Contractors All Risk Insurance Form

CONTRACTORS ALL RISK
APPLICATION FORM FORINSURANCE

SHIFA
Contractors’ All Risks Insurance
INIDIVIDUAL/FAMILIES PLANS
Contractors’ All Risks Insurance
Proposal FormAPPLICATION FORM FOR SHIFA
INIDIVIDUAL/FAMILIES
1. POLICYHOLDER DETAILS PLANS
Proposal Form
ADNIC
Last name .........................................................................................................
is a Public Joint Stock Company incorporated First name ..................................................................................................
in the United Arab Emirates
....................................................................................................................
Title by Law No. (4) of
1. POLICYHOLDER DETAILS1972, and it is governed by
Date provisions...................................................................
the(dd/mm/yyyy)
of birth of the UAE Federal
ADNIC
Law
Marital No.
status is(6)a of Public 2007Joint Stock Company
“Establishment of theincorporated
....................................................................................................
Insurance
Sex Min the FUnited
Authority Arab Emirates
& Organization of its
Last name ......................................................................................................... First name ..................................................................................................
by Law No. (4) withofRegistration
1972, and No. it is(1). governedHeight
.......................................................................................................
Operations”,
Occupation by (cm)
the ..................................
provisions ofWeight the (kg)
UAE................................
Federal
Title .................................................................................................................... Date of birth (dd/mm/yyyy) ...................................................................
Law
Monthly No.
gross (6)
salary of 2007 Less“Establishment
than AED 4,000/- of Greater
the Insurance than AED 4,000/-
Marital status .................................................................................................... Sex
Authority
M F
& Organization of its
Operations”,
Nationality
Occupation
withform
this Registration
............................................................
Completing Passport No.no.(1). .............................................
....................................................................................................... Emirate of visa issuance
Height (cm) .................................. ................................................
Weight (kg) ................................
Monthly gross salary Less than AED 4,000/- Greater than AED 4,000/-
Completing
InNationality to apply this form
order ............................................................
for this insurance, Passport no. please complete allEmirate
............................................. partsof of visathis
issuance proposal form and
................................................
the.....................................................................................................................................................................................................................................
Address annexures, if any.
In order to apply for this insurance, please complete all parts of this proposal form and
Town/City ......................................................................................................... Country/State ..........................................................................................
the annexures, if any.
Mobile number.....................................................................................................................................................................................................................................
Address ................................................................................................ Email ..........................................................................................................
You must provide full, accurate, and true answers to all questions listed below. Material
facts which you know or ought to know should be fully and accurately disclosed.
Mobile number ................................................................................................ Email ..........................................................................................................
Failure
You must toprovidedo so may full, result accurate, in rejecting
and true answers your claim to all and/orquestions terminating listed below. the insurance Material
2. COMPANY
policy DETAILS
from inception. (if applicable)
facts which you know or ought to know should be fully and accurately disclosed.
Failure name to
2. COMPANY
Company do DETAILSso may (ifresult applicable)
in rejecting your claim and/or terminating the insurance
........................................................................................................................................................................................................................
policy from inception.
Address .....................................................................................................................................................................................................................................
IfCompany
you name are ........................................................................................................................................................................................................................
in any doubt about what you should disclose, please do not hesitate
Address .....................................................................................................................................................................................................................................
to contact us. A material fact is one that would influence our decision whether to offer
..........................................................................................................................................................................................................................................
Email Town/City
If
you you are
insurance in or anythedoubt termsabout whichwhat you should
.........................................................................................................
we offer. Country/State disclose, please do not hesitate
..........................................................................................
toEmail ..........................................................................................................................................................................................................................................
contact us. A material fact is one that would influence our decision whether to offer
you
If the insurance
space provided or the terms which we offer.
is inadequate, please provide details using an additional
3. DEPENDENTS TO BE INCLUDED IN THE PLAN
information
3. DEPENDENTS sheet,TO BE signed and dated.
INCLUDED IN THE PLAN
Please enter the details of all the dependents to be covered under this policy. This can include your legal spouse and your unmarried,
If the space provided is inadequate, please provide details using an additional
financially
Pleasedependent children
enter the details under
of all the age of to
the dependents 18.beThe place under
covered of residence of the
this policy. Thislegal spouseyour
can include and legal
the unmarried
spouse andfinancially dependent
your unmarried,
information
Your
children insurance sheet,
must bedependent
financially does signed
with the Policyholder not
children underunless
and
commence
the
the age
dated.
of Insurance when
company
18. The place you sign
approves
of residence of thethe the
other
legal proposal.
arrangements.
spouse Your cover will only
and the unmarried financially dependent
commence once
children must be with we haveunless
the Policyholder reviewed the
the Insurance proposal
company form
approves and
Heightconfirmed
the other arrangements.
Weight Date cover in writing.
of birth Emirate of
Last name First name Relation Sex
(cm) (kg) Date(dof- birth
m - y) Emirate
visa issuance
Your Last
insurance
name doesFirstnotname
commence when you Sex
Relation sign the proposal. Your cover will only
Height Weight of
(cm) (kg) (d - m - y) visa issuance
M F / /
commence
Please keep once a copy weofhave reviewedform
this proposal the for
proposal
your form
M record F and
along confirmed cover in writing.
with any/ correspondence/
/
M F / /
information provided to us and policies/endorsements
M F that are/ issued
/ to you
M F / /
Please keep a copy of this proposal form for your
subsequently. M record
F along with any/ correspondence/
/
M F / /
information provided to us and policies/endorsements
M F that are/ issued
/ to you
M F / /
M F / /
subsequently.
Policyholder is theisperson/company
Policyholder who
the person/company hashas
who thethe
right totoconfirm,
right confirm,alter
alter or
or renew thisinsurance
renew this insurancecover
coveronon behalf
behalf of the
of all all the insured
insured
members underunder
members the same policy,
the same andand
policy, who is responsible
who is responsiblefor
forthe
thepremium
premium payment againstinsurance
payment against insurance cover
cover under
under thisthis policy.
policy.
P.O.Box 839 Abu Dhabi - U.A.E. • Tel: +971(0) 2 4080100 • Fax: +971(0) 2 4080604 • www.adnic.ae • Toll free: 800 8040 • Email: info@adnic.ae
Public Shareholding Company established in 1972 with a paid up capital of AED (375)m, Registered at the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007.
ADNIC-COMU-02-PF05 1/10
P.O.Box 839 - Abu Dhabi, U.A.E. P.O.Box 8392 4080100
Tel: +971 (0) Abu Dhabi
Fax:-+971
U.A.E.
(0) 2•4080604
Tel: +971(0) 2 4080100••Toll
• www.adnic.ae Fax: +971(0)
free: ͧ˻!˯Vp`
2 4080604
800 8040 • +971 (0) 2 4080604
• www.adnic.ae ͧ6\T
• Toll free: 800+971 (0) 2•4080100
8040 ͧVo΀,%˯z0M`/eʞ ͅ{Hs΀839ͧͨ;
Email: info@adnic.ae
P.O.Box 839 - Abu Dhabi, U.A.E.2007kȽȽ5`(6)gX/x+%ʘisjY`c]$ʜM@(r22/07/1984*y/(1)ͧ˾e`
Tel: +971 (0) 2 4080100 Fax: +971 (0) 2 4080604 • www.adnic.ae • Toll free: 800 8040 ͧ˻!˯Vp`• +971 (0) 2 4080604 ͧ6\T +971 (0) 2 4080100 ͧVo΀,%˯z0M`/eʞ ͅ{Hs΀839ͧͨ;
ͨqʙy,Mr
Public Shareholding Company established in 1972 with a paid up capital of AED (375)m, Registered at the Insurance zot,`,zY`gX/rgo/+570,000,000KsT,˯p`˴ȽȽ4/r1972cLȽȽ54eLfoȽȽ5e\ʀ
Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007.
ͨqʙy,Mr
Public Joint2007kȽȽ5`(6)gX/x+%ʘisjY`c]$ʜM@(r22/07/1984*y/(1)ͧ˾e` zot,`,zY`gX/rgo/+570,000,000KsT,˯p`˴ȽȽ4/r1972cLȽȽ54eLfoȽȽ5e\ʀ
Stock Company established in 1972 with Paid up Capital of AED 570,000,000 and licensed by the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007 (as amended).
Public Joint Stock Company established in 1972 with Paid up Capital of AED 570,000,000 and licensed by the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007 (as amended).
ADNIC-COMU-02-PF05 1/4 1/10
1/4
SHIFA
Important note APPLICATION FORM FOR SHIFA

