CONTRACTORS’ PLANT & MACHINERY (CPM) INSURANCE
Co-op Consultancy & Insurance Agency Limited.
Co-operative House, 13th Floor, Haile Selassie Avenue.
P.O. BOX 48231-00100, TEL: 020 – 3276000/0711049000
FAX: 020 – 2219821, EMAIL:
NAME OF PROPOSER
LAST NAME OTHER NAMES
POSTAL ADDRESS CODE TOWN
PIN NUMBER ID/PASSPORT NO MOBILE NO.
OCCUPATION/PROFESSION EMAIL ADDRESS
INSURANCE
- On annual basis
- For months/ years (specify period)
Geographical scope of cover
Has there been any previous CPM insurance?
- Yes No
If so for which item(s) of the specification and by what companies?
Have the plant and machinery to be insured (partly or in total) been hired?
- Yes No If so, please specify the owner’s name and address
Are the plant and Machinery highly exposed to special hazards?
- Fire Earthquake, volcanic activity, tsunami
- Storm, cyclone Flood, induction
- Landslide Employment underground
- Employment in mountainous Blasting
Do you wish the cover to include inland transport?
- Yes No If so please specify
DECLARATION
I /we do hereby declare that the above answers and statements are true, and that I/we have not withheld any material information regarding this proposal.
DATE:
Date /Month/Year
Signature of Proposer
Rubber Stamp/Seal.
SPECIFICATION of PLANT and MACHINERY to be INSUREDASSET ALL RISK INSURANCE
Co-op Consultancy & Insurance Agency Limited.
Co-operative House, 13th Floor, Haile Selassie Avenue.
P.O. BOX 48231-00100, TEL: 020 – 3276000/0711049000
FAX: 020 – 2219821, EMAIL:
NAME OF PROPOSER
LAST NAME OTHER NAMES
POSTAL ADDRESS CODE TOWN
PIN NUMBER ID/PASSPORT NO MOBILE NO.
OCCUPATION/PROFESSION EMAIL ADDRESS
Type of cover: -Machinery breakdown -Burglary -Fire and Perils
Building occupied as hospital
Machinery Insured
Itemno / Description / Manufacture of / Year of manufacture / Value
2
3
4
DESCRIPTION OF THE PREMISES AND OTHER PARTICLARS
1.Construction of walls Brick & concrete Brick & Timber or Corrugated IronTimber only
2. Construction of roof: Tiles/ concrete/ Asbestos Metal/ Aluminum Sheets
Others
3.Type of building: Detached Non-detached No. of storey ( )
4. Are there any other insurance held on the same premises? Yes No
if ‘Yes’, please give details
5. Have you ever suffered loss or damage by fire? Yes No
6. Has any insurer decline to insure your property? Yes No
7. Are any highly combustible or inflammable goods stored in the premises?
Yes No
8. Are the adjoining nearby premise of similar construction? Yes No
9. Fire Fighting Facilities? Yes No
10. Please state business/ trade carried on the adjacent premises.
On the LEFT: On the RIGHT:
GENERAL QUESTIONS APPLICABLE TO ALL SECTIONS:
1.
i.Are fire extinguishing appliances installed and are they maintained under contract? Yes No
ii.Are smoke detectors installed in the rooms? Yes No
2.
- Are the premises or any part of them exposed to storm or strong winds?
- Is there any history or flooding in the area or any other exposure?
3.
- Is there an intruder alarm? Yes No
- Main Entrance / doors:
-What locks or other devices are they fitted with:
4. Has any of your property during the last three years been destroyed or damaged by fie. Yes No
If yes, give details
I/We declare that the above statement are true and that to the best of our knowledge and believe nothing materially affecting the risk has been concealed, and that the amount proposed for insurances represents the full value of the property to be insured and I/We agree that this proposal shall be the basis of the contract between me/us and the Underwriters.
Date…………… Signature of proposer………………………………..
NB: APPLIED PERILS
(1)Impact (2) aircraft and/ or Articles dropped there from (3) Explosions (4) Tornado/Windstorm (5) Bursting or Overflowing of water pipes (6) Floods (7) Earthquakes and Volcanic Eruption (8) Riot and Strikes, Civil Commotion and Malicious Damage