Anexa 3 Cerere Chestionar- Acoperire Activitate Si Proiect

7/23/2019 Anexa 3 Cerere Chestionar- Acoperire Activitate Si Proiect

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Cerere de asigurare raspundere civila arhitecti si ingineri proiectanti Clasificare: Public

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CERERECHESTIONARI NSURANCE QUESIONNAIRE

Privind rspunderea civil profesional a arhitecilor i inginerilor proiectantiin respect of Professional Liability for Architects and Design Engineers

I. DATE GENERALE / General I nformation

1. Nume solicitant /Name of applicant______________________________________________________________

2. Adresa de desfurare a activit ii (sediul social) /Legal Address________________________________________________________________________________________________________________________________

Tel /Fax/adresa web___________________________________________________________________________

3. Data autorizrii n profesie/Date on which the Practice was established:_________________________________4. Sunteimembru n una sau mai multe asociaii/uniuni profesionale? Dac da, enumerai-le: Nu/ NO Da/YES

Please list the professional bodies or associations to which the Applicant belongs.

____________________________________________________________________________________________

5. Denumirea societii s-a schimbat n ultimii 3 ani? Nu/ NO Da/YES Has the name of the practice ever been changed?

Dac rspunsul este afirmativ prezentati detalii/ If yes,please supply details____________________________________________________________________________________________

II. DATE REFERITOARE ACTIVITATEA DESFASURATA/ Detail s of Practice

1. PENTRU PERSOAN FIZIC/ FOR INDIVIDUALS:A. Calitatea/ Quality: Arhitect Inginer proiectant n construcii

Architect Design Engineer

B.Modul de desfasurare a activitatii:

Persoana fizica autorizata /Authorised Individual

Birou individual /Individual Office

Salariat/colaborator la o societate comerciala de proiectare

Employee / Collaborator on a design commercial company

C.experienta asiguratului in exercitarea profesiei asigurate (numar de ani) ________________________________

Insureds experience in the profession provided (number of years)

2. PENTRU PERSOANA JURIDICA /FOR LEGAL PERSONS:

A.Modul de desfasurare a activitatii:

Birou individual cu mai multi angajati /Individual office with several employees

Birouri associate/ associated offices

Societate comerciala de arhitectura/ proiectare /Architecture / Design Commercial Company

B. Date despre acionari/ asociai/personalul angajat n cadrul profesiei:Shareholders / associates / employees within the profession

Categoria Nr

.

crt

Numele i prenumele/ Name CalificareaQualification

Experienaprofesional

ProfessionalExperience

Poziia deinut ncadrul societii

Position in firm

Asociai/

actionari

Associates/

shareholders

1

2

3

4

Personal

angajat ncadrul

profesiei

qualified

persons

1

2

3

4

5

6*dac spaiul este insuficient se anexeaz lista


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C. Numar total angajati/employees: din care/from which:

- total persoane de specialitate/specialised:

- alte persoane calificate(precizati specializarile)/other qualified persons:

-personal non-tehnic (administrativ)/non technical personnel

3. Bifai tipurile de activitti pe care le efectuai si precizai ponderea lor n total activitate/ Check the types of activitiesyou perform and specify their share in the total activity::

Arhitectura constructii civile/industriale/Industrial/civil Architectural Engineering %

Arhitectura/proiectare peisagistica /Landscape design %

Design amenajri interioare/ exterioare /Interior/exterior design %proiectare structuri de rezistenta / design of structural resistance %

proiectare infrastructura / infrastructure design

- Utilitati / Utilities

- retele edilitare / Urbanistic

%

proiectare instalaii fixe (electrice/sanitare, HVAC, termo)/ design of fixed installations %

proiectare construcii civile / civil engineering design %

proiectare construcii industriale / industrial engineering design %

supervizare lucrari/dirigenie de antier /supervision works site inspectors %consultanta in constructii / construction consultancy %