In order to apply for the Contractors’ All Risks insurance, please complete all parts of this proposal and
the annexure form. Insurance begins when ADNIC confirms cover in writing.
....................................................................................................................
Title You
1. POLICYHOLDER
must provide full DETAILS
and true answers to all questions Date oflisted
birth (dd/mm/yyyy) ...................................................................
below. Material facts which you know
or status
Marital ought....................................................................................................
to know should be fully disclosed. FailingSex to do so, may M resultF in the insurance cover not
protecting you in the event of a claim and the policy issued may be -
Occupation ....................................................................................................... Height (cm) .................................. Weight (kg) ................................
- Canceled from inception
Marital status .................................................................................................... Sex M F
- Altered with revised terms
Nationality ............................................................
Occupation Passport no. .............................................
Height (cm) .................................. ................................................
Weight (kg) ................................
You should keep a record (including but limited to a copies of proposal forms, letters/correspondence)
Monthly
of gross salary supplied
all information Less
tothan AEDthe
us for 4,000/-
purpose Greater than AED
of entering 4,000/-
this contract.
IfNationality
the space ............................................................
provided is inadequate Passport please no. .............................................
provide the details using Emirate
theofAdditional ................................................
visa issuance Information Section.
For .....................................................................................................................................................................................................................................
Address harbors, piers, docks, tunnels, galleries, dams, roads, airports, railway facilities, sewerage and water
supply systems, and bridges see additional questionnaires.
Address
Mobile number.....................................................................................................................................................................................................................................
................................................................................................ Email ..........................................................................................................
+LÄUP[PVUVM4H[LYPHS-HJ[Z

