BORANG CADANGAN BAGI SKIM TAKAFUL KONTRAKTOR SEMUA RISIKO

PROPOSAL FORM FOR CONTRACTOR’S ALL RISK TAKAFUL PERHATIAN: DENGAN INI ADALAH DIKEHENDAKI MENERANGKAN DENGAN SEPENUHNYA DAN SEBENARNYA BUTIR-BUTIR YANG ANDA TAHU SEPATUTNYA TAHU DALAM BORANG CADANGAN INI, JIKA TIDAK SIJIL YANG DIKELUARKAN MENURUT CADANGAN INI ADALAH TIDAK SAH. NOTE: YOU ARE TO DISCLOSE IN THIS PROPOSAL FORM, FULLY AND FAITHFULLY, ALL THE FACTS WHICH YOU KNOW OR OUGHT TO KNOW, OTHERWISE THE CRTIFICATE ISSUED HERUNDER MAY BE VOID.

1. T

HE

PRO

POSE

R

a) Name & Address of the Principal

Trade or business

b) i) Name & Address of the Contractor

Trade or business

ii) Company Registration No.

a) i) Name & Address of the Sub Cont-

tractor, if any, Trade or Business

ii) Company Registration No.

b) Telephone/Fax/E-mail

/ /

c) Whose Interests are to be insured?

d) Past experience of the Contractor

(provide list of major contract with contract details)

e) Claim history for the past 5 years

(please provide details)

2. T

HE

CON

TRA

CT W

ORK

S

a) Full description of the Contract/

Contract Title

b) Please give details –

i. Building (type of construction,

number of storeys/Basement etc.)

ii. Blasting operation

iii. Excavation work

iv. Pile type/dimension/depth

v. Tunneling

vi. Dam Construction or diversion

of water

vii. Others (Specify)

Note - A site plan of contract works to be enclosed.

Contractor Sub-Contractor Principal

c) i) Is this a Contract/Sub-contract

forming part of an overall construction project

ii) If yes, give name of the Project

d) i) Will the construction be carried out

by your own personnel?

ii) If not, by whom?

e) i) Will any sub-contractors be taking

part in the work of construction?

ii) if yes, what is their position as regards to this Takaful

iii) Past experience of the Sub-

Contractor (provide list of major contract with contract details)

3. T

HE

CON

TRA

CT S

ITE

a) Location of Contract site

a)

b) Nearest port and/or Railway Station

and distance.

b)

Note - A complete lay out of the site may be enclosed

c) Are any one or more of the following

perils/risks likely to be involved?

c)

i) Earthquake-Fire & Shock

ii) Landslide/Rockslide/

Subsidence

iii) Flood/Inundation

iv) Storm/Tempest/Hurricane/Typ

hoon/ Cyclone

v) Collapse

vi) Water Damage for ’Wet’ risk

i.e. Contract involving construction in rivers, canals, lakes or sea.

d) Distance from nearest river, lake,

reservoir or sea - the names and particulars to be given

d)

e) Elevation of construction site above

normal river, lake, reservoir or sea level

e)

f) Is there any record of the

construction site ever having been affected by any of the major perils specified in (c) above?

f)

Yes No

Yes No

Yes No

g) Give full details regarding geological

condition including sub soil

g)

h) Brief description of the

arrangements made for storage of construction materials and equipments - whether in open or closed premises.

h)

i) i) Will there be a watch and ward

round the clock?

i)

ii) If not, what precautions will be

taken against theft, malicious damage etc.

ii)

4.

TH

E TA

KAFU

L

a) Estimated construction period excluding maintenance period (cover

to commence from the date of first arrival of consignment material at site or commencement of work whichever is earlier)

Months:__________ From: __________________ To: ____________________

b) Cover required during maintenance period, if any

Months:__________ From: __________________ To: ____________________

c) Probable date on which construction is expected to be completed

d) Period of Takaful required

Months:__________ From: __________________ To: ____________________

e) i) Have you approached any other Takaful/Insurance company for

Takaful/Insurance Cover in respect of this Proposal?

ii) If yes, please state name of the Takaful/Insurance company.

f) Has any such proposal been:-

i) declined?

ii) withdrawn?

iii) accepted subject to an increased rate or special conditions?

Note-Please attach schedule of quantities and rates and/or values (Permanent & Temporary works including all materials to be incorporated therein)

Yes No

Yes No

Yes No

Yes No

g) Section I: Contract Works

i) Contract Price

B$

ii) Materials or items supplied by the Principal

B$

iii) Any additional items not included in (i) and (ii) above

B$

iv) Landed cost of imported items as at construction site

(please specify whether included in (i) and/or (ii) above) at Exchange Rate:

______________________

B$

TOTAL VALUE OF CONSTRUCTION

B$

v) Construction Plant & Machinery to be used at the construction site

(please provide details in separate sheet)

B$

vi) Professional Fees

B$

vii) Clearance & Removal of Debris

viii) Insured's own surrounding property.

B$

ix) Extra charges for Express Freight (excluding Air Freight) overtime

Sunday & Holiday rates of wages, if required.

B$

x) On increased Replacement value for item i (a) (b) & (d) above, if

required

B$ ( %)

h) Section II: Third Party liability –

Limit of Indemnity

i) for any one accident

B$

ii) for all Accidents during the period

B$

Do you wish to opt for higher amounts of Deductible/Excess? If yes, whether

i) 2 times

ii) 3 times

iii) 5 times

iv) 10 times

v) _________

Yes No

5.

