CERERE CHESTIONAR

INSURANCE QUESIONNAIRE
Privind rspunderea civil profesional a arhitecilor i inginerilor proiectanti
in respect of Professional Liability for Architects and Design Engineers
I. DATE GENERALE / General Information
1. Nume solicitant / Name of applicant______________________________________________________________
2. Adresa de desfurare a activitii (sediul social) /Legal Address _____________________________________
___________________________________________________________________________________________
Tel /Fax/adresa web___________________________________________________________________________
3. Data autorizrii n profesie / Date on which the Practice was established: _________________________________
4. Suntei membru n una sau mai multe asociaii/uniuni profesionale? Dac da, enumerai-le: Nu/ NO
Da/YES
Please list the professional bodies or associations to which the Applicant belongs.
____________________________________________________________________________________________
5. Denumirea societii s-a schimbat n ultimii 3 ani?
Nu/ NO
Da/YES
Has the name of the practice ever been changed?
Dac rspunsul este afirmativ prezentati detalii / If yes, please supply details
____________________________________________________________________________________________
II. DATE REFERITOARE ACTIVITATEA DESFASURATA / Details of Practice
1. PENTRU PERSOAN FIZIC / FOR INDIVIDUALS:
A. Calitatea/ Quality:
Arhitect
Inginer proiectant n construcii
Architect
Design Engineer
B. Modul de desfasurare a activitatii:
Persoana fizica autorizata / Authorised Individual
Birou individual / Individual Office
Salariat/colaborator la o societate comerciala de proiectare
Employee / Collaborator on a design commercial company
C. experienta asiguratului in exercitarea profesiei asigurate (numar de ani) ________________________________
Insureds experience in the profession provided (number of years)
2. PENTRU PERSOANA JURIDICA /FOR LEGAL PERSONS:
A. Modul de desfasurare a activitatii:
Birou individual cu mai multi angajati / Individual office with several employees
Birouri associate/ associated offices
Societate comerciala de arhitectura/ proiectare / Architecture / Design Commercial Company
B. Date despre acionari/ asociai/personalul angajat n cadrul profesiei :
Shareholders / associates / employees within the profession
Categoria

Nr
.
crt

Asociai/
actionari
Associates/
shareholders

1
2
3
4

Numele i prenumele / Name

Calificarea
Qualification

Experiena
profesional
Professional
Experience

Poziia deinut n
cadrul societii
Position in firm

1
2
3
4
5
6
*dac spaiul este insuficient se anexeaz lista

Personal
angajat
cadrul
profesiei
qualified
persons

Cerere de asigurare raspundere civila arhitecti si ingineri proiectanti

Clasificare: Public

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C. Numar total angajati/employees: din care/from which:

- total persoane de specialitate /specialised:
- alte persoane calificate (precizati specializarile)/other qualified persons:
- personal non-tehnic (administrativ)/non technical personnel
3. Bifai tipurile de activitti pe care le efectuai si precizai ponderea lor n total activitate / Check the types of activities
you perform and specify their share in the total activity::
Arhitectura constructii civile/industriale/ Industrial/civil Architectural Engineering
Arhitectura/proiectare peisagistica / Landscape design
Design amenajri interioare / exterioare / Interior/exterior design
proiectare structuri de rezistenta / design of structural resistance
proiectare infrastructura / infrastructure design
- Utilitati / Utilities
- retele edilitare / Urbanistic
proiectare instalaii fixe (electrice/sanitare, HVAC, termo)/ design of fixed installations
proiectare construcii civile
/ civil engineering design
proiectare construcii industriale / industrial engineering design
supervizare lucrari/dirigenie de antier / supervision works site inspectors
consultanta in constructii / construction consultancy
Asistenta tehnica / technical assistance