These are facts which an Insurer would regard as likely to influence the acceptance and assessment of the
2. COMPANY
proposal. If youDETAILS are in any (if applicable)
doubt about what you should disclose, do not hesitate to contact us. Making
sure we are informed completely is for your own protection.
Company name ........................................................................................................................................................................................................................
2. COMPANY DETAILS (if applicable)
Address .....................................................................................................................................................................................................................................
Company name ........................................................................................................................................................................................................................
Address .....................................................................................................................................................................................................................................
1. Proposer details
..........................................................................................................................................................................................................................................
Email Town/City ......................................................................................................... Country/State ..........................................................................................
a. ..........................................................................................................................................................................................................................................
Name
Email of the proposer (in full):

b. Trading name (if different from business name):
c. Postal address:
financially
the dependents 18.be
The place under
the unmarried
your unmarried,
d.
children Contact
must be
financially
person:
with the Policyholder
dependent children underunless the
the age of Insurance company
18. The place approves
of residence of thethe other
legal arrangements.
spouse and the unmarried financially dependent
children
e. must be with
Telephone No.:theLandline:
Policyholder unless the Insurance company approves the other arrangements.
Mobile:Height Weight Date of birth Emirate of
(cm)
Height (kg)
Weight Date(dof- birth
m - y) Emirate
visa issuance
of
f. FaxLast
No.:
name First name g.
Relation Email: Sex
M F / /
M F / /
g. VAT Tax Registration Number (if applicable): M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
2. Project/Contract details M F / /
M F / /
Policyholder is theisperson/company who hashas

the right
righttotoconfirm,
confirm,alter
alter or renewthis
thisinsurance
insurancecover
coveronon behalf of the
all the insured
a. Name of contract/project:
Policyholder the person/company who the or renew behalf of all insured
members underunder
the same andand
forthe
thepremium
cover under
policy.
b. Site/exact location:
c. Area (Zone and sector):
d. Country/Province/District:
P.O.Box 839 - Abu Dhabi, U.A.E. P.O.Box 839

2 4080100 Fax:-+971
U.A.E.
(0) 2•4080604
Tel: +971(0) 2 4080100• •Toll
free: ͧ˻!˯Vp`
2 4080604
800 8040 • +971 (0) 2 4080604
• Toll free: +971
800 (0) 2•4080100
8040 ͧVo΀,%˯z0M`/eʞ ͅ{Hs΀839ͧͨ;
ͨqʙy,Mr
ͨqʙy,Mr
1/4
SHIFA
2. Project/Contract details
APPLICATION
(continued) FORM FOR SHIFA
e. City/Town/Village:
f. Name and address of principal:
Title ....................................................................................................................
1. POLICYHOLDER DETAILS Date of birth (dd/mm/yyyy) ...................................................................

g. Name(s)
Occupation and address(es) of contractor(s):
....................................................................................................... Height (cm) .................................. Weight (kg) ................................
Nationality ............................................................
Height (cm) .................................. ................................................
Weight (kg) ................................
h. Name(s) and address(es) of sub-contractor(s):
Nationality ............................................................ Passport no. ............................................. Emirate of visa issuance ................................................
Address .....................................................................................................................................................................................................................................

Address .....................................................................................................................................................................................................................................
Mobile Name................................................................................................
i. number and address of consulting engineer: Email ..........................................................................................................
j. Any other party involved for the execution of the project*:

name ........................................................................................................................................................................................................................
2. COMPANY
Company DETAILS (if applicable)
Address *Cover will be limited to the site activity only
.....................................................................................................................................................................................................................................
Company name ........................................................................................................................................................................................................................
Address .....................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
Email ..........................................................................................................................................................................................................................................
3. The insured interests
3. DEPENDENTS
Whose interestsTO
areBE
to INCLUDED
be insured? IN THE PLAN
Please enterPrincipal
the details of all the dependents to be covered under this policy.
Contractor This can include your legal spouse
Sub-contractor and your unmarried,
Others*
financially
The place under
the unmarried
your unmarried,
*Others
children
financially please
with thespecify
must bedependent Policyholder
children underunless the
legal arrangements.
children must be with the Policyholder unless the Insurance company approves the other arrangements.
Height Weight Date of birth Emirate of
(cm)
Height (kg)
m - y) Emirate
visa issuance
of
M F / /
M F / /
4. Contract work M F / /
M F / /
M F / /
Description of contract work (Please give detailed technical
M information.)
F / /
M F / /
M F / /
M F / /
M F / /
Policyholder who
who thethe
right totoconfirm,
right confirm,alter
alter or
coveronon behalf
behalf of the
insured
members underunder
the same andand
forthe
thepremium
cover under
policy.
P.O.Box
P.O.Box 839 - Abu Dhabi, U.A.E. Tel: 839
+971 (0) Abu Dhabi
2 4080100 Fax:-+971
U.A.E.
(0) 2•4080604
Tel: +971(0) 2 4080100• •
• www.adnic.ae Fax:
Toll +971(0)
free: ͧ˻!˯Vp`
2 4080604
800 8040 • +971 (0) 2 4080604
• Toll free: +971
800 (0) 2•4080100
8040 ͧVo΀,%˯z0M`/eʞ ͅ{Hs΀839ͧͨ;
ͨqʙy,Mr
ͨqʙy,Mr
1/4
SHIFA
5. Insurance amount APPLICATION FORM FOR SHIFA