Asistenta tehnica / technical assistance %

4. Numar de contracte de prestri servicii estimate pe anul n curs/Estimated annual no of contracts_______________5. Venitul realizat pe anul anterior /Income for the previous year:_________________________________________6. Venitul estimat pe anul n curs /Estimated current annual Income_______________________________________7. Nominalizati cele mai importante proiecte pe care le-ati realizat n ultimii 3 ani/Main projects in the last 3 years::

________________________________________________________________________________________________

_______________________________________________________________________________________________

8. Bifati dac obiectivele proiectate/ obiectivul proiectat (in cazul acoperirii per proiect) sunt destinateurmtoarelor domenii / check if the if project designed / objective of the project (if coverage per project) are for the

following areas :

Minier / mining

Energetic (hidroenergetic, termoenergetic, nuclear, eolian si altele neconventionale)

Energy (hydro, thermal, nuclear, wind and other unconventional)

Aviatie /Aircraft

Maritim /Maritime

Lucrri hidrotehnice i imbunatatiri funciare/Hydro works and land reclamationDrumuri, poduri, tuneluri/ Roads, bridges, tunnels

Ci ferate/Rail waysParcuri de distractii / amusement parks

Utilitati publice (reele ap, gaze, energie electric)/ public utilities (water, gas

electrical energy networks)Echipamente, instalaii, utilaje, sau componente/parti ale acestora, piese,

subansammble,scule/dispozitive / equipment, facilities, equipment, or components /

parts of those, pieces, parts, tools / devices

Fabrici la cheie / turnkey factories

Mijloace de transport / means of transportation

Aparate de uz casnic, mobilier, obiecte de decor interior si exterior / household

appliances, furniture, interior and exterior decoration and / or other similar. Nota: proi ectele reali zate pentr u aceste domenii nu sunt acoperite automat in poli ta , ele pot

fi incluse in acoperi re numai cu acceptul special al Administratiei Centrale./Projects completed for

those areas are not automatically covered in the policy, those projects can be covered only with

Head Quarters Approval

9. Exist proiecte la care realizai i construcia obiectivelor proiectate? Nu DaAre there projects for which you make the design and also the construction?

Dac raspunsul este da, menionai% din Cifra de afaceri __________________________________________________


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If yes, please specify % from the turnover

III. DATE REFERITOARE LA PROIECTUL PENTRU CARE SE DORESTE ASIGURAREA /

I nformati on related to the project for which you want to be insured

(se completeaza numai daca se solicita acoperire per proiect/compl ete onl y if you want singl e project coverage)

1. Calitatea deinut n cadrul proiectului: Proiectant general / General Designer Da

\ Quality held in the project Subcontractor /subcontractor DaContractor general / General Contractor Da

2. Beneficiarul proiectului /Project Beneficiary_____________________________________________________________

3. Numele Proiectului /Project Name ____________________________________________________________________

4. Obiectivul de proiectat/ descriere si domeniul de utilizare / description and area of use of the project

___________________________________________________________________________________________________

___________________________________________________________________________________________________

6. Descriei complet activitile dvs.desfurate in legatura cu proiectul (execuie, avizare, supervizare si coordonare,asisten si consultan, elaborri de caiete de sarcini, instruciuni tehnice privind execuia, proiecte de urmrire privindcomportarea n timp a cldirilor, asistarea fazelor de execuie, dirigentie antier, verificarea calitii execuiei, soluii

pentru tratarea defectelor, etc.) Fully describe your activities conducted in connection with the project ( execution,

approval, supervision and coordination, assistance and consultancy, tender books, technical guidance on

implementation, projects while tracking the behaviour of buildings, assisting the execution phase, Coordination on site,

checking the quality of execution, defect treatment solutions, etc)___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

6. Locatia obiectivului proiectat/ Location of the designed project______________________________________________

7. Valoarea totala a contractului de executie (=valoare deviz constructie)/ value of construction project________________

