CONTRACTORS ALL RISKS INSURANCE INSURANS SEMUA RISIKO KONTRAKTOR PROPOSAL FORM / BORANG CADANGAN
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1 DMS/15/CAR/P/001/Jan. LONPAC INSURANCE BHD ( T) Head Office : LG, 6th, 7th, 21st to 26th Floor, Bangunan Public Bank, 6, Jalan Sultan Sulaiman, Kuala Lumpur, Malaysia. P.O. Box 10708, Kuala Lumpur, Malaysia. Tel: (03) , Fax: (03) , , , , , Website: IMPORTANT NOTICE / NOTIS PENTING CONTRACTORS ALL RISKS INSURANCE INSURANS SEMUA RISIKO KONTRAKTOR PROPOSAL FORM / BORANG CADANGAN Consumer Insurance Contract Pursuant to Paragraph 5 of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance wholly for purposes unrelated to your trade, business or profession, you have a duty to take reasonable care not to make a misrepresentation in answering the questions in this Proposal Form. You must answer the questions in this Proposal Form fully and accurately. Failure to take reasonable care in answering the questions may result in avoidance of your contract of insurance, refusal or reduction of your claim(s), change of terms or termination of your contract of insurance. The above duty of disclosure shall continue until the time your contract of insurance is entered into, varied or renewed with us. In addition to answering the questions in this Proposal Form, you are required to disclose any other matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied. You also have a duty to tell us immediately if at any time after your contract of insurance has been entered into, varied or renewed with us any of the information given in this Proposal Form is inaccurate or has changed. Kontrak Insurans Pengguna Menurut Perenggan 5 daripada Jadual 9 Akta Perkhidmatan Kewangan 2013, jika anda memohon Insurans ini sepenuhnya untuk tujuan yang tidak berkaitan perdagangan, perniagaan atau profesion anda, anda mempunyai kewajipan untuk mengambil langkah yang munasabah untuk tidak salah nyata dalam menjawab soalan-soalan dalam Borang Cadangan ini. Anda dikehendaki menjawab soalan-soalan dalam Borang Cadangan ini dengan lengkap dan tepat. Kegagalan untuk mengambil langkah yang munasabah dalam menjawab soalan-soalan, mungkin mengakibatkan pembatalan kontrak insurans anda, keengganan atau pengurangan gantirugi, perubahan terma atau penamatan kontrak insurans anda. Kewajipan pendedahan di atas hendaklah diteruskan sehingga kontrak insurans anda dimeterai, diubah atau diperbaharui dengan kami. Sebagai tambahan kepada soalan-soalan dalam Borang Cadangan ini, anda dikehendaki untuk mendedahkan apa-apa perkara lain yang anda tahu akan mempengaruhi keputusan kami dalam menerima risiko dan menentukan kadar dan terma yang dikenakan. Anda juga mempunyai kewajipan untuk memberitahu kami dengan serta-merta jika pada bila-bila masa selepas kontrak insurans anda ditandatangani, diubah atau diperbaharui dengan kami, apa-apa maklumat yang dinyatakan dalam Borang Cadangan ini tidak tepat atau telah berubah. Non-Consumer Insurance Contract Pursuant to Paragraph 4(1) of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance for a purpose related to your trade, business or profession, you have a duty to disclose any matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied and any matter a reasonable person in the circumstances could be expected to know to be relevant, otherwise it may result in avoidance of your contract of insurance, refusal or reduction of your claim(s), change of terms or termination of your contract of insurance. The above duty of disclosure shall continue until the time your contract of insurance is entered into, varied or renewed with us. You also have a duty to tell us immediately if at any time after your contract of insurance has been entered into, varied or renewed with us any of the information given in this Proposal Form is inaccurate or has changed. Kontrak Insurans Komersial Menurut Perenggan 4(1) Jadual 9 Akta Perkhidmatan Kewangan 2013, jika anda memohon Insurans ini untuk tujuan yang berkaitan dengan perdagangan, perniagaan atau profesion anda, anda berkewajipan untuk mendedahkan apa-apa perkara yang anda tahu akan mempengaruhi keputusan kami dalam menerima risiko dan menentukan kadar dan terma yang dikenakan, dan apa-apa perkara yang munasabah yang boleh dijangka sebagai relevan, jika tidak ia boleh menyebabkan pembatalan kontrak insurans, keengganan atau pengurangan gantirugi, perubahan terma atau penamatan kontrak insurans anda. Kewajipan pendedahan di atas hendaklah diteruskan sehingga kontrak insurans anda dimeterai, diubah atau diperbaharui dengan kami. Anda juga mempunyai kewajipan untuk memberitahu kami dengan serta-merta jika pada bila-bila masa selepas kontrak insurans anda ditandatangani, diubah atau diperbaharui dengan kami, apa-apa maklumat yang dinyatakan dalam Borang Cadangan ini tidak tepat atau telah berubah.