State hereunder the amounts you wish to be insured and the limits of indemnity required:
Section I - Material damage
Title ....................................................................................................................
Marital status ....................................................................................................

Items to be insured Sex M
Currency F
(Sums to be insured)
Title .................................................................................................................... Date
(Sumof birth (dd/mm/yyyy)
insured ...................................................................
to reflect full value of the contract
Monthly gross salary Less than AED 4,000/- Greater than AEDat4,000/-
works the completion of the construction)
Nationality ............................................................
Height (cm) .................................. ................................................
Weight (kg) ................................
1) Value of contract work (permanent and
temporary work, including all materials to be
incorporated
Nationality herein)
............................................................ Passport no. ............................................. Emirate of visa issuance ................................................
Address .....................................................................................................................................................................................................................................
1.1) Contract price
1.2) Materials
Address
Mobile number or items supplied by the principal(s) Email ..........................................................................................................
.....................................................................................................................................................................................................................................
................................................................................................
(items
Town/City like free issue)
......................................................................................................... Country/State ..........................................................................................

2)
Construction plant/equipment/machinery
2. COMPANY DETAILS
(please attach list)(if applicable)
2.3)
Company Removal
COMPANY
name of debris (if applicable)
........................................................................................................................................................................................................................
DETAILS
Address .....................................................................................................................................................................................................................................
Total sum
Company ........................................................................................................................................................................................................................
nameto be insured under Section I
Address .....................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
Is Third Party Liability to be included? Yes No
Email ..........................................................................................................................................................................................................................................
Section II - Third Party Liability

Please enter the details ofItems
all the dependents to be covered under this policy.
to be insured LimitThis can include per
of indemnity youraccident
legal spouse
andand
in your unmarried,
the aggregate
financially
The place under
the unmarried
your unmarried,
children must bedependent
financially with the Policyholder
legal arrangements.
(cm)
Height (kg)
m - y) Emirate
visa issuance
of
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
Policyholder who
who thethe
right totoconfirm,
right confirm,alter
alter or
coveronon behalf
behalf of the
insured
members underunder
the same andand
forthe
thepremium
cover under
policy.
P.O.Box
+971 (0) Abu Dhabi
2 4080100 Fax: -+971
U.A.E.
(0) 2•4080604
Tel: +971(0) 2 4080100• Toll
• www.adnic.ae • Fax:
free:+971(0) ͧ˻!˯Vp`
2 4080604
800 8040 • +971 (0) 2 4080604
• Toll free: +971
800 (0) 2•4080100
8040 ͧVo΀,%˯z0M`/eʞ ͅ{Hs΀839ͧͨ;
ͨqʙy,Mr
ͨqʙy,Mr
1/4
SHIFA
6. Period of insurance
APPLICATION FORM FOR SHIFA
1. POLICYHOLDER of INIDIVIDUAL/FAMILIES
DETAILS
a. Commencement work: PLANS
Last name .........................................................................................................
b. Duration of works: months First name ..................................................................................................
Title ....................................................................................................................
c. Maintenance period*: months
Last
*If name
it is .........................................................................................................
required for this period. First name ..................................................................................................
Nationality ............................................................
Height (cm) .................................. ................................................
Weight (kg) ................................
7. Operational information

a. What work will be done by sub-contractors?
Address .....................................................................................................................................................................................................................................
Town/City .........................................................................................................
Sub-contract type Name of sub-contractor Country/State ..........................................................................................
Value
Mobile number.....................................................................................................................................................................................................................................
Address ................................................................................................ Email ..........................................................................................................
Company name ........................................................................................................................................................................................................................

