Questionnaire for Machinery Breakdown Insurance (MB) Bimeh Iran insurance company


For download this form, Please click on bellow link :

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1. Title of contract (If project consists of several sections, specify sections to be insured):




1. 2. Site address (County / Province / District / City / Town / Village):



3. Name and address of principal:



4. Names and addresses of main contractors:



5. Names and addresses of subcontractors:



6. Name and address of consulting engineer:



7. Description of contract work (please give details of technical information such as dimensions (length, height, depth, span, number of floors), type of foundation and level of deepest excavation, construction method and construction materials:






8. Is the contractor experienced in this type of work or construction method?

Yes o No o

9. Period of insurance:

commencement of work:

duration of construction & erection: days months years

duration of maintenance: months

type of maintenance coverage required: simple¨ extended¨

termination of work:


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10. What will be done by subcontractors?




11. Special risks?

fire, explosion: Yes¨ No¨ - flood, inundation: Yes¨ No¨

landslide, storm, cyclone: Yes¨ No¨ - blasting work: Yes¨ No¨

volcanic, tsunami: Yes¨ No¨ - other risks (please specify):

have earthquakes been observed in this area: Yes¨ No¨

if so, please state magnitude of intensity in Richter:

is the design of the structure which is going to be insured based on the regulations for earthquake-resistant structures: Yes¨ No¨

is the design standard higher than that stipulated in the relevant regulations:

Yes¨ No¨

12. Details of subsoil: rock o gravel o sand o clay o filled ground o other subsoil conditions:

do geological faults exist in the vicinity: Yes o No o

13. Ground water?Level below grade: m

14. Name of the nearest river, lake, sea, etc.?

distance from site:

levels of Low water: mean water: highest level recorded:

debit of water (if so river): width of water flow (if so river):

mean level of site:

15. Meteorological conditions?

rainy season from: to:

max. rainfall in mm: per hour o per day o per month o

Storm hazard:minor o medium o high o

16. Are extra charges for overtime, night work, work on public holidays to be included? Yes o No o

for airfreight: Yes o No o

17. Is third party liability to be included? Yes o No o

has the contractor concluded a separate policy for T.P.L? Yes o No o Yes o No o

If No, please give exact description of these buildings/structures and limits of indemnity:





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18. 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 or indirect consequence of the contract work (excavating, underpinning, piling, vibrating, ground water lowering, etc.)? Yes o No o

If so, please give exact description of these buildings/structures:




19. Is coverage of construction / erection equipment (scaffolding, huts, tools, etc.) required?Yes o No o

(If so, please attach list of them with breakdown values).

20. Is coverage construction / erection machinery (excavators, cranes, etc.) required? Yes o No o

(If so, please fill out questionnaire of CPM insurance).

21. State here the amounts you wish to insure and the limits of indemnity required:

Sum Insured

(currency: )

Insured Items

Section I (Material Damages)


1. Contract price:

(cost of constructional & erection works)


2. Materials or items supplied by the principal:


3. Adjustment of the amount:


4. Construction plant and equipment (question 19):


5. Clearance of debris:


6. Existing properties (question 18):


7. Others:


Total sum insured under section I:

Limit of Indemnity1

Requested Special Risks for Limit of Indemnity







(1) Limit of indemnity in respect of each and every loss or damage and/or series of losses or damages arising out of any one event & aggregate.










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Limit of Indemnity1

Items to be Insured (question 17)

Section II (T.P.L)


Bodily injury for any one person:


1. Bodily injury for total person:


2. Property damage:


Total limits of indemnity under section II:

(1) Limit of indemnity in respect of each and every loss or damage and/or series of losses or damages arising out of any one event & aggregate.












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 this questionnaire and proposal form the basis and are part of any policy issued in connection with the above risk.

It is agreed that the insurers are liable in accordance with the terms of the policy only and that the insured will not lodge any other claims of whatever nature. The insurers undertake to deal with this information in strict confidence.





Signature and Seal:



Bimeh Iran


Agency code 3115 - Etead Gostar Hakim Co.

Tel : +989124138231