Proposer S Name in Full

F G A - P R O 0 2 2 PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

ARCHITECTS AND CONSULTING ENGINEERS PROJECT COVER

I. General Data

a. Name of Firm :

b. Address of Head Office :

c. Address of Branch Office(s) and Name(s) of : Resident Partner(s)

d. When was the firm established? :

e. Details of all participating principals or partners

Names Qualifications, dates qualified/ total Position held in company and how duration of professional experience long

f. Total number of principals, partners and staff Numbers

Technical : Principals, partners or officers Other qualified engineers Qualified Architects Surveyors Draught men Other qualified staff (please specify) : Trainee staff (please specify) :

Total non-technical/ administration staf

g. Do you give work to independent firms (subcontractors) and / or specialists? Yes No

If so, please state kind of work and percentage of fees. %

(The professional liability of such independent firms is not covered under the proposed policy)

h. Are you financially connected with the principal of the project and/ or with contractor(s)? Yes No

1 of 4 ( رأس المال المدفوع و المصرح به ( 120 ) مليون درهم خاضعة لحكام القانون التحادي رقم 9 لسنة 1984 ومقيدة بسجل شركات التأمين الرقم ( 10 أبوظبيأبوظبي -- هاتفهاتف :: 41853004185300 ،، فاكسفاكس :: 67766286776628 ،، ص.بص.ب :: Abu Dhabi - Tel.:4185300 , Fax: 6776628 , P.O. Box: 45154 4515445154 العيـنالعيـن –– هاتفهاتف :: 76408887640888 ،، فاكسفاكس :: 76408807640880 ،، ص.بص.ب :: Al Ain - Tel.:7640888 , Fax: 7640880 , P.O. Box: 15883 1588315883 دبـيدبـي –– هاتفهاتف :: 22280782228078 ،، فاكسفاكس :: 22703422270342 ،، ص.بص.ب :: Dubai - Tel.:2228078 , Fax: 2270342 , P.O. Box: 6807 68076807 الشارقةالشارقة –– هاتفهاتف :: 56944905694490 ،، فاكسفاكس :: 56944915694491 ،، ص.بص.ب :: Sharjah - Tel.:5694490 , Fax: 5694491 , P.O. Box: 4131 41314131 E Mail: [email protected] Web: www.awnic.com F G A - P R O 0 2 2 PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

II Nature of your activities

a. In which of the following professions is your firm engaged?

Civil engineering Structural engineering Mechanical engineering Electrical engineering Heating and ventilating engineering Chemical engineering Soil engineering Others, not shown please specify

b. In what type of projects is your firm specialized? Please specify.

c. List some of the largest and typical jobs performed by your firm during the last five years (brief description including values and fees).

III General questions regarding the project

a. Principal :

b. Main contractor/ consortium :

c. Nature and purpose of project : d. Location of project :

e. Total contract value :

How much of total sum refers to building structure? :

f. Your fees :

IV Nature of your work/ responsibilities/ period

Nature of your work (detailed description including special techniques and hazardous factors) :

Your responsibility (e.g. design and/ or supervision) :

Commencement and duration of your work :

Commencement and duration of construction work :

Probable date of handing over :

Period of your liability/ statutory limitation :

V Technical details

Soil conditions :

Ground-water conditions :

Nature of foundations :

VI Surrounding property

Please give description of the neighborhood of the site (details of existing buildings or surrounding property possibly affected by contract works such as excavation, underpinning, piling, vibration or ground-water lowering).

VII Insurance/ claims experience

1. Are you protected by an annual professional indemnity insurance policy? Yes No If so, please advise: Insurance company : Limit of indemnity : 2. Number and amount of claims during last 5 : years:

VIII Indemnity required

Limit any one accident :

Limit in the annual aggregate :

Deductible each and every claim to be borne by : insured

IX Scope of coverage

Design only Yes No

Supervision only Yes No

Design and supervision Yes No

Loss of documents Yes No Limit :

Dishonesty of employees Yes No If so, please answer the following questions:

- Has the firm sustained any loss through the fraud or dishonesty of any employee? Yes No - Is any employee allowed to sign cheques without countersignature by a partner? Yes No If so, up to what amount? Libel and slander Yes No

I/ We declared that the statement and particulars in this proposal are true and that I/we have not misstated or suppressed any material facts. I/We agree that this proposal, together with any other information supplied by me/us, shall form the basis of any contract of insurance effected thereon.

Signing this proposal form does not bind the proposer or underwriter to complete this insurance.

Dated this day of 20

For and on behalf of (Insert Name of Firm)

Signature of partner of Principal:

Please attach a brochure concerning your firm.

4 of 4 ( رأس المال المدفوع و المصرح به ( 120 ) مليون درهم خاضعة لحكام القانون التحادي رقم 9 لسنة 1984 ومقيدة بسجل شركات التأمين الرقم ( 10 أبوظبيأبوظبي -- هاتفهاتف :: 41853004185300 ،، فاكسفاكس :: 67766286776628 ،، ص.بص.ب :: Abu Dhabi - Tel.:4185300 , Fax: 6776628 , P.O. Box: 45154 4515445154 العيـنالعيـن –– هاتفهاتف :: 76408887640888 ،، فاكسفاكس :: 76408807640880 ،، ص.بص.ب :: Al Ain - Tel.:7640888 , Fax: 7640880 , P.O. Box: 15883 1588315883 دبـيدبـي –– هاتفهاتف :: 22280782228078 ،، فاكسفاكس :: 22703422270342 ،، ص.بص.ب :: Dubai - Tel.:2228078 , Fax: 2270342 , P.O. Box: 6807 68076807 الشارقةالشارقة –– هاتفهاتف :: 56944905694490 ،، فاكسفاكس :: 56944915694491 ،، ص.بص.ب :: Sharjah - Tel.:5694490 , Fax: 5694491 , P.O. Box: 4131 41314131 E Mail: [email protected] Web: www.awnic.com