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Questionnaire and Proposal for
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Contractors' Plant and Machinery (CPM) Insurance No
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1Name and address
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of proposer
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2Insurance
On annual basis
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For months/ year (specify period)
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3Has there been any previousYesNoIf so, for which item(s) of the specification
and by what companies?
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CPM insurance
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4Have the plant and
machinery to be insured
(partly or in total) been hired?		YesNoIf so, please specify the owner's name and address
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5Are the plant and machinery highly exposed to special hazards?FireEarthquake, volcanic activity, tsunami
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Storm, cycloneFlood, inundation
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LandslideBlasting
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Employment in mountainous terrain
Employment underground
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Other
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6Do you wish the cover to
overtime, night work, work on public holidays?
Yes No
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include extra charges for
Limit of indemnity for such extra charges:
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7Do you wish the cover to
Yes No
If so, please specify.
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include inland transport?
Maximum value transported by one means of transport:
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We hereby declare that the statements made by us in this Questionnaire and Proposal to the best of our knowledge and belief, complete and true, and we hereby agree that this Questionnaire and Proposal forms the basis and is 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.
We hereby agree to BAOVIET’s General Terms and Conditions of Personal Data Protection specified at BAOVIET's website: https://www.baoviet.com.vn/insurance/Tin-tuc/Tin-doanh-nghiep/DIEU-KHOAN-VA-DIEU-KIEN-CHUNG-VE-BAO-VE-VA-XU-LY-DU-LIEU-CA-NHAN/19/3722/MediaCenterDetail/. It is also agreed that BAOVIET has the right to collect, utilize, process and store personal data information provided by Policy holder/Insured and related personal data for the purpose of implementing the Insurance Policy, as well as to comply with other requests for information prescribed by law.
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Executed atDateSignature
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