%
%
%
%
%

%
%
%
%
%
%

4. Numar de contracte de prestri servicii estimate pe anul n curs/Estimated annual no of contracts_______________

5. Venitul realizat pe anul anterior / Income for the previous year:_________________________________________
6. Venitul estimat pe anul n curs /Estimated current annual Income_______________________________________
7. Nominalizati cele mai importante proiecte pe care le-ati realizat n ultimii 3 ani/ Main projects in the last 3 years::
________________________________________________________________________________________________
_______________________________________________________________________________________________
8. Bifati dac obiectivele proiectate/ obiectivul proiectat (in cazul acoperirii per proiect) sunt destinate
urmtoarelor domenii / check if the if project designed / objective of the project (if coverage per project) are for the
following areas :
Minier / mining
Energetic (hidroenergetic, termoenergetic, nuclear, eolian si altele neconventionale)
Energy (hydro, thermal, nuclear, wind and other unconventional)
Aviatie / Aircraft
Maritim / Maritime
Lucrri hidrotehnice i imbunatatiri funciare / Hydro works and land reclamation
Drumuri, poduri, tuneluri / Roads, bridges, tunnels
Ci ferate / Rail ways
Parcuri de distractii / amusement parks
Utilitati publice (reele ap, gaze, energie electric) / public utilities (water, gas
electrical energy networks)
Echipamente, instalaii, utilaje, sau componente/parti ale acestora, piese,
subansammble,scule/dispozitive / equipment, facilities, equipment, or components /
parts of those, pieces, parts, tools / devices
Fabrici la cheie / turnkey factories
Mijloace de transport / means of transportation
Aparate de uz casnic, mobilier, obiecte de decor interior si exterior / household
appliances, furniture, interior and exterior decoration and / or other similar.
Nota: proiectele realizate pentru aceste domenii nu sunt acoperite automat in polita , ele pot
fi incluse in acoperire numai cu acceptul special al Administratiei Centrale. /Projects completed for
those areas are not automatically covered in the policy, those projects can be covered only with
Head Quarters Approval
9. Exist proiecte la care realizai i construcia obiectivelor proiectate?
Nu
Da
Are there projects for which you make the design and also the construction?
Dac raspunsul este da, menionai % din Cifra de afaceri __________________________________________________
Cerere de asigurare raspundere civila arhitecti si ingineri proiectanti

Clasificare: Public

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If yes, please specify % from the turnover

III. DATE REFERITOARE LA PROIECTUL PENTRU CARE SE DORESTE ASIGURAREA /

Information related to the project for which you want to be insured

(se completeaza numai daca se solicita acoperire per proiect/complete only if you want single project coverage)
1. Calitatea deinut n cadrul proiectului: Proiectant general / General Designer
Da
\ Quality held in the project
Subcontractor /subcontractor
Da
Contractor general / General Contractor Da
2. Beneficiarul proiectului / Project Beneficiary_____________________________________________________________
3. Numele Proiectului / Project Name ____________________________________________________________________
4. Obiectivul de proiectat/ descriere si domeniul de utilizare / description and area of use of the project
___________________________________________________________________________________________________
___________________________________________________________________________________________________
6. Descriei complet activitile dvs. desfurate in legatura cu proiectul (execuie, avizare, supervizare si coordonare,
asisten si consultan, elaborri de caiete de sarcini, instruciuni tehnice privind execuia, proiecte de urmrire privind
comportarea n timp a cldirilor, asistarea fazelor de execuie, dirigentie antier, verificarea calitii execuiei, soluii
pentru tratarea defectelor, etc.) Fully describe your activities conducted in connection with the project ( execution,
approval, supervision and coordination, assistance and consultancy, tender books, technical guidance on
implementation, projects while tracking the behaviour of buildings, assisting the execution phase, Coordination on site,
checking the quality of execution, defect treatment solutions, etc)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
6. Locatia obiectivului proiectat / Location of the designed project ______________________________________________
7. Valoarea totala a contractului de executie (=valoare deviz constructie) / value of construction project________________
8. Valoarea venitului dvs. realizat din proiect( valoare onorarii) / Your Fees______________________________________
9. Perioada de realizare a proiectului/designului: de la data___________________la data ___________________________
Design Phase/period
from
until
10. Perioada de constructie/realizare a obiectivului proiectat de la data___________________la data __________________
Construction Phase/period
from
until
11. Data estimata de predare-primire a obiectivului / constructiei _______________________________________________
Hand/Over estimated date
12. Durata raspunderii Dvs. referitoare la proiect/Your liability period i.r.o. project:
13. Solicitati includerea subcontractorilor n polia de asigurare de raspundere profesionala: Nu
Da
Do you require subcontractors to be included in your Professional Indemnity policy
No
Yes
Daca da, va rugam sa completati tabelul de mai jos / If Yes, please complete the below table:
Denumirea firmei/persoanei care
subcontracteaza
Name of the sub-contractor

Descrierea lucrarilor realizate de

subcontractor /
Services provided

Ponderea lucrarilor realizate de

subcontractor n total proiect
Share in total work performed
by the subcontractor in the
project

14. La proiectul/proiectele pentru care solicitati acoperire, realizati si constructia?

For the projects for which you ask coverage, are you also involved in construction?