2 LONPAC INSURANCE BHD ( T) Head Office : LG, 6th, 7th, 21st to 26th Floor, Bangunan Public Bank, 6, Jalan Sultan Sulaiman, Kuala Lumpur, Malaysia. P.O. Box 10708, Kuala Lumpur, Malaysia. Tel: (03) , Fax: (03) , , , , , Website: CONTRACTORS ALL RISKS INSURANCE INSURANS SEMUA RISIKO KONTRAKTOR Agency A/C No: No. Akaun Agensi Policy No: No. Polisi PROPOSER / PENCADANG 1. Name(s) and address(es) of Contractor(s) : Nama dan alamat Kontraktor-Kontraktor Telephone No. : No. Telefon 2. Name(s) and address(es) of Subcontractor(s) 1 : Nama dan alamat Subkontraktor 1-3. Name and address of Principal : Nama dan alamat Prinsipal Telephone No. : No. Telefon 4. Name and address of Consulting Engineer : Nama dan alamat Jurutera Perunding - 5. Name of Employer : Nama Majikan 6. Nature of Business : Jenis Perniagaan PARTICULARS OF CONTRACT WORK / BUTIR-BUTIR KERJA KONTRAK 1. Title of contract (if project consists : of several sections, specify section(s) to be insured) Nama Kontrak (jika projek terdiri daripada beberapa seksyen, sila nyatakan seksyen-seksyen) yang hendak di perlindungkan) 1 If necessary on a separate sheet. / Jika perlu di atas kertas yang berasingan.
3 2. Location of site : Lokasi tapak 3. Description of contract work 2 : (please give detailed technical information) Keterangan mengenai kerja kontrak 2 (sila nyatakan butiran teknikal) Dimensions (length, height, depth, spans, number of floors) Dimensi (panjang, tinggi, dalam, luas, bilangan tingkat) Foundation (method, level of deepest excavation) Tapak Asas (cara, tahap penggorekan terdalam) Construction methods / Cara binaan Construction materials / Bahan binaan 4. Work to be carried out by Subcontractors : Kerja yang akan dikendalikan oleh Subkontraktor PERIOD OF INSURANCE / TEMPOH INSURANS 1. Commencement of work : Permulaan Kerja 2. Duration of construction : Tempoh kerja binaan Months / Bulan 3. Date of completion / Tarikh Siap : 4. Maintenance period : Tempoh Penyelenggaraan Months / Bulan COVER REQUIRED / PERLINDUNGAN YANG DIKEHENDAKI 1. Is Third Party Liability to be included? Adakah Liabiliti Pihak Ketiga akan diliputi? Has the Contractor concluded a separate policy for TPL? Sudahkah kontraktor mengeluarkan sijil berasingan bagi liabiliti pihak ketiga? Limit of Indemnity / Hak Gantirugi 2. Please state hereunder the amounts you wish to insure and the limits of indemnity required (of Policy Wording, Section I, Memo 1, and Section II). Sila nyatakan amaun yang ingin dilindungi dan had ganti rugi yang diperlukan (Seksyen I, Memo I dan Seksyen II dalam Sijil Insurans) SECTION I Material Damage SEKSYEN I Kerosakan Bahan Items to be insured 1. Contract work (permanent and temporary work, including all materials to be incorporated herein) Kerja Kontrak (kerja tetap dan sementara termasuk semua bahan yang akan diperbadankan didalamnya) Sums to be insured Amaun yang akan diperlindungkan (RM) 1.1 Contract price Harga kontrak 2 For harbours, piers, docks, tunnels, galleries, dams, roads, airports, railway facilities, sewerage and water supply systems, bridges and structures in earthquake zones also see special questionnaires. 2 Untuk pelabuhan, dermaga, limbungan, terowong, galeri, empangan jalan raya, lapangan terbang, kemudahan keretapi, pembentungan dan sistem bekalan air, jambatan dan struktur di zon gempa bumi sila lihat soalan khas.
