Car Proposal Form 1

PROPOSAL FORM
PROPOSAL AND QUESTIONNAIRE FOR CONTRACTOR'S ALL RISKS

INSURANCE
(The liability of the Company does not commence until this proposal has been
accepted by the Company and the premium paid)
Information given herein will be treated in strict Confidence.
Put a () mark wherever applicable.
S. No. Details Answer
1. a) Name & Address of the Principal Trade a) Mangalore Smart City Limited
or business Mangalore city corporation building,
2nd floor, M.G Road, Lalbag
Mangalore -575003
b) Name & Address of the Contractor b) M/s SKS Karkala Infra Projects Pvt Ltd
Trade or business #111-494/17, Suvarna complex, Mangalore
Road, Karkala , Udupi District , Karnataka 574104
c) Name & Address of the Sub Cont- c)

ractor, if any, Trade or Business
2. THE INSURED INTERESTS - 

Contractor Sub- Principal
Whose Interests are to be Insured? contractor
3. THE CONTRACT WORKS -

Scope of work includes Excavation work, filling work,
a) Full description of the Contract construction of embankment, Pile foundation,
WMM, RCC, foot path work, drains and, bird
watching and garden work, Dry stone pitching
Mangalore corporation limit.
b) Please give details -

i) Building (type of construction,
number of storeys etc.)
ii) Blasting operation
iii) Excavation work
iv) Pile driving
v) Tunneling
vi) Dam Construction or diversion of
water
vii) Others (Specify)
Note - A site plan of contract works may

be enclosed.
4. i) Is this a contract/Sub-contract 
forming part of an overall Yes No.
construction project
ii) If yes, give name of the Project Name of work: Promenade

development of waterfront
projects for Mangaluru
Smart city Limited Phase - 1
A
5. a) Will the construction be carried out by 

your own personnel? Yes No.
b) If not, by whom? b)
c) Past experience of the Contractor c) About 20 years
6. a) Will any sub-contractors be taking part Yes No.

in the work of construction?
b) If yes, what is their position as regards b)

this insurance?
7. THE CONTRACT SITE -
c) Location of Contract site a) Mangalore

Corporation
d) Nearest port and/or Railway Station b) Kankanady

and distance. station aprox 6
km
Note - A complete lay out of the site may

be enclosed
8. a) Are any Special Risks of one or more of a)

the following involved?
i) Earthquake-Fire & Shock -NO-

ii) Landslide/Rockslide/ Subsidence -NO-
iii) Flood/Inundation -NO-
iv) Storm/Tempest/Hurricane/Typhoon/ -NO -
Cyclone
v) Collapse -NO-
vi) Water Damage for ’Wet’ risk i.e. -NO-
Contract involving construction in
rivers, canals, lakes or sea.
b) Distance from nearest river, lake, b) Netravati

reservoir or sea - the names and
particulars to be given
River
c) Elevation of construction site above c)

normal river, lake, reservoir or sea level
d) Is there any record of the construction d)

site ever having been affected by any
of the major perils specified in (a)
above?
9. Give full details regarding geological

condition including sub soil
10. a) Brief description of the arrangements a)

made for storage of construction
materials and equipments - whether in
open or closed premises.
b) i) Will there be a watch and ward b) (i)

round the clock?
ii) If not, what precautions will be
taken against theft, malicious ii)
damage etc.
11. THE INSURANCE -
a) Estimated construction period a) 12 Months

excluding maintenance period (cover from
to commence from the date of first ……… to ....
arrival of consignment material at site
or commencement of work whichever
is earlier)
b) Cover required during maintenance b) 12 months,

period, if any from…….. To…………..
c) Probable date on which construction is d) Approx September

expected to be completed 2023
e) Period of Insurance required c) 24 months,

from……… To………..
12. a) Have you approached any other

Yes 
Insurance Co. for Insurance Cover in
No
respect of this Proposal?
b) If yes, please state name of the b)

