Machinery Package application Form

Transcription

1 Machinery Package application Form Includes Machinery Breakdown, Stock Deterioration and Business Interruption. Additional Business Insurance Application Page This additional page must be attached to either a Business Insurance Application booklet or form. Insured s name Agent s name Machinery to be insured (Boilers and pressure vessels to be listed in next section.) Code Year of manufacture Description and make New replacement cost Rate % Premium 100/101 Sum insured limit any one loss Boilers and Pressure Vessels to be insured (Other machinery to be included in previous section.) Code Year of manufacture Description and make New replacement cost Rate % Premium Additional Cover Code Description and make Sum insured Rate % Premium 205 Expediting expenses? Yes No 206 Overseas airfreight charges? Yes No 207 Inclusion of dies? Yes No 301 Reinstatement conditions boilers/pressure vessels? Yes No Deductible The company shall not be liable for the first $ of each and every claim. PAGE 1

2 about the machinery 1. Is there a regular preventive maintenance programme on any of the machinery included in this application? Yes No 2. Is there any fault or defect known to you in any part of the equipment? Yes No 3. Refrigeration/Air conditioning plant to be insured? Yes No If Yes, please answer 4. (If No, please skip to 5.) 4. Has the gas been changed from another type and/or model since this equipment was first installed? Yes No If Yes, please answer 4(a) and (b) (a) What refrigeration gas was used? (b) What refrigeration gas is now used? 5. Submersible/bore pumps to be insured? Yes No If Yes, please answer 5(a) and (b) (a) Have you included in the New Replacement Cost the value of raising and lowering the pump and any bore case? Yes No (b) Do want to insure this cost? Yes No If Yes, sum insured: $ 6. Boiler/pressure vessel to be insured? Yes No If Yes, please answer 6(a) and (b) (a) Are the boilers/pressure vessels subject to an annual maintenance or inspection contract other than the statutory inspection? Yes No If Yes, name of service organisation (b) Is the boiler feed water treated? Yes No If Yes, state by whom and type of treatment Is this treatment: automatic manual continuous periodic state period (c) What percentage of condensate is returned to the boiler? % (d) If the boilers do not require certified attendant under statutory regulations, who is appointed to exercise general supervision and the safe operation of the boilers? 7. Have you any machinery, boilers or pressure vessels other than those included in this application? Yes No PAGE 2

3 Stock Deterioration This policy is only available if you have taken out Machinery Breakdown Cover. Property Insured Code Full description of type of stock Identify storage chamber Sum insured (replacement value) Rate % Premium Note: It is a requirement of this insurance that all the refrigerated stock on the premises must be insured for its replacement value. In the event of under-insurance, you will be required to be your own insurer for the difference. Total sum insured $ Total premium $ Is there a significant fluctuation in the values of stock throughout the year? Yes No If Yes, please attach details. Excess This insurance is subject to an excess of: % of each and every net loss with a minimum of $ ; or $ The Risk 1. Does the sum(s) insured on stock represent Full Value? Yes No 2. Is the refrigerating machinery: (a) maintained by your own engineering staff? Yes No (b) the subject of a regular maintenance contract? Yes No 3. (a) Is there an automatic temperature alarm system? Yes No (b) Is it monitored? Yes No If Yes to (a) or (b) above, please provide details. 4. Are there any alternative storage facilities that can be used in the event of a claim? Yes No. 5. Do you store goods belonging to others? Yes No If Yes, do you have printed storage conditions? Yes No PAGE 3

4 business interruption This policy is only available if you have taken out Machinery Breakdown Cover. Items Insured INP REV RRV Loss of profit Loss of revenue Loss of rents Sum insured Rate/Premium WAG Wages 100% PFB Payroll DWB Dual wages 100% for weeks, plus % for the balance with the option to consolidate to weeks WLN Wages in lieu of notice weeks PDB Dual payroll 100% for weeks, plus % for the balance with the option to consolidate to weeks AEW CPC Additional increased cost of working Claim preparation costs 232 Book debts Total sum insured $ Additional Extensions Code Description and make Rate % Premium 235 Customers /Suppliers premises? Yes No 222 Electric power stations and substations? Yes No 223 Gas supply breakdown? Yes No 224 Premium adjustable on certified figures? Yes No Time Deductible hours (the period not insured immediately following the breakdown). Indemnity Period What indemnity period do you require? 3 months 6 months 9 months 12 months 18 months Other number of months: PAGE 4

5 the business 1 (a) How long has the business been in existence as a going concern? years/months (b) How long have your owned the business? years/months 2. When does your financial year end? 3. What are the normal working hours of items of plant? 4. Are there any fluctuations in your trading pattern throughout the year (seasonal variations)? Yes No. the machinery If more than one machine, please complete the following table. Indicate how much of the turnover and insured profit is generated by each machine. Supply a separate flow diagram if this will help. Machine Turnover Profit Estimated max. repair time (months) 1 % % 2 % % 3 % % 4 % % 5 % % office use only Policy Number PAGE 5