Chestionar – cerere de asigurare / questionnaire – proposal form

aferent poli\ei tip “toate riscurile” pentru lucr`rile de construc\ii-montaj ]i r`spunderea

constructorului/ for contractor’s all risks insurance
1. Titlul contractului ]i Beneficiarul (dac`
proiectul are mai multe sec\iuni, specifica\i
sec\iunile care urmeaz` a fi asigurate)/Title
of contract and the Beneficiary (if project
consist of several sections, specify section(s)
to be insured)

2. Localizare/Location of site

3. Numele ]i adresa antreprenorului/

Name and address of principal

4. Numele ]i adresa contractorului/

Contractor’s name and address

5. Numele ]i adresa(ele) subcontractorului(ilor)/

Subcontractor’s name and address

6. Numele ]i adresa inginerului consultant/

Name and address of consulting engineer

7. Prezentarea construc\iei contractate Dimensiuni (lungime, [n`l\ime, ad@ncime, deschideri,

(informa\ii tehnice detaliate)/Contract num`r de nivele/Dimensions (length, height, depth,
works’ description (please, give spans, number of floors:
detailed technical information)
Funda\ie (tipuri, nivelul la care s-a efectuat cea mai
ad@nc` excavare)/Foundation (method, level of
deepest excavation:

Metode de construc\ie/Construction methods:

Materiale de construc\ie/Construction materials:

8. Contractorul are experien\a necesar` la

aceste tipuri de construc\ii ]i [n
folosirea acestor metode?/Is the
contractor experienced in this type of
work?

9. Perioada asigurat`/ Data [nceperii lucr`rii/Commencement of work:

Insurance period: Data termin`rii lucr`rii/Date of completion:
Durata construc\iei (luni)/Duration of construction (months):
Perioada de garan\ie (luni)/Maintenance period (months):

10. Lucr`ri ce urmeaz` a fi efectuate de

Prezentul chestionar face parte integrant` din poli\a de asigurare
Formular D2.1-PL1-CH_CM / e/r 1/2 1
 subcontractori/Work to be carried out
by subcontractors

11. Riscuri speciale/ Incendiu, explozie/Fire, explosion da/yes  nu/no 

Special risks
Inunda\ie/Flood, inundation da/yes  nu/no 
Alunecare de teren, furtun`, ciclon/
Landslide, storm, cyclone da/yes  nu/no 
Explozie dirijat`/Blasting work da/yes  nu/no 
Altele/Other risks da/yes  nu/no 
Zon` seismic`, tsunami/Volcanism, tsunami da/yes  nu/no 
S-au [nregistrat cutremure [n aceast` zon`?/Have earthquakes been observed in
this area? da/yes  nu/no 
Intensitate/Intensity and magnitude:
Standardul proiectului este superior celui prev`zut de prevederile legale?/Is the
standard design higher that that stipulated in the relevant regulations? da/yes
 nu/no 

12. Condi\iile piatr`/rock  pietri]/gravel  nisip/sand  argil`/clay 

subsolului/Subsoil
umpluturi/filled ground 
conditions
altele/other subsoil conditions:
au fost [nregistrate alunec`ri de teren sau sufozii?/Do geological
faults exist in the neighborhood? da/yes  nu/no 

13. Nivelul apelor freatice/Ground-water level

14. Cel mai apropiat r@u, lac, mare, Numele/Name:

etc./Nearest river, lake, sea, etc. Distan\a/Distance:
Nivel/Level:

15. Condi\ii meteo/ Sezon ploios de la la /rainy season from to

Meteorological Cantit`\i de precipita\ii maxime (mm) pe or`, pe zi,
conditions pe lun`/max. rainfall (mm) per hour, per day, per month
Riscul de furtun` minor  mediu  ridicat  /
Storm hazard minor  medium  high 

16. Urmeaz` s` fie incluse cheltuieli suplimentare da/yes  nu/no 

pentru lucrul peste program, [n timpul nop\ii Limita r`spunderii/Limit of liability:
sau s`rb`torilor legale?/Are extra charges for
overtime, night work, work on public holidays
to be included?

17. Va fi inclus` ]i r`spunderea civil` legal`?/Is da/yes  nu/no 

third party liability to be included?

18. Contractorul a f`cut o poli\` separat` pentru da/yes  nu/no 

r`spunderea civil` legal`?/Has the contractor Limita r`spunderii/Limit of liability:
concluded a separate policy for TPL?

