<p>F G A - P R O 0 2 2 PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM</p><p>ARCHITECTS AND CONSULTING ENGINEERS PROJECT COVER </p><p>I. General Data</p><p> a. Name of Firm : </p><p> b. Address of Head Office : </p><p> c. Address of Branch Office(s) and Name(s) of : Resident Partner(s) </p><p> d. When was the firm established? : </p><p> e. Details of all participating principals or partners</p><p>Names Qualifications, dates qualified/ total Position held in company and how duration of professional experience long</p><p> f. Total number of principals, partners and staff Numbers</p><p>Technical : Principals, partners or officers Other qualified engineers Qualified Architects Surveyors Draught men Other qualified staff (please specify) : Trainee staff (please specify) : </p><p>Total non-technical/ administration staf </p><p> g. Do you give work to independent firms (subcontractors) and / or specialists? Yes No</p><p>If so, please state kind of work and percentage of fees. %</p><p>(The professional liability of such independent firms is not covered under the proposed policy)</p><p> h. Are you financially connected with the principal of the project and/ or with contractor(s)? Yes No</p><p>%</p><p>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</p><p>ARCHITECTS AND CONSULTING ENGINEERS PROJECT COVER </p><p>II Nature of your activities</p><p> a. In which of the following professions is your firm engaged?</p><p>Civil engineering Structural engineering Mechanical engineering Electrical engineering Heating and ventilating engineering Chemical engineering Soil engineering Others, not shown please specify</p><p> b. In what type of projects is your firm specialized? Please specify.</p><p> c. List some of the largest and typical jobs performed by your firm during the last five years (brief description including values and fees).</p><p>III General questions regarding the project</p><p> a. Principal : </p><p> b. Main contractor/ consortium : </p><p> c. Nature and purpose of project : d. Location of project : </p><p> e. Total contract value : </p><p>How much of total sum refers to building structure? : </p><p> f. Your fees : </p><p>IV Nature of your work/ responsibilities/ period</p><p>Nature of your work (detailed description including special techniques and hazardous factors) : </p><p>Your responsibility (e.g. design and/ or supervision) : </p><p>Commencement and duration of your work : </p><p>Commencement and duration of construction work : </p><p>Probable date of handing over : </p><p>Period of your liability/ statutory limitation : </p><p>2 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</p><p>ARCHITECTS AND CONSULTING ENGINEERS PROJECT COVER </p><p>V Technical details</p><p>Soil conditions : </p><p>Ground-water conditions : </p><p>Nature of foundations : </p><p>VI Surrounding property</p><p>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).</p><p>VII Insurance/ claims experience</p><p>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: </p><p>VIII Indemnity required</p><p>Limit any one accident : </p><p>Limit in the annual aggregate : </p><p>Deductible each and every claim to be borne by : insured </p><p>IX Scope of coverage</p><p>Design only Yes No</p><p>Supervision only Yes No</p><p>Design and supervision Yes No</p><p>Loss of documents Yes No Limit : </p><p>Dishonesty of employees Yes No If so, please answer the following questions:</p><p>- 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</p><p>3 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</p><p>ARCHITECTS AND CONSULTING ENGINEERS PROJECT COVER </p><p>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.</p><p>Signing this proposal form does not bind the proposer or underwriter to complete this insurance.</p><p>Dated this day of 20 </p><p>For and on behalf of (Insert Name of Firm)</p><p>Signature of partner of Principal: </p><p>Please attach a brochure concerning your firm.</p><p>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</p>