NOTIFICATION OF LOSS OR DAMAGE FOR COMPREHENSIVE GE Yo: ‘Thro: UNIFIED ADJUSTERS AND SURVEYORS (PAR BAST), INC. Date: Policy No: INERAL LIABILITY INSURANCE ‘Claim No.: ‘Tilly of contract insured: Name(s) and address(es) of lnsured(s); Location and address of Contract Site: ‘Name of supervising Eugineer: ‘Nowrest railway station (airport): Adviseble approach route to Contract Site from railway station (airport) or otherwise: 1. Which Hema were daaiaged? ©) Contract worka (b) Conmmuction plant aud equipment (6) Construction mactinery “E. When did the Toas or daaage occur? «Stale “ate and exact time) 3. How did the damage occur and whal ‘was its probable eause? (Attach sketches, photos, ete.) * “The iaaue of this form isnot io be taken as ei admission of lability by io Taner4 How fir bad the construction of the damages item(s) progressed at the Aine of the occurrence of the damage? "5. Give nume and address of witnesses (0 the occurreneo? 6. How will the damaged items be 7. Will any alteruiions or improvements be made to design, construction or materials whea repairs are carried out? a. What are the estimated costs for the repair of damuge to - (a) Contract works? (b) Construction plant and equipment? (©) Construction machinery? “9. Is Third Party Liability involved? ‘10. Are existing buildings or rurrounding property damaged? 11, Kemarka: “The Uudorsigned Insured declares to have wiswered the above queulious conscleahiously and trulafilly. Dated at this day of _ 2 Signature :