Insurance Company.
13. Has any such proposal been -


a) declined? Yes No

b) withdrawn? Yes No

c) accepted subject to an increased rate No
Yes
or special conditions?
14. SUM INSURED -
i) Contract works -
Note-Please attach schedule of quantities and rates and/or values (Permanent & Temporary
works including all materials to be incorporated therein)
a) Contract Price Rs. 19.38 Crore
b) Materials or items supplied by the

principal Rs. .N.A
c) Any additional items not included

in (a) and (b) above Rs. . . . . . . . . .
d) Landed cost of imported items as

at construction site (please specify Rs. . . . . . . . . .
whether included in (a) and/or (b)
above)
at Exchange Rate -------------
TOTAL VALUE OF CONSTRUCTION . . . Rs Aprox 19.38 Crore
ii) Construction Plant & Machinery to

be used at the construction site (Details Rs. . . . . . . . . .
as per attached sheet)
iii) Clearance & Removal of Debris Rs. . . . . . . . . .
iv) Insured's own surrounding property. Rs. . . . . . . . . .
v) Extra charges for Express Freight

(excluding Air Freight) overtime Sunday Rs. . . . . . . . . .
& Holiday rates of wages, if required.
vi) On increased Replacement value

for item i (a) (b) & (d) above, if Rs. . . . . . . . . . ( --------- % )
required
vii) Third Party liability –
a) for any one accident Rs. . . . . . . . . .
a) for all Accidents during the period Rs. . . . . . . . . .
15. Do you wish to opt for higher amounts of Deductible Excess? Yes No
If yes, whether i) 2 times ii) 5 times Iii ) 10 times iv) 20 times

I/We the undersigned hereby declare that the above statements and
particulars are true and complete and I/We declare and agree that this
declaration and the answers given above shall be held to be promissory and
shall be the basis of the contract between me/us and the company.
Place.................
Date.................. Proposer’s Signature.....................
Section 41 of Insurance Act 1938
PROHIBITION OF REBATES
1. No person shall allow or offer to allow, either directly or indirectly as an

inducement to any person to take out or renew or continue an insurance in
respect of any kind of risk relating to lives or property in India, any rebate of
the whole or part of the commission payable or any rebate of the premium
shown in the policy; nor shall any person taking out or renewing or
continuing a policy accept any rebate, except such rebate as may be
allowed in accordance with the published prospectus or tables of the
Insurer.
2. Any person making default in complying with the provisions of this section
shall be punishable with fine, which may extend to five hundred rupees.
*****

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PROPOSAL FORM

PROPOSAL AND QUESTIONNAIRE FOR CONTRACTOR'S ALL RISKS

Information given herein will be treated in strict Confidence.

Put a () mark wherever applicable.

S. No. Details Answer

c) Name & Address of the Sub Cont- c)

2. THE INSURED INTERESTS - 

3. THE CONTRACT WORKS -

b) Please give details -

Note - A site plan of contract works may

ii) If yes, give name of the Project Name of work: Promenade

5. a) Will the construction be carried out by 

c) Past experience of the Contractor c) About 20 years

6. a) Will any sub-contractors be taking part Yes No.

b) If yes, what is their position as regards b)

7. THE CONTRACT SITE -

c) Location of Contract site a) Mangalore

d) Nearest port and/or Railway Station b) Kankanady

Note - A complete lay out of the site may

8. a) Are any Special Risks of one or more of a)

i) Earthquake-Fire & Shock -NO-

b) Distance from nearest river, lake, b) Netravati

c) Elevation of construction site above c)

d) Is there any record of the construction d)

9. Give full details regarding geological

10. a) Brief description of the arrangements a)

b) i) Will there be a watch and ward b) (i)

11. THE INSURANCE -

a) Estimated construction period a) 12 Months

b) Cover required during maintenance b) 12 months,

c) Probable date on which construction is d) Approx September

e) Period of Insurance required c) 24 months,

12. a) Have you approached any other

b) If yes, please state name of the b)

13. Has any such proposal been -

a) Contract Price Rs. 19.38 Crore

b) Materials or items supplied by the

c) Any additional items not included

d) Landed cost of imported items as

TOTAL VALUE OF CONSTRUCTION . . . Rs Aprox 19.38 Crore

ii) Construction Plant & Machinery to

iii) Clearance & Removal of Debris Rs. . . . . . . . . .

iv) Insured's own surrounding property. Rs. . . . . . . . . .

v) Extra charges for Express Freight

vi) On increased Replacement value

vii) Third Party liability –

a) for any one accident Rs. . . . . . . . . .

a) for all Accidents during the period Rs. . . . . . . . . .

If yes, whether i) 2 times ii) 5 times Iii ) 10 times iv) 20 times

Section 41 of Insurance Act 1938

1. No person shall allow or offer to allow, either directly or indirectly as an

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