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Title of Contract insured |
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Name(s) and adress(es) of insured(s) |
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Location and address of contract site |
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Nearest railway station/ airport |
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Easiest access to contract site from railway station/ airport |
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| 2. |
When did the loss of damage occur?
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When was notice first given to the Insurer?
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To whom? |
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By whom? |
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| 3 |
Are there any witness?
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Yes
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No
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If so, please give names, professions and addresses. |
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| 4. |
Which item was damaged?
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Erection Work
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Civil Engineering work
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Construction/erection machinery
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Item No. in Specification of policy Schedule |
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Sum insured |
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Name of manufacturer, type of machine |
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Year of manufacture, serial number(Please give full details as on manufaturer's plate) |
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Description of damaged item (capacity, r.p.m., weight, etc.) |
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How far had the erection of the damaged item progressed at the time of the occurrence? |
% complete
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on trail
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| 5. |
Which parts were damaged? |
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| 6. |
How did the damage occur and what was its probable cause? |
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Please attach sketches, photos; if available, indication on amounts of rainfall, water levels, rates of flow; police reports and newspaper cuttings. |
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| 7. |
Do the fractures show any sign of faulty casting, faulty material or previous repair?
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Yes
No |
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If so, please give details. |
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| 8. |
Are any alterations to or improvements of design, construction, execution or material being effected whilst repairs are being made?
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Yes
No |
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If so, please give details. |
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| 9. |
Ho will the damaged item by repaired, by whom and where? |
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Please indicate estimated repair period. |
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| 10. |
What are the estimated repair costs? |
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| 11. |
Is overtime and/or night work or work on publick holidays or express freight involved in order to repair the damaged items?
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Yes
No |
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If so, to what extent and why? |
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| 12. |
Was any third party or surrounding property damaged? |
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If so, please give details. |
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What is the estimated indemnity for third party liability claims?
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Property |
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Bodily injury |
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Were any existing buildings or surrounding property damaged?
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Yes
No |
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If so, by what? |
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Estimated claims amount? |
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| Please submit copy(es) of repair estimate(s). which should show a breakdown into material costs, labour charges-including man-hours warked - and freight charges to the company. |
| We declares that we have the above questions conscientiously and truthfully. |
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| If more than one scheduled item is affected, please complete one form per item. |
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Note:
If the space is not sufficient for reply to any question, please email us on premier@picl.com.np |
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