … … … … … … … … months

Type of Maintenance Coverage Required:

a. Extended maintenance Yes No b. Maintenance Visit Yes No

Termination of Insurance … … … … … … … … … … … … … … … …

13. Have plans, designs and materials of the kind used in this project been used and/or tested in:

If “YES” to (b), please give details of similar projects carried out by

(a) Any previous constructions? Yes No

(b) Previous constructions by the Contractor(s)? Yes No

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Contractor(s)

14. Is this an extension of an existing plant?

Yes No

If “YES” will operation of existing plant Yes Nocontinue during erection period? Enclose plans.

15. Have the buildings and civil engineer-ing works already been completed?

Yes NoIf “NO” please give stage of their completion

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16. What work will be carried out by Sub- contractors?

Please give values of sub-contract works

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Please also give answers to numbers 17 to 21 as far as information is obtainable

17. Is there any aggravated risk of:

If “YES” please give details

Fire Explosion? Yes No

Flood, Inundation? Yes No

Landslide, Storm, Cyclone? Yes No

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18. Ground Water Level Mtrs: --------------------------------------------- ft: -------------------------------------------

19. Nearest Wadi, Water Canal, Sea...Etc

Details of their highest recorded water levels relation to site

Name: --------------------------------------------------- Distance from site: ----------------

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20. Metrological condition Rainy Seasons to

Max rainfall(mm) per hour per day per month

Max wind velocity storm frequency low medium high

21. Hazards of earthquake, Volcanism, tsunami

Is there a history of volcanism, tsunami at the site? Yes No

Have earthquakes, etc been observed in this area? Yes No

Is the design of the structures to be insured based on regulations regarding earthquake resistant structures? Yes No

Is the design of a higher standard than that stipulated in Yes NoThe relevant regulation

22. Details of subsoil condition

Rock Gravel Sand Clay Filled ground

Other Subsoil ConditionsPage 3 of 7

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Do Geological Faults exist in the area? Yes No

23. Estimate, if possible, the probable maximum loss, expressed as percentage of the sum insured, in a single occurrence

a due to earthquake b due to fire

c due to flood and inundation

d due to other cause -------------------------------------------------------------------------- (please specify) --------------------------------------------------------------------------

24. Is coverage of construction/ erection equipment (scaffolding, huts, tools, etc) required?

Please give brief description and state replacement value under No. 30.3

Yes No------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

25. Is coverage of construction/erection machinery (excavators, cranes etc) required?

Yes NoPlease attach list of major machines showing individual new replacement values and state total value under No. 30.4

26. Are existing building 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(s), to be insured against loss or damage arising out of or in connection with the contract work to be covered?

State Limit under 30.6

Yes NoIf “YES” give exact description of these buildings/structures

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27. Is the Third Party Liability to be covered in excess of SR 500,000 any one occurrence and in aggregate during the policy period, including the liability to the family members of the Insured (Contribution not charged for liability up to SR 500,000) if so, please furnish details

Yes No

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under serial number 30 of Section II

Further, give brief description of surrounding and existing buildings and/or structures not belonging to the principal or contractors. (Enclose maps, if possible).

State limit under No. 30, Section II.

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28. Do you wish cover to include extra charges (in case of loss)?

Express freight, overtime, night work, Yes Nowork on public holidays?

If YES State Limit of Indemnity--------------------------------------------------------------.

Air freight? Yes No

If YES State Limit of Indemnity--------------------------------------------------------------.

29. Give details of any special extension of cover required.

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Please attach a separate list with sub-limits required

30. Please state hereunder the amounts you wish to insure or where applicable the limits of indemnity required Currency:

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Section IMaterial Damage Items To be Insured Sums to be Insured

1. Erection Works, split up as follows: 1.1 Items to be erected (Please attach a breakdown of the erection works including bill of quantity)1.2 Freight

1.3 Customs duties and dues

1.4 Cost of erection

2. Civil Engineering Works

3. Construction/erection equipments

4. Construction Machinery (Please attach List)

5. Clearance of Debris (limit of indemnity)

6. Property located on the principal’s or on the site, belonging to the principal or held in care, custody or control (limit of indemnity see Memo 4 of the Policy)

TOTAL SUM TO BE INSURED UNDER SECTION I

Please indicate limits of indemnity required for the following perils:

Risk Limits of Indemnity (in respect of any one accident or series of accidents arising out of one event)

Earthquake, volcanism, tsunami, storm, cyclone, flood, inundation, landslide.

Section IIThird Party Liability Item To be Insured Limits of Indemnity

(In respect of any one accident or series of accidents arising out of any one event.)

Bodily Injury – any one person

Bodily injury – total

Property damage

Underground Cables, Pipes, Facilities

TOTAL LIMIT TO BE INSURED UNDER SECTION II

Please attach: - Scope of Work and method statement - Bar Chart- Graphic representation of time

schedule of the project works. - Breakdown of Sum insured in respect of

items 30 (1.1), 30 (1.2), 30 (1.4), 30 (2) & 30(3)- Site Layout and drawing- Contract Copy and other related addl. information.

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DECLARATION:

We hereby declare that the statements made by us in this Proposal are , to the best of our knowledge and belief, complete and true. Submitting this form does not bind the Proposer to complete the Insurance, Nor Tawuniya to accept, but it is agreed that this Proposal form shall be the basis of the contract should a policy be issued.

Date:__________________________________Proposer(s) Signature_____________________________________

Designation________________________

________ Office

seal________________________________Important: No insurance is in force until this Proposal has been accepted by the Company

T + 966 1 2180100 Head Office هاتف : 2180100 1 966 + الرئيسي المركزF + 966 1 2180102 P.O.Box 86959 فاكس : 2180102 1 966 + صب : 86959Toll Free 800 249990 Riyadh 11632 الرقمالمجاني : 249990 1 800 الرياض : 11632

www.tawuniya.com.sa Kingdom of Saudi Arabiaالمملكةالعربيةالسعودية

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