Contractor's Plant & Machinery

Corporate Information

Company Name *

Activity Of The Company *

Title*

First Name*

Last Name*

Occupation *

Mobile *

Email *

Address *

Website

Contractors Plants & Machinery Data

On annual basis

OR

From

Geographical scope of cover

Has there been any previous CPM insurance?

Yes

If so, for which item(s) of the specification and by what companies?

Have the plant and machinery Yes to be insured (partly or in total) been hired?

Yes

If so, please specify the owner’s name and address

Are the plant and machinery highly exposed to special hazards?

Fire explosion

Earthquake or volcanic activity or tsunami

Storm or cyclone

Flood or inundation

Landslide

Blasting

Employment in mountainous terrain

Employment underground

Do you wish the cover to include extra charges for Overtime or Night work or Work on Public Holidays?

Yes

Limit of indemnity for such extra charges

Do you wish the cover to include inland transport?

Yes

If so, please specify

Maximum value transported by one means of transport

Specification of Plant and Machinery to be Insured

Number of Items

We hereby acknowledge and confirm that all the submitted data above are correct and We did not hide any information related to the risk to be insured. And We authorize Brokerage Insurance Brokerage in executing this insurance request with the concerned insurance company and facilitate the policy issuance, renewals and claims follow-up and communicate specific information about us and our account to third parties if needed, in accordance with the privacy policy. We also accept that this insurance application and approval be the basis of the contract and an integral part of the insurance policy.

Contractor's Plant & Machinery