Prezentul chestionar face parte integrant` din poli\a de asigurare

Formular D2.1-PL1-CH_CM / e/r 1/2 2
 19. Detalii privind cl`dirile sau alte propriet`\i
[nvecinate, care pot fi afectate prin lucr`ri de
construc\ie ca: excavare, subzidire, construc\
ie de st@lpi, vibra\ii, lucr`ri pentru sc`derea
nivelului apelor freatice etc./Details of
existing buildings or property surroundings
possibly affected by contract works
(excavating, pilling, underpinning,
vibrating)

20. Cl`dirile existente ]i/sau structurile de pe sau da/yes  nu/no 

din vecin`tatea terenului [n construc\ie aflate Limita r`spunderii/Limit of liability:
[n posesia sau [n grija, custodia sau sub
controlul contractorilor sau a antreprenorului Descrierea exact` a acestor cl`diri/structuri/Exact
urmeaz` s` fie asigurate [mpotriva description of these buildings/structures:
pierderilor sau avarierii ca urmare a, sau [n
leg`tur` cu lucr`rile contractate?/Are existing
buildings and/or structures on or adjacent to
the site, owned by or held in care, custody or
control of the contractor or the principal to
be insured against loss or damage arising out
or in connection with the contract works?

V` rug`m, specifica\i [n continuare sumele care urmeaz` a fi asigurate conform Sec\iunii I ]i limitele
r`spunderii conform Sec\iunii a II-a/Please state hereunder the amounts you wish to insure and the
limits of indemnity required:
Sec\iunea I – Pagube materiale/Section I – Material damages
Obiectul asigur`rii/ Sume asigurate/
Items to be insured Amounts to be insured
1. Lucr`ri contractate/contract works
(activit`\i permanente ]i temporare inclusiv materialele ce urmeaz` a fi
folosite)/(permanent and temporary works, including all materials to be
incorporated herein)
1.1. Pre\ul contractului/contract price
1.2. Materiale furnizate de antreprenori/materials or items supplied by
the principal
2. Instala\ii ]i echipamente de construc\ii/construction plant and
machinery
3. Utilaje de construc\ii (rug`m, ata]a\i list`)/construction machinery
(please attach list showing replacement values of new items)
4. Cheltuieli de [ndep`rtare a resturilor/clearance of debris (insured only
up to the amount indicated)
Suma asigurat` conform Sec\iunii I/
Total sum to be insured under Section I

Riscuri speciale asigurate/ Limita r`spunderii/

Special risks to be insured Limits of indemnity
Cutremure, erup\ii vulcanice/Earthquake, volcanism, tsunami
Furtun`, ciclon, inunda\ii, alunec`ri de teren/
Storm, cyclone, flood, inundation

Prezentul chestionar face parte integrant` din poli\a de asigurare

Formular D2.1-PL1-CH_CM / e/r 1/2 3
 Sec\iunea a II-a – R`spundere civil` legal`/Section II – Third Party Liability
Riscuri asigurate/Items to be insured Limita r`spunderii/Limit of indemnity
1. V`t`mare corporal`/bodily injury

1.1. invaliditate permanent`/ persoan`/ eveniment/

permanent disability/person/event
1.2. deces/persoan`/eveniment/
death/person/event
2. Daune materiale/property damage
Limita r`spunderii conform Sec\iunii a II-a/ Total
limit to be applied under Section II

Certific`m prin prezenta c` declara\iile f`cute în prezentul chestionar sunt complete, conforme cu
cuno]tin\ele noastre ]i consim\im ca prezentul chestionar s` stea la baza ]i s` constituie parte integrant`
a oric`rei poli\e emise în leg`tur` cu riscul/riscurile de mai sus. S-a convenit ca asigur`torii s` r`spund`
numai [n limita condi\iilor poli\ei ]i c` Asiguratul nu va depune o alt` cerere de desp`gubire de orice
natur`./ We hereby declare that the statements made by us in this Questionnaire - Proposal From are to
the best of our knowledge and belief, complete and true, and we hereby agree that this Questionnaire –
Proposal Form is the basis and forms part of any policy issued in connection with the above risk.
It is agreed that the Insurers are liable in accordance with the terms of the Policy only that the Insured
will lodge any claims of whatever nature.
ASIBAN S.A. se oblig` s` p`streze secretul informa\iilor primite./The Insurers undertake to deal with
this information in strict confidence.
Data/Date:

SOLICITANT/ASIGURAT
APPLICANT/INSURED

Prezentul chestionar face parte integrant` din poli\a de asigurare

Formular D2.1-PL1-CH_CM / e/r 1/2 4