Nu

Da

No

Yes

IV. INFORMATII REFERITOARE LA ASIGURARI SI DAUNE / Previous insurance and claims history
1. Ai avut anterior o asigurare de rspundere civil profesional ?
Nu
Da
Have you previously been insured for professional liability?
No
Yes
Dac da, va rugm precizai / If yes please specify:
Asigurtorul, perioada de asigurare, limita rspunderii, despgubiri pltite / Insurer, Insurance period,
limit of indemnity, paid claims :
____________________________________________________________________________________
____________________________________________________________________________________
A existat vreun asigurator care a anulat sau refuzat rennoirea polielor?
Was there any insurer that cancelled or refused renewal policies?
Cerere de asigurare raspundere civila arhitecti si ingineri proiectanti

Nu
No

Da
Yes
Clasificare: Public

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2. Ai avut reclamaii , n activitatea dvs. profesional, n ultimii 3 ani:

Have you had any claims regarding your activity in the last three years?
3. Ai avut cereri de despgubire n ultimii 3 ani:
Have you had any indemnity claims in the last three years?
4. Ati platit despagubiri n ultimii trei ani:
Have you paid indemnity in the last three years?

Nu
No
Nu
No
Nu
No

Da
Yes
Da
Yes
Da
Yes

Dac da, menionai anul, motivele, sumele pltite/ If yes, specify the year, the reasons, indemnities paid:____________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
5. Cunoatei circumstane care pot determina reclamaii/plangeri mpotriva dvs / Is your firm aware of any
circumstances or incidents which may result in a claim against your firm:
Dac da, va rugm detaliati / If yes please provide details:
______________________________________________________________________________________________
______________________________________________________________________________________________
6. Limita rspunderii solicitat pentru rspundere civil profesional / Limit of liability requested
a. Limita agregat pe ntreaga perioada de asigurare / Limit in aggregate for the entire period______________________
b. Limita pe eveniment / Limit per event _______________________
7. Solicitai extinderea poliei pe perioada de anterioritate / Do you ask for anteriority coverage? Nu/No
Da/Yes
(acoperire pentru activitatea realizat pe perioada anterioar emiterii poliei / coverage for worked performed before the
issuance of the policy)?
Daca DA, bifai perioada de anterioritate solicitat: 12 luni/months
24 luni
36 luni
If YES, please check on the retro-coverage period requested
8. Franiza solicitat/Deductible:
Franiza minim obligatorie 250 EUR /daun, numai pentru pierderi financiare:
Nu
Da
Minimum compulsory deductible 250 EUR /damage only for financial losses
No
Yes
Alt franiz solicitat (mai mare decat fransiza minima obligatorie) / other deductible________________________
9. Perioada de asigurare / _________(luni, ani): de la ______________pan la______________________________
Insurance period:
(months, years): from
until
10. Modalitatea de ncheiere a poliei de asigurare/ Policy currency: Valut/ foreign currency
Lei/RON
11. Modalitatea de plat a primei de asigurare /Payment of insurance premiums
Integral / In full
In rate / In installments
Solicitantul declar c datele incluse n aceast cerere sunt reale i n conformitate cu documentele i informaiile de care dispune,
fiind de acord s stea la baz i s fie parte a poliei emise.
We declare that the statements in this proposal are true and according to all documents and all information supplied by me/us. We
agree that this proposal shall form the basis of any contract of insurance affected thereon.
ASIGURAT/INSURED
________________________
(numele, semntura, tampila)
(name, signature, stamp)
ncheiat polita nr
(Se completeaz de ctre reprezentantul Asigurtorului.)

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Clasificare: Public

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