DEC

LARA

TIO

N

Akuan Bahawasanya dengan ini saya/kami mengakui dan mengesahkan sepanjang pengetahuan saya/kami, penyataan-penyataan yang terkandung di dalam Borang Cadangan dan Akuan ini adalah benar dan betul dan saya/kami tidak menyembunyi,menyalah tafsir,memalsukan atau memberi penyataan-penyataan yang tidak benar mengenai apa-apa keterangan penting. Bahawasanya saya/kami dengan ini bersetuju menyertai Skim Takaful Am berdasarkan kepada prinsip At-Tabarru`at sebagaimana yang ditakrif oleh Takaful Brunei Am Sdn Bhd bahawasanya sumbangan Takaful saya/kami akan dikreditkan ke dalam Kumpulanwang Takaful Am secara Tabarru’ bagi tujuan Takaful Brunei Am Sdn Bhd membantu peserta-peserta yang ditimpa musibah yang mana berhak kepada manfaat/tuntutan yang terkandung di bawah perjanjian ini dan juga bagi tujuan Takaful Brunei Am Sdn Bhd menguruskan berbagai skim Takaful di bawah Perniagaan Takaful Am termasuk pelaburan bagi kumpulanwang tersebut mengikut cara-cara yang difikirkan sesuai oleh Takaful Brunei Am Sdn Bhd serta menepati syariah. Berdasarkan prinsip Al-Wakalah, saya/kami seterusnya bersetuju membenarkan Takaful Brunei Am Sdn Bhd mengambil 35% daripada sumbangan tersebut sebagai yuran Wakalah. Mana-mana keuntungan yang diperolehi daripada pelaburan di dalam satu-satu bulan akan dikreditkan semula ke dalam kumpulanwang tersebut. Saya/Kami juga selanjutnya memahami bahawa lebihan bersih dari Kumpulanwang Takaful Am, jika ada, akan diagihkan sebagai hibah mengikut cara-cara yang difikirkan sesuai oleh Takaful Brunei Am Sdn Bhd sebagaimana yang dipersetujui dan diluluskan oleh Badan Penasihat Syariah. Saya/kami dengan ini bersetuju, tanggungan Takaful Brunei Am Sdn Bhd tidak akan bermula sebelum Borang Cadangan dan Akuan ini diterima oleh Takaful Brunei Am Sdn Bhd dan sumbangan takaful telah saya /kami bayar kepada Takaful Brunei Am Sdn Bhd kecuali terdapat nota perlindungan resmi yang dikeluarkan oleh Takaful Brunei Am Sdn Bhd. Akad Saya/kami seterusnya bersetuju bahawa penyata-penyata dan pengakuan-pengakuan yang terkandung di dalam Borang Cadangan dan Akuan ini akan menjadi asas kepada perjanjian takaful dengan Takaful Brunei Am Sdn Bhd dan disifatkan sebagai diperbadankan di dalam perjanjian ini.

Declaration I/We to the best of my/our knowledge hereby confirm that the statements contained in this Proposal Form are true and correct and I/We have not concealed, misrepresented or mis-stated any material fact. I/We hereby agree to participate in General Takaful Scheme that on the basis of the principles of At-Tabarru`at as defined by Takaful Brunei Am Sdn Bhd that my/our takaful contribution be credited into the General Takaful Fund as tabarru’ for Takaful Brunei Am Sdn Bhd to help other Participants in time of misfortune who are entitled to such benefits/claims under the takaful contract and to manage the various schemes of takaful under its General Takaful Business including the investment of the said fund in a manner deemed fit by Takaful Brunei Am Sdn Bhd and in accordance to Shariah. On the basis of the Al-Wakalah principles, I/We further agree to allow Takaful Brunei Am Sdn Bhd to deduct 35% of the takaful contribution as Wakalah Fee. Any profit arising out of the investment in each month, shall be allocated back to the General Takaful Fund. I/We also understand that the net surplus arising from the said fund, if any, shall be distributed as hibah in a manner deemed fit by Takaful Brunei Am Sdn Bhd according to the agreed upon and approval by the Shariah Advisory Body. I/We hereby agreed that liability of Takaful Brunei Am Sdn Bhd does not commence until this proposal has been accepted by Takaful Brunei Am Sdn Bhd and the Takaful Contribution paid by me/us, except as provided by any official cover note issued by Takaful Brunei Am Sdn Bhd.

The Akad I/We agree that the statements and declaration contained in this Proposal Form shall be the basis of the contract of takaful with Takaful Brunei Am Sdn Bhd and are deemed to be incorporated in the contract. Date : _______________________ Signature of Proposer : _________________________________________

6.RE

QU

IRED

DO

CUM

ENTS

Site Development Plan

Scope of Work/Limestone Bar Graph/Activity

Elevation and Sectional View Plan

Soil Test Report

Photograph of Contract Site

Monthly Progress Report

7.

OFF

ICE

USE

ON

LY

Cross Liability Clause Warranty on Sections

Extended Maintenance Clause Warranty – Camps and Stores

Exclusion of Windstorm Clause Safety Measures with Respect to Inundation

Testing of Machinery & Installations Clause Fire Fighting Facilities and Safety on Sites

Crops, Forests and Cultures Water Supply and Sewer Pipes

Underground Cables, Pipes & Facilities Designer’s Risk – Resultant Damage

Crops, Forests and Cultures Water Supply and Sewer Pipes

Vibration, Removal or Weakening of Support Manufacturer’s Risk

Guarantee Cover Piling Foundation and Retaining Wall Works

Endorsement A: Property of the Government’s Employees and Consultant Clause

Others-Please specify:

Endorsement B: Cross Liability Clause Signature/Name of

Underwriter: