Chestionar pentru asigurarea de Rspundere Profesional a Arhitecilor

Professional Liability Application Form Architects

Se va rspunde complet la toate ntrebrile. Nu lsai spaii necompletate. Completai n/a dac una dintre ntrebri nu
se aplic n cazul Dv. Dac spaiul alocat rspunsurilor este insuficient, v rugm s continuai pe o pagin separat.
Pentru a bifa, apsai de dou ori deasupra csuei i alegei opiunea Checked
All questions must be answered in full. Do not leave any blank spaces. Indicate n/a if question is not applicable. If the space provided is
not sufficient to answer a question fully, please attach details on a separate sheet. To tick, please click twice and choose Checked

ntrebare / Question
1.

Contractant - Numele i adresa: /

2.

Activitile principale i ponderea

fiecreia n cifra de afaceri (%):

Rspuns / Answer

Policy holder - Name and address:

Main activities and their weight within

total income (%):

3.

Informaii despre manageri, asociai i

consultani (ingineri, arhiteci etc.):
Nume, calificare i experien (nr.
ani), poziie n companie /
Information
on
managers/partners/
consultants
(engineers,
architects):
Name, qualification, experience (years),
position held.

4.

Persoane cu drept de semntur

(nume i vechime n profesie):
Persons with signature right (name and
professional experience no. of years)

5.

Venituri n anul financiar precedent

(cifra de afaceri):
Total incomes for the past financial year
(Turnover):

6.

Venituri estimate pentru perioada

asigurat (cifra de afaceri):
Total incomes estimated for the
insurance period (Turnover):

7.

Tipuri de lucrri realizate / proiectate

(ex. comerciale, rezideniale,
industriale)
Type of works performed
(e.g. commercial, residential, industrial)

Numr n Registrul Asiguratorilor: RA-021/2003; Autorizat de Comisia de Supraveghere a Asigurrilor

Nr. Reg. Com. J40/9518/2003; C.U.I. 12408250; Capital social 33.288.761,60 RON
Bucureti, Str. Nicolae Caramfil Nr. 61B, Sector 1,
Tel.: +4 021 311 91 04; Fax: +4 021 311 50 56; www.certasig.ro; office@certasig.ro
1/5

ntrebare / Question
8.

Rspuns / Answer

5 din cele mai mari proiecte realizate

i descrierea acestora:
5 largest projects worked and their
description:

9.

Denumirea contractului pentru care

se dorete ncheierea asigurrii (dac
proiectul const din mai multe
seciuni, specificai seciunea care se
asigur) /
Title of contract to be insured (if project
consists of several sections, specify
section(s) to be insured).

10. Amplasarea locului de construcie:

Location of construction site:

11. Valoarea contractului:

Contract price:

12. Ofertantul de contract - Numele i

adresa

Principal - Name and address

13. Contractor(ii) principal(i)

Main contractor(s)

14. Sub-contractant(ii) pentru execuie

Numele i adresa

Subcontractor(s) for the execution

Name(s) and address(es)

15. Sub-contractant(ii) pentru calcule

proiectare - Numele i adresa

Subcontractor(s) for the engineering/

design - Name(s) and address(es)

16. Ce procent din lucrri se realizeaz

cu ajutorul sub-contractanilor?

What % of works are sub-contracted out?

17. Ce tipuri de lucrri sunt subcontractate?

What type of works is sub-contracted out?

18. Descrierea lucrrilor de construcii:

Description of construction works:

Numr n Registrul Asiguratorilor: RA-021/2003; Autorizat de Comisia de Supraveghere a Asigurrilor

Nr. Reg. Com. J40/9518/2003; C.U.I. 12408250; Capital social 33.288.761,60 RON
Bucureti, Str. Nicolae Caramfil Nr. 61B, Sector 1,
Tel.: +4 021 311 91 04; Fax: +4 021 311 50 56; www.certasig.ro; office@certasig.ro
2/5

ntrebare / Question

Rspuns / Answer

Construcii montaj: Dimensiuni

(lungime, nlime, adncime,
distane, nr. de etaje).
Furnizai informaii tehnice detaliate:
tipul fundaiei, nivelul celei mai adnci
excavaii, metoda de construcie,
materiale de construcie.
Construction-Erection: Dimensions
(length, height, depth, spans, number of
floors).
Provide detailed technical information:
type of foundation and level of deepest
excavation,
construction
method,
construction materials.

20. Detalii despre cldirile existente sau

despre proprietile din vecintate
care ar putea fi afectate de ctre
lucrrile de construcii (excavri,
piloni, vibraii, ap subteran etc.):
Details
of
existing
buildings
or
surrounding property possibly affected by
the
contract
work
(excavating,
underpinning, piling, vibrating, ground
water lowering etc.):

21. Distana pn la cel mai apropiat ru,

lac, mare:

Distance to the nearest river, lake, sea:

22. Perioada de asigurare (max. 12 luni)

Period of insurance (max. 12 months)

de la

___.___.______

from

zz.ll.aaaa
dd.mm.yyyy

pn la
to

___.___.______

zz.ll.aaaa
dd.mm.yyyy

Data nceperii lucrrilor de construcii

(zz.ll.aaaa)
Date of commencement of construction
works (dd.mm.yyyy)

Durata construciei
Duration of construction

Durata testrii
Duration of testing

Perioada de ntreinere
Maintenance period

____

____

____

luni
months

luni
months

luni
months

Tipul de ntreinere
Type of maintenance cover

29. Ai avut / avei n vigoare o poli de

Rspundere Profesional?
Dac DA, menionai detalii:

Asigurtorul / Insurer
Perioada asigurat /
Insurance period

Numr n Registrul Asiguratorilor: RA-021/2003; Autorizat de Comisia de Supraveghere a Asigurrilor

Nr. Reg. Com. J40/9518/2003; C.U.I. 12408250; Capital social 33.288.761,60 RON
Bucureti, Str. Nicolae Caramfil Nr. 61B, Sector 1,
Tel.: +4 021 311 91 04; Fax: +4 021 311 50 56; www.certasig.ro; office@certasig.ro
3/5

ntrebare / Question

Rspuns / Answer

Have you ever had or do you have in

force a Professional Liability insurance
policy?
If YES, specify:

Limita de despgubire /Limit of

liability

Daune pltite (dac au existat)

Paid claims (if the case)

33. Dac dorii s schimbai societatea de

asigurare, specificai motivul:

If you are switching insurance company,

mention why:

34. A existat vreun asigurtor care a

anulat o poli/ a refuzat rennoirea

poliei/ nu a aprobat cererea de
asigurare/ a modificat termenii
asigurrii?
Dac DA, menionai detalii.
Has any insurer ever cancelled your
insurance policy/ refused renewal/
rejected
your
insurance
request/
requested increase of rates/ terms?
If YES, provide details.

35. Ai avut cereri de despgubire n

ultimii 5 ani? Dac DA, menionai

detalii (cauzele care au determinat
cererea de despgubire i, dac ai
fost obligat la plata unor despgubiri,
cuantumul acestora):
Have you had any indemnity claims over
the past 5 years? If YES, please give
details (causes that generated the claim
and if you paid indemnities, the paid
amounts):

36. Menionai msurile corective luate

pentru evitarea repetrii

circumstanelor care au generat cereri
de despgubire.
Mention details about the corrective
measures taken to avoid recurrence of
claim generating circumstances.

37. Care credei ca sunt punctele slabe

care
va
expun
despgubire?

cererilor

de

Where do you see your potential

exposure to claims?

38. Cunoatei circumstane care ar putea

determina cereri de despgubire

mpotriva societii Dv.? Daca DA,
explicai pe scurt:
Are you aware of circumstances which
may result in claims against your
company? If YES, explain briefly.

Numr n Registrul Asiguratorilor: RA-021/2003; Autorizat de Comisia de Supraveghere a Asigurrilor

Nr. Reg. Com. J40/9518/2003; C.U.I. 12408250; Capital social 33.288.761,60 RON
Bucureti, Str. Nicolae Caramfil Nr. 61B, Sector 1,
Tel.: +4 021 311 91 04; Fax: +4 021 311 50 56; www.certasig.ro; office@certasig.ro
4/5

ntrebare / Question

Rspuns / Answer

39. Limita rspunderii dorit:

Requested Limit of liability:

40. Franiza dorit:

Requested Deductible:

41. Moneda poliei de asigurare:

RON

EUR

42. Modalitatea de plat a primei de

anual

semestrial

annual

biannual

Policy currency:

asigurare:

Insurance premium payment:

DECLARAIE
STATEMENT
Declarm pe proprie rspundere c informaiile furnizate n prezenta cerere sunt reale i corecte i c nu s-au omis
informaii relevante, n conformitate cu documentele i informaiile de care dispunem i care ar putea influena decizia
asigurtorilor n aceast privin. nelegem i suntem de accord ca acest document s stea la baza i s fie parte
integrant din polia de asigurare dac aceasta va fi emis. Vom informa asigurtorii n cazul n care apar modificri la
cele declarate aici si dac acestea se produc nainte de ncheierea Contractului de Asigurare. Completarea acestui
document nu oblig n niciun fel pe cel care l completeaz s achiziioneze asigurarea i nici nu oblig asigurtorul s
ncheie asigurarea.
We hereby declare that to the best of our knowledge and belief, the particulars and answers herein are true and correct and that we
have not knowingly withheld any information that would influence the decision of the underwriters in regard to this proposal. It is
understood and agreed that this proposal shall form the basis of the contract should this policy be issued. We undertake to inform
Insurers of any material alteration to those facts occurring before completion of the Contract of Insurance. Completion of this document
does not constitute a binder or obligate the applicant to purchase the insurance, nor does it bind the insurer to complete this insurance.

Data:
Date:

______________________
_

Nume / Prenume:

___________________

Name:

Semntura
solicitantului
tampila societii:

Signature of applicant and company

stamp:

___________________

Numr n Registrul Asiguratorilor: RA-021/2003; Autorizat de Comisia de Supraveghere a Asigurrilor

Nr. Reg. Com. J40/9518/2003; C.U.I. 12408250; Capital social 33.288.761,60 RON
Bucureti, Str. Nicolae Caramfil Nr. 61B, Sector 1,
Tel.: +4 021 311 91 04; Fax: +4 021 311 50 56; www.certasig.ro; office@certasig.ro
5/5