b. Ground water
Address .....................................................................................................................................................................................................................................
Company name ........................................................................................................................................................................................................................
Level
Town/City below grade: m Country/State ..........................................................................................
......................................................................................................... ft
Address .....................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
Email Town/City
c. Nearest river, lake, sea, etc. (if any)
......................................................................................................... Country/State ..........................................................................................
Email ..........................................................................................................................................................................................................................................
i) Name:
3. DEPENDENTS
ii) Distance:TO BE INCLUDED IN THE PLAN
iii) the
Please enter Levels:
detailsLow
of allwater Mean
the dependents to be covered under this policy. Thiswater:
can include your legal spouse and your unmarried,
financially
The place under
the unmarried
your unmarried,
iv) Highest level ever recorded: Date:
legal arrangements.
children
d. must be with theconditions
Meteorological Policyholder unless the Insurance company approves the other arrangements.
(cm)
Height (kg)
m - y) Emirate
visa issuance
of
i) Last name
Rainy First name
season: From: Relation
M
Sex
To:
F
(cm) (kg) (d - m - y)
/
visa issuance
/
M F / /
ii) Max rainfall M F / /
M F / /
M F / /
M F / /
Per hour MPer day
F / Per/ month
M F / /
M F / /
mm M F / /
Policyholder who
who thethe
right totoconfirm,
right confirm,alter
alter or
coveronon behalf
behalf of the
insured
members
members in
under the same
under policy,
the same andand
forthe
thepremium
cover under
policy.

Fax:-+971
U.A.E.
(0) 2•4080604
Tel: +971(0) 2 4080100••Toll
free: ͧ˻!˯Vp`
2 4080604
800 8040 • +971 (0) 2 4080604
• Toll free: 800+971 (0) 2•4080100
8040 ͧVo΀,%˯z0M`/eʞ ͅ{Hs΀839ͧͨ;
ͨqʙy,Mr
ͨqʙy,Mr
1/4
SHIFA
7. Operational information
APPLICATION
e. Are existing buildings and/or structures on or adjacent to the site, owned by or held in care, custody
or control of the contractor(s) or the principal, to be insured against loss or damage arising as a direct
....................................................................................................................
Title 1. POLICYHOLDER DETAILS Date of birth (dd/mm/yyyy) ...................................................................
or indirect consequence of the contract work? Yes No
If Yes, Limit of indemnity:
Monthly Exact
gross salary
description Less than AED 4,000/-
of these buildings/structures and surrounding: Greater than AED 4,000/-
Nationality ............................................................
Height (cm) .................................. ................................................
Weight (kg) ................................
Address .....................................................................................................................................................................................................................................

Address
Mobile .....................................................................................................................................................................................................................................
number ................................................................................................ Email ..........................................................................................................
Company name ........................................................................................................................................................................................................................

Address .....................................................................................................................................................................................................................................
Company name ........................................................................................................................................................................................................................
Address .....................................................................................................................................................................................................................................
8. Cover
Email information
..........................................................................................................................................................................................................................................
Email ..........................................................................................................................................................................................................................................
a. The insurance excludes terrorism risks totally. Do you require a quotation for terrorism cover?
3. DEPENDENTS TO BE INCLUDED IN THE PLAN Yes No

b.enter
Please Havethe you inofthe
details past
all the 5 years tohad
dependents any claims
be covered under
under this any
policy. section
This youyour
can include arelegal
proposing in your
spouse and respect of any
unmarried,
financially
The placeunder
the unmarried
your unmarried,
similar project you executed? Yes No
children must be
financially with the children
dependent Policyholder
underunless
the agethe
of Insurance company
legal arrangements.
children must
If Yes, be with provide
please the Policyholder unless the Insurance company approves the other arrangements.
details: Height Weight Date of birth Emirate of
(cm)
Height (kg) Date(dof-birth
Weight m - y) Emirate
visa issuance
of
M F / /
M F / /
M F / /
M
or anyFFother office?
c. Has the proposal been at any time declined by this M / / Yes No
/ /
M F / /
M F / /
M F / /
d. Loss record for similar projects in the last 3 years: M F / /
M F / /
Policyholder who
who the right
the righttotoconfirm,
confirm,alter
alter or renewthis
insurance cover
cover onon behalf
behalf of the
insured
members under
members the same
under policy,
the same andand
forthe
thepremium paymentagainst
insurance cover
cover under
policy.
P.O.Box
+971 (0) Abu Dhabi
2 4080100 Fax:-+971
U.A.E.
(0) 2•4080604
Tel: +971(0) 2 4080100• •
• www.adnic.ae Fax:
Toll +971(0)
free: ͧ˻!˯Vp`
2 4080604
800 8040 • +971 (0) 2 4080604
• Toll free: +971
800 (0) 2•4080100
8040 ͧVo΀,%˯z0M`/eʞ ͅ{Hs΀839ͧͨ;
ͨqʙy,Mr
ͨqʙy,Mr
1/4
SHIFA
9. Additional informations
APPLICATION FORM FOR SHIFA
Please attach a copy of the following:
a. Scope of work
....................................................................................................................
b. Work method statement
c. Site.......................................................................................................
Occupation layout Height (cm) .................................. Weight (kg) ................................
d. Barstatus
Marital chart.................................................................................................... Sex M F
Nationality ............................................................
Height (cm) .................................. ................................................
Weight (kg) ................................
e. Breakdown of contract value
f. Loss prevention and minimization measures
g. Details of Third Party and principal existing property

Address .....................................................................................................................................................................................................................................