4 Items to be insured Sums to be insured Amaun yang akan diperlindungkan (RM) 1.2 Materials or items supplied by the Principal(s) Bahan yang dibekalkan oleh prinsipal 2. Construction plant and equipment Loji dan kelengkapan binaan 3. Construction machinery (please attach list showing replacement values of new items) Alat jentera binaan (sila lampirkan senarai yang menunjukkan nilai gantian alat-alat baru) 4. Clearance of debris (insured only up to the amount indicated) Pembersihan sarap (dilindungi setakat amaun yang disebut) Total sum to be insured under Section I: Jumlah amaun dilindungi di bawah Seksyen I: Items to be insured Limits of indemnity 4 Had Gantirugi 4 SECTION II Third Party Liability SEKSYEN II Liabiliti Pihak Ketiga 1. Bodily injury / Kecederaan tubuh badan 1.1 any one person / setiap seorang 1.2 total / jumlah keseluruhan 2. Property damage / Kerosakan harta benda Total limit to be applied under Section II: Jumlah had dibawah Seksyen II: 3 Limit of indemnity in respect of each and every loss or damage and/or series of losses or damages arising out of any one event. 3 Had gantirugi bagi tiap-tiap satu kehilangan atau kerosakan dan/atau satu siri kehilangan atau kerosakan akibat daripada mana-mana satu kejadian. 4 Limit of indemnity in respect of any one accident or series of accidents arising out of any one event. 4 Had gantirugi bagi mana-mana satu kemalangan atau satu siri kemalangan akibat daripada mana-mana satu kejadian.
5 GENERAL QUESTIONNAIRE / PERKARA AM 1. Is the Contractor experienced in this type of work or construction methods? Adakah Kontraktor ini mempunyai pengalaman bagi jenis kerja atau cara binaan ini? 2. Details of existing buildings or surrounding property possibly affected by the contract work, such as by excavating, underpinning, piling, vibration, groundwater lowering, etc. Butir-butir mengenai bangunan yang sedia ada atau hartabenda berdekatan yang mungkin tergugat oleh kerja kontrak seumpama penggorekan penunjangan, pemasangan cerucuk, gegaran, penurunan air tanah dan lain-lain. 3. Are existing buildings and/or structures on or adjacent to the site, owned by or held in care, custody or control of the Contractor(s) or the Principal, to be insured against loss or damage arising out of or in connection with the contract works? Adakah bangunan yang sedia ada dan/atau struktur berhampiran dengan tapak yang dimiliki oleh atau dibawah tangan, tanggungan atau kawalan kontraktor atau prinsipal akan dilindungi daripada kehilangan atau kerosakan akibat daripada atau berkaitan dengan kerja-kerja kontrak ini? DECLARATION / PENGAKUAN I/We understand that it is my/our duty to take reasonable care not to make a misrepresentation in answering the questions in this Proposal Form and I/we hereby declare that I/we have fully and accurately answered the questions above. Saya/Kami faham bahawa menjadi tanggungjawab saya/kami untuk mengambil langkah yang munasabah untuk tidak salah nyata semasa menjawab soalan-soalan dalam Borang Cadangan ini dan saya/kami dengan ini mengaku bahawa saya/kami telah menjawab dengan sepenuhnya dan dengan tepat soalan di atas. Date: Tarikh: Signature of Proposer / Tandatangan Pencadang Full Name of Signatory Nama Penuh NRIC No: No. K/P: Business Reg. No: No. Pendaftaran Perniagaan Business Reg. No. / NRIC Verified By : Signature & Name of Agent/Staff The English version of the proposal form and declaration shall solely be used to determine all differences arising out of the same. Naskah Bahasa Inggeris adalah borang cadangan dan akuan yang akan dirujuk sekiranya ada apa-apa perbezaan mengenai cadangan dan akuan ini. PRIVACY POLICY / POLISI PRIVASI For information on our privacy policy, please visit our website Bagi maklumat mengenai polisi privasi kami, sila lawat laman web kami
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