CERERE CHESTIONAR - privind asigurarea tip “toate riscurile” a utilajelor si echipamentelor

constructorului / Questionnaire proposal form for Contractor’s plant and equipment insurance
(CPE)

1. Numele si adresa
asiguratului / Name and
the address of insured
2. Adresa bunurilor
asigurate / Location of
goods insured
3. Profilul activităţii
desfăşurate / Type of
activity
4. Numele persoanei de
contact / Name of the
contact person
5. Descrierea utilajului / echipamentului / ce
urmeaza a fi asigurat (se vor anexa detalii
tehnice, facturi, etc.) / Description of equipment /
plant to be insured (technical description,
invoices etc. will be attached)
Daca este vorba despre mai multe utilaje, se va
anexa lista completa: denumire, descriere,
cantitate, model, serie, detalii tehnice / If more,
complete list of plant to be insured stating
quantity, model and serial numbers, technical
description etc. will be attached
6. Data fabricatiei / Date of fabrication

7. Suma asigurata solicitata / Requested sum insured

Asigurati-va ca suma asigurata pentru fiecare utilaj
corespunde valorii de nou a acestuia / Verify that the
sum insured corresponds to the new replacement value
per plant item
8. Destinatia bunurilor descrise mai sus /
Destination of goods decribed above

9. Utilajele au fost achizitionate pentru propria folosinta/ Plant or machinery has been purchased for
your own use  sau spre a fi inchiriate/ or are you going to lend it ?

Vor fi inchiriate cu operator /You will lend it with operator  sau fara operator/or
without operator  ?

10. Marcati cu un asterix utilajele care vor lucra pe pontoane,

barje, docuri, nave, vase etc.? / Mark all plant items
installed on barges and pontoons with an asterisk
Prezentul chestionar face parte integranta din polita de asigurare 1
Formular D2.1-PL1-CH_CPE e/r 1/3
11. Programul normal de lucru al unitatii / Nr. schimburi pe zi / Number of changes by day:
Working hours of the unit :
Nr. ore pe schimb / Number of hours by change:

Nr. zile pe saptamana / Number of days by week:

12. Regimul de functionare al masinilor, utilajelor,
echipamentelor / Work schedule of the machineries,
equipments
13. Mediul in care functioneaza utilajele
Background of the aria where the
equipments are working
In timpul unui an / Durind the year:
 cu caracter rar /with character rare 
uniform repartizat / equable allocated
In timpul unei zile / During one day
 intermitent /discontinuous 
continuu, intensiv / intensively

14. Utilajele sunt folosite pe un singur santier? Daca da,  da / yes  nu / no

mentionati locatia exacta, denumirea si descrierea proiectului,
descrierea topografica a zonei, eventuale expuneri la riscuri
naturale (furtuna, cutremur, inundatie etc.)
Is Plant and equipment deployed at one site only? If so, state
exact location of contract site, name and
type of project, topography, eventual perils of nature (storm,
earthquake, flood etc.)
15. Utilajele sunt folosite pe diverse santiere? Daca da,  da / yes  nu / no
indicati aprox. locatiile acestor santiere
Does Plant and equipment operate at several sites
per year within the country? If so, please indicate
general areas
16. Bunurile sunt deja asigurate in  DA  NU
baza unei polite de incendiu si alte Daca “DA”, rugam detalii / If „YES”, please details
calamitati, casco, etc.? The goods
are already insured by a fire and
allied perils / motor hull / etc
policy
17. Utilajele / echipamentele sunt in  DA  NU
termenul de garantie? / Are the Daca „DA”, va rugam sa mentionati cand expira termenul de
equipments in guarantee period ? garantie / If „YES”, please mentioned the expiry date of the
guarantee.

18. Aveti contract de service pentru utilaje / echipamente?

Cu ce firma? Daca nu, cine se ocupa de intretinere?
Do you have a service agreement for machineries /
equipments? If, yes with what company? If not who is
in charge of maintenance?
19. *Ati avut daune, in ultimii 5 ani  DA  NU
care ar fi putut fi acoperite de Daca “DA”, rugam detalii (cauza, data evenimentului, valoarea
prezenta polita de asigurare? / pagubei etc.) / If „YES”, please details (effect, date of event,
Loss history in the last five years? value of damage, etc.)
Prezentul chestionar face parte integranta din polita de asigurare 2
Formular D2.1-PL1-CH_CPE e/r 1/3
20. Perioada de asigurare / Insurance
period

21. Doriti ca asigurarea sa includa si Montare / demontare: assembling / disassembling

acoperiri suplimentare pentru /
Do you need extended coverage
for:
Raspunderea civila: Third party liability
Daca da, va rugam sa mentionati sumele asigurate / limitele de
raspundere/ If „YES”, please mentioned sums insured / limits of
liability:

*A nu se completa daca utilajele sunt noi / Not to be completed if the equipments are new :

Declaram ca detaliile furnizate in aceasta cerere chestionar sunt complete, reale si in conformitate cu
informaţiile de care dispunem, fiind de acord sa stea la baza si sa fie parte integranta a politei sau a
politelor de asigurare emise in conformitate (legatura) cu riscurile de mai sus.
We hereby declare that the statement made by us in this Questionnaire are complete and true to the best
of our knowledge and belief and we hereby agree that this Questionnaire shall form the basis and be
part of any Policy or Policies issued in connection with the above risk or risks.
Data / Date……………………………

ASIGURAT, ASIGURATOR,
INSURED INSURER
……………………………………… ………………………………………..
(nume, semnatura si stampila) (nume, semnatura si stampila)

Prezentul chestionar face parte integranta din polita de asigurare 3

Formular D2.1-PL1-CH_CPE e/r 1/3