Contractors All Risks Claim

Policy No

Title of Contract Insured(s)

Name(s) and Address(es) Insure(d)

Location and Address of Contract Site

Name of Supervising Engineer

Nearest Railway Station (Airport)

Advisable approach route to Contract Site from Railway Station (Airport) or otherwise

(a) Contract Works

(b) Construction Plant and Equipment

When did the Loss or Damage occur? (State Date and exact Time)

How did the Damage occur and what was its probable cause? (Attach sketches, photos, etc)

Give Name and Address of witness to the occurrence

How will the damaged items be repaired?

Will any alterations or improvements be made to Design, Construction or Material when repairs are carried out?

(a) Contract Works?

(b) Construction Plant and Equipment?

Is Third Party Liability involved?

NoYes

Are existing buildings or surrounding Property damaged?

NoYes

Remarks

The undersigned Insured declares to have answered the above questions Conscientiously and Truthfully

Dated on

Attach sketches, photos, etc