Address
Mobile .....................................................................................................................................................................................................................................
number ................................................................................................ Email ..........................................................................................................
10. Additional information
Company name ........................................................................................................................................................................................................................

Address .....................................................................................................................................................................................................................................
Company name ........................................................................................................................................................................................................................
Address .....................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
EmailTown/City ......................................................................................................... Country/State ..........................................................................................
Email ..........................................................................................................................................................................................................................................

financially
enter the details of allunder the age ofto
the dependents 18.beThe placeunder
can include andlegal
the unmarried
your unmarried,
children must be
underunless
the agethe Insurance
of 18. company
The place approves
of residence of the the
legalother arrangements.
(cm)
Height (kg) Date(d
Weight of-birth
m - y) Emirate
visa issuance
of
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
Policyholder is the
Policyholder is person/company who
the person/company has
who the
has theright
righttotoconfirm,
confirm, alter or renew
alter or renewthis
thisinsurance
insurance cover
cover on on behalf
behalf ofthe
of all all insured
the insured
members under
members the same
under policy,
the same andand
policy, who is is
who responsible
responsiblefor
forthe
the premium paymentagainst
insurance cover
cover under
policy.
P.O.Box
+971 (0) Abu Dhabi
2 4080100 Fax: -+971
U.A.E.
(0) 2•4080604
Tel: +971(0) 2 4080100• Toll
free:+971(0) ͧ˻!˯Vp`
2 4080604
800 8040 • +971 (0) 2 4080604
• Toll free: +971
800 (0) 2•4080100
8040 ͧVo΀,%˯z0M`/eʞ ͅ{Hs΀839ͧͨ;
ͨqʙy,Mr
ͨqʙy,Mr
Public Joint 2007kȽȽ5`(6)gX/x+%ʘisjY`c]$ʜM@(r22/07/1984*y/(1)ͧ˾e` zot,`,zY`gX/rgo/+570,000,000KsT,˯p`˴ȽȽ4/r1972cLȽȽ54eLfoȽȽ5e\ʀ
1/4
SHIFA
APPLICATIONAnnexure
FORM FOR SHIFA
1. POLICYHOLDER DETAILS
1. General information
....................................................................................................................
a. status
Marital Type....................................................................................................
of foundation and level of deepest excavation: Sex M F
b. Will.......................................................................................................
Occupation any piling be performed? Height (cm) .................................. Weight
Yes(kg) ................................
No
If so,
Marital status ....................................................................................................
please answer as follows: Sex M F
Nationality ............................................................
Height (cm) .................................. ................................................
Weight (kg) ................................
i) Method:
ii) Dimensions
Nationality of piles:
............................................................ Passport no. ............................................. Emirate of visa issuance ................................................
Address iii) Maximum and average depth driven:

.....................................................................................................................................................................................................................................
iv).........................................................................................................
Town/City Total number of piles: Country/State ..........................................................................................
Address
Mobile .....................................................................................................................................................................................................................................
number ................................................................................................ Email ..........................................................................................................
v) Contract value for piling works:
c. Please
Mobile describe
number any underpinning to be performed:Email
................................................................................................ ..........................................................................................................
Company name ........................................................................................................................................................................................................................

Address .....................................................................................................................................................................................................................................
d. Height of building/stories/no. of units:
Company name ........................................................................................................................................................................................................................
e. Type.....................................................................................................................................................................................................................................
Address of construction:
..........................................................................................................................................................................................................................................
EmailTown/City ......................................................................................................... Country/State ..........................................................................................
f. Construction materials:
Email ..........................................................................................................................................................................................................................................
g. Other relevant details:
h. Is the contractor experienced in this type of work or construction method? Yes No
financially
The placeunder
the unmarried
your unmarried,
children must be
underunless
of 18. company
The place approves
of residence of the the other
legal arrangements.
2. Special risks
children must aggravated
be with the Policyholder unless the Insurance company approves the other arrangements.
(cm)
Height (kg) Date(d
Weight of-birth
m - y) Emirate
visa issuance
of
M F / /
a. Fire, explosion? M F / /
Yes No
M F / /
b. Flood, inundation? M F / /Yes No
M F / /
M F / /
c. Landslide, storm, cyclone? M F / Yes
/ No
M F / /
d. Blasting work? M
M F
F
/
/
/
Yes
/ No
e.Policyholder
Other
Policyholder risks
is theis person/company who
the person/company has
who the
has right
the righttotoconfirm,
confirm, alter or renew
alter or renewthis
thisinsurance
insurance cover
cover onon behalf
behalf
Yes
ofthe
of all all the insuredNo
insured
members under
members the same
under policy,
the same andand
policy, who is is
who responsible
responsiblefor
forthe
thepremium paymentagainst
insurance cover
cover under
policy.
f. Volcanism, tsunami? Yes No
g. Have earthquakes been observed in this area? Yes No
If so, please state intensity (Mercalli):
P.O.Box
+971 (0) Abu Dhabi
2 4080100 Fax: -+971
U.A.E.
(0) 2•4080604
Tel: +971(0) 2 4080100• Toll
• www.adnic.ae • Fax: +971(0)
free: ͧ˻!˯Vp`
2 4080604
800 8040 • +971 (0) 2 4080604
• Toll free: +971
800 (0) 2•4080100
8040 ͧVo΀,%˯z0M`/eʞ ͅ{Hs΀839ͧͨ;
ͨqʙy,Mr
ͨqʙy,Mr
1/4
SHIFA
2. Special risks aggravated

