Machinery Breakdown Insurance Proposal Form

Name of Proposer*

Phone*

Fax*

P.O.Box*

E-Mail*

Address*

Identity or C.R.No

Nature of Business*

Name of Chief Engineer or Plant Manager*

Proposed Period of Insurance:From:*

Proposed Period of Insurance:To:*

Has any of the Machinery to be insured, been insured previously by other insurance companies?* YesNo

If yes, mention the items of the specification and the name of Insurance Company*

YEAR*

CONTRIBUTION PAID*

CLAIMS INCURRED*

NUMBER OF CLAIMS*

Do you have any other machinery not included in this Proposal*YesNo

If yes, please indicate which items are excluded and why?

Do you wish to insure the foundations of the machinery?YesNo

If yes, please state the relevant items of the specification

Do you wish the cover to include extra charges (in case of loss) for: Express Freight, Overtime, Night Work, Work on Public Holidays?YesNo

Air Freight?YesNo

Has your machinery sustained any damage from breakdown or other cause during last 3 years?YesNo

If yes, give details of damage(s) and repairing cost

Give details of any special extension of cover required

What arrangements are made for and who carries out the regular maintenance / inspection of the machinery?

Date of last thorough examination of machinery.
Who carried out the examination?

Is the last statutory report / certificate up-to-date and satisfactory? YesNo

SPECIFICATION OF ITEMS TO BE INSURED
Please ATTACH document of all items to be Insured, in the below format:

Item No. | Description of Items | Year of Manufacture | Remarks | Replacement Value

NOTES:
1. Please give full description of all machines in column No. 2 including name of manufacturer, type, capacity, speed, load, weight, voltage, amperage, cycles, fuel, pressure, temperature, etc.
2. Replacement value in column No. 4 must be calculated on the current cost of replacing the machine by new machinery of same kind and capacity (inclusive of oil in the case of transformers and other electrical equipment) plus freight charges, custom duties, cost of erection,
3. If you also wish to cover the foundations, declare the value of foundations separately for each machine.
4. If any of the machines is a “stand-by”, the same should be identified in the following schedule.