ANNEX 1

QUESTIONNAIRE AND PROPOSAL FORM

FOR CONSTRUCTION WORKS INSURANCE
Promulated with Circular 329/2016/TT-BTC dated December 26, 2016 dated December 26, 2016

1. Title of contract (if project

consists of several sections,
specify section(s) to be insured)
2. Location of site
(Country/province/district/
City/town/village)
3. Policyholder
Name and address
4. Main Contractor
Name(s) and address(es)
5. Subcontractor
Name(s) and address(es)
6. Surveying Consultancy
Engineer
Name(s) and address(es)
7. Designing Consultancy
Engineer
Name(s) and address(es)
8. Firm supervising construction
Name(s) and address(es)
9. Firm supervising erection
Name(s) and address(es)
10. Insureds
Name(s) and address(es)
11. Description of contract work Dimensions (length, height, depth, spans, number of floors)
(please give detailed technical
Foundation (method, level of deepest excavation)
information)
Construction methods
If necessary on a separate sheet)
Construction materials
(*)
(*) For special work with
complicated design, please
provide supplementary
questionnaire/ proposal form
requested by Insurer
12. Is the Contractor
experienced in this type of work
Name of subcontractor Yes 
or construction method?
(detailed to each Subcontractor) No 
Name of subcontractor Yes 
No 
13. Have plans, designs and Yes  No 
materials of the kind used in this
project been used and/or tested
in previous constructions?
(pls give name of similar
project(s) – if any)
14. Have plans, designs and Yes  No 
materials of the kind used in this
project been used and/or tested
in previous constructions by the
Contractors?
(pls give name of similar
project(s) – if any)
15. Is this an extension of an Yes  No 
existing plant?
If so, will operation of the
existing plant continue during Yes  No 
construction/ erection period?
(enclose plan layout – if any)
16. Period of Insurance From........................................To.........................................
(stipulated in the investment
decision-making authority’s Maintenance Period: From.....................To............................
documents)
17. Work to be carried out by
Subcontractors
18. Exact description of the
property to be erected (if secon-
hand items are to be erected,
please state)
In case of machines:
manufacturer’s name, number,
type, size, capacity, weight,
pressure, temperature (if any)
In case of complete factories:
general drawing of plant, nature
of civil engineering work (if
any)
19. Special risks Fire, explosion? Yes  No 
Flood, inundation Yes  No 
 Landslide, storm, cyclone Yes  No 
Blasting Yes  No 
Volcanism, tsunami Yes  No 
Have earthquakes been observed in this area Yes  No 
If so, please state intensity magnitude
Others Yes  No 
Is the design of the structures to be insured based on
regulations regarding earthquake-resistant structures?
Yes  No 
Is the design standard higher than that stipulated in the
relevant regulation? Yes  No 
20. Subsoil conditions rock gravel sand clay filled site
Other types
Do geological faults exist in the vicinity?
Yes  No 
21. Ground-water level Depth from ground: (m)
22. Nearest river, lake, sea, etc. Name
Distance
Levels
- Low water
- Mean water
- Highest water
Highest level recorded on date
23. Meteorological conditions Rainy season from …… to
Max. rainfall (mm) per hour per day per month
Storm hazard minor medium high
Express Freight:
Air Freight:
Material Damage Items to be insured Sums to be insured
1. The total value of insured work/
sections work
1.1. Total value of the construction
contract
1.2. Materials or items supplied by
the Principal
2. Cost of erection
3. Freight
 4. Customs duties and dues
5. Clearance of debris (if any)
Total Sum to be insured

We hereby declare that the statements made by us in this Questionnaire and Proposal are,
to the best of our knowledge and belief, complete and true, and we hereby agree that the
this Questionnaire and Proposal forms the basis and is part of any policy issued in
connection with the above risk.

Executed at ................................................... Date .................................

Signature & Stamp....................................................