APPLICATION
h. Is the design of the structure to be insured based on regulations for earthquake-resistant structures?
Yes No
....................................................................................................................
Marital Is the....................................................................................................
i. status design standard higher than that stipulated in the Sexrelevant M F
regulations?
Yes No
Nationality ............................................................
Height (cm) .................................. ................................................
Weight (kg) ................................
3. Subsoil
Address .....................................................................................................................................................................................................................................
a. Details of subsoil:
Address
Rock Gravel Sand Clay Filled ground
.....................................................................................................................................................................................................................................
b. Other.........................................................................................................
Town/City subsoil conditions: Country/State ..........................................................................................

c. Do geological faults exist in the vicinity? Yes No
d. Storm hazard: Minor Medium High
Company name ........................................................................................................................................................................................................................
Address .....................................................................................................................................................................................................................................
Company name ........................................................................................................................................................................................................................
Address .....................................................................................................................................................................................................................................
4. Building/Property
Email ..........................................................................................................................................................................................................................................
Email ..........................................................................................................................................................................................................................................
Details of existing buildings or surrounding property possibly affected by the contract work as excavating,
underpinning, piling, vibrating ground, water lowering.
3. DEPENDENTS
(Description of TO BE INCLUDED
the neighborhood of IN
theTHE
site) PLAN
financially
enter the details of allunder the age ofto18.beThe
the dependents placeunder
covered of residence of This
this policy. the legal spouseyour
the unmarried
spouse and financially dependent
your unmarried,
children must be
financially with thechildren
under unless
of 18. company
The place approves
of residence the other
of the legal arrangements.
(cm) Weight
Height (kg) Date(dof -birth
m - y) Emirate
visa issuance
of
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
Executed at Date M F Signature /
/
/
/
M F
Policyholder is the
Policyholder person/company
is the who
person/company has
who hasthe
theright
rightto
toconfirm, alter or
confirm, alter orrenew
renewthis
thisinsurance
insurance cover
cover on on behalf
behalf ofthe
of all all insured
the insured
members under
members the the
under same policy,
same and
policy, who
and is isresponsible
who responsiblefor
for the
the premium paymentagainst
premium payment against insurance
insurance cover
cover under
under this this policy.
policy.
P.O.Box
+971 (0) Abu Dhabi
2 4080100 - U.A.E.
Fax: +971 (0) 2 • Tel: +971(0)
4080604 2 4080100
• Toll free:+971(0) 2 ͧ˻!˯Vp`
800 8040 • +971 (0) 2 4080604
4080604 • www.adnic.ae ͧ6\T
• Toll free: +971
800 (0) 2 •
8040 Email: ͧVo΀,%˯z0M`/eʞ
4080100 info@adnic.ae ͅ{Hs΀839ͧͨ;
P.O.Box 839 - Abu Dhabi, U.A.E.
ͨqʙy,Mr 8040 ͧ˻!˯Vp`• +971 (0) 2 4080604 ͧ6\T +971 (0) 2 4080100 ͧVo΀,%˯z0M`/eʞ ͅ{Hs΀839ͧͨ;
Tel: +971 (0) 2 4080100 Fax: +971 (0) 2 4080604 • www.adnic.ae • Toll free: 800 zot,`,zY`gX/rgo/+570,000,000KsT,˯p`˴ȽȽ4/r1972cLȽȽ54eLfoȽȽ5e\ʀ
2007kȽȽ5`(6)gX/x+%ʘisjY`c]$ʜM@(r22/07/1984*y/(1)ͧ˾e`
Public Shareholding Company established in 1972 with a paid up capital of AED (375)m, Registered at the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007.
ͨqʙy,Mr 2007kȽȽ5`(6)gX/x+%ʘisjY`c]$ʜM@(r22/07/1984*y/(1)ͧ˾e`
Public Joint Stock zot,`,zY`gX/rgo/+570,000,000KsT,˯p`˴ȽȽ4/r1972cLȽȽ54eLfoȽȽ5e\ʀ
Company established in 1972 with Paid up Capital of AED 570,000,000 and licensed by the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007 (as amended).
1/4
SHIFA
Declaration APPLICATION FORM FOR SHIFA

I/We hereby declare that the statements/information given by me/us in the Proposal Form are full,
Title ....................................................................................................................
accurate and true. It is hereby understood and agreed that the statements, answers and particulars
Marital status .................................................................................................... Sex M
provided
Last namein this Proposal Form and as per the attachments
......................................................................................................... First name are the basis Fon which the insurance
..................................................................................................
policy
Occupation is.......................................................................................................
being issued/effected. If after the insurance policy
Height (cm) is..................................
effected, it is found Weight (kg) that................................
any fact
in thegross
Monthly statements,
salary answers Less than or particulars
AED 4,000/- in this Proposal
Greater than AED Form4,000/- is incorrect, untrue, inaccurate,
misrepresented
Nationality
or non-disclosed in
............................................................
any material
Passport no.
respect, ADNIC
.............................................
shallofhave
Emirate
no liability
visa issuance
under the
................................................
insurance policy and/or shall have the right to terminate the insurance policy from inception.
Name.....................................................................................................................................................................................................................................
Address of Proposer:
Mobile number.....................................................................................................................................................................................................................................
Address ................................................................................................ Email ..........................................................................................................
Title:
2.Signature:
COMPANY DETAILS (if applicable)
Company name ........................................................................................................................................................................................................................

Address .....................................................................................................................................................................................................................................
Stamp:
Company name ........................................................................................................................................................................................................................
Address .....................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
Date:
Email ..........................................................................................................................................................................................................................................

Note: Please note that each page of the proposal form should be signed by the Proposer or its legal representative
financially
The place under
the unmarried
your unmarried,
legal arrangements.
(cm)
Height (kg)
m - y) Emirate
visa issuance
of
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
Policyholder who
who thethe
right totoconfirm,
right confirm,alter
alter or
coveronon behalf
behalf of the
insured
members underunder
the same andand
forthe
thepremium
cover under
policy.

Fax:-+971
U.A.E.
(0) 2•4080604
Tel: +971(0) 2 4080100••Toll
free: ͧ˻!˯Vp`
2 4080604
800 8040 • +971 (0) 2 4080604
• Toll free: 800+971 (0) 2•4080100
8040 ͧVo΀,%˯z0M`/eʞ ͅ{Hs΀839ͧͨ;
ͨqʙy,Mr
ͨqʙy,Mr
ADNIC-COMU-02-PF05 1/4 10/10
1/4

Contractors All Risk Insurance Form

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Contractors All Risk Insurance Form

Uploaded by

Copyright:

Available Formats

CONTRACTORS ALL RISK

APPLICATION FORM FORINSURANCE

Important note APPLICATION FORM FOR SHIFA

Mobile number ................................................................................................ Email ..........................................................................................................

3. DEPENDENTS TO BE INCLUDED IN THE PLAN

Policyholder is theisperson/company who hashas

c. Area (Zone and sector):

P.O.Box 839 - Abu Dhabi, U.A.E. P.O.Box 839

Marital status .................................................................................................... Sex M F

Town/City ......................................................................................................... Country/State ..........................................................................................

Mobile number ................................................................................................ Email ..........................................................................................................

2. COMPANY DETAILS (if applicable)

j. Any other party involved for the execution of the project*:

5. Insurance amount APPLICATION FORM FOR SHIFA

Marital status ....................................................................................................

Mobile number ................................................................................................ Email ..........................................................................................................

Section II - Third Party Liability

Nationality ............................................................ Passport no. ............................................. Emirate of visa issuance ................................................

Mobile number ................................................................................................ Email ..........................................................................................................

2. COMPANY DETAILS (if applicable)

Company name ........................................................................................................................................................................................................................

P.O.Box 839 - Abu Dhabi, U.A.E. P.O.Box 8392 4080100

Nationality ............................................................ Passport no. ............................................. Emirate of visa issuance ................................................

Town/City ......................................................................................................... Country/State ..........................................................................................

Mobile number ................................................................................................ Email ..........................................................................................................

2. COMPANY DETAILS (if applicable)

Company name ........................................................................................................................................................................................................................

3. DEPENDENTS TO BE INCLUDED IN THE PLAN Yes No

g. Details of Third Party and principal existing property

Town/City ......................................................................................................... Country/State ..........................................................................................

2. COMPANY DETAILS (if applicable)

Company name ........................................................................................................................................................................................................................

3. DEPENDENTS TO BE INCLUDED IN THE PLAN

Address iii) Maximum and average depth driven:

2. COMPANY DETAILS (if applicable)

Company name ........................................................................................................................................................................................................................

g. Have earthquakes been observed in this area? Yes No

If so, please state intensity (Mercalli):

2. Special risks aggravated

Mobile number ................................................................................................ Email ..........................................................................................................

Declaration APPLICATION FORM FOR SHIFA

Nationality ............................................................ Passport no. ............................................. Emirate of visa issuance ................................................

Mobile number ................................................................................................ Email ..........................................................................................................

Company name ........................................................................................................................................................................................................................

3. DEPENDENTS TO BE INCLUDED IN THE PLAN

P.O.Box 839 - Abu Dhabi, U.A.E. P.O.Box 8392 4080100

You might also like