8. Valoarea venitului dvs. realizat din proiect( valoare onorarii) / Your Fees______________________________________

9. Perioada de realizare a proiectului/designului: de la data___________________la data ___________________________

Design Phase/period from until

10. Perioada de constructie/realizare a obiectivului proiectat de la data___________________la data __________________

Construction Phase/period from until

11. Data estimata de predare-primire a obiectivului / constructiei _______________________________________________

Hand/Over estimated date12.Durata raspunderii Dvs. referitoare la proiect/Yourliability period i.r.o. project:

13. Solicitati includerea subcontractorilor n polia de asigurare de raspundere profesionala: Nu DaDo you require subcontractors to be included in your Professional Indemnity policy No Yes

Daca da, va rugam sa completati tabelul de mai jos /If Yes, please complete the below table:

Denumirea firmei/persoanei care

subcontracteaza

Name of the sub-contractor

Descrierea lucrarilor realizate de

subcontractor /

Services provided

Ponderea lucrarilor realizate de

subcontractor n total proiectShare in total work performed

by the subcontractor in the

project

14. La proiectul/proiectele pentru care solicitati acoperire, realizati si constructia? Nu DaFor the projects for which you ask coverage, are you also involved in construction? No Yes

IV. INFORMATII REFERITOARE LA ASIGURARI SI DAUNE / Previous insurance and claims history

1.Ai avut anterior o asigurare de rspundere civil profesional ? Nu DaHave you previously been insured for professional liability? No Yes

Dac da, va rugm precizai/If yes please specify: Asigurtorul, perioada de asigurare, limita rspunderii, despgubiri pltite/Insurer, Insurance period,

limit of indemnity, paid claims :

____________________________________________________________________________________

____________________________________________________________________________________

A existat vreun asigurator care a anulat sau refuzat rennoirea polielor? Nu DaWas there any insurer that cancelled or refused renewal policies? No Yes


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2.Ai avut reclamaii , n activitatea dvs. profesional, n ultimii 3 ani: Nu DaHave you had any claims regarding your activity in the last three years? No Yes

3.Ai avut cereri de despgubire n ultimii 3 ani: Nu DaHave you had any indemnity claims in the last three years? No Yes

4.Ati platit despagubiri n ultimii trei ani: Nu DaHave you paid indemnity in the last three years? No Yes

Dac da, menionai anul, motivele, sumele pltite/If yes, specify the year, the reasons, indemnities paid:_________________________________________________________________________________________________________

_____________________________________________________________________________________________

5. Cunoateicircumstane care pot determina reclamaii/plangeri mpotriva dvs/Is your firm aware of anycircumstances or incidents which may result in a claim against your firm:

Dac da, va rugm detaliati /If yes please provide details:______________________________________________________________________________________________

______________________________________________________________________________________________

6. Limita rspunderii solicitat pentru rspundere civil profesional/Limit of liability requested

a. Limita agregat pe ntreaga perioada de asigurare/Limit in aggregate for the entire period______________________

b. Limita pe eveniment /Limit per event_______________________7. Solicitai extinderea poliei pe perioada de anterioritate /Do you ask for anteriority coverage? Nu/No Da/Yes

(acoperire pentru activitatea realizat pe perioada anterioar emiterii poliei / coverage for worked performed before theissuance of the policy)?

Daca DA, bifai perioada de anterioritate solicitat: 12 luni/months 24 luni 36 luniIf YES, please check on the retro-coverage periodrequested

8. Franiza solicitat/Deductible:Franiza minim obligatorie 250 EUR /daun, numai pentru pierderi financiare: Nu Da

Minimum compulsory deductible 250 EUR /damageonly for financial losses No YesAlt franiz solicitat(mai mare decat fransiza minima obligatorie)/ other deductible________________________

9. Perioada de asigurare /_________(luni, ani): de la ______________pan la______________________________Insurance period: (months, years): from until

10. Modalitatea de ncheiere a poliei de asigurare/Policy currency:Valut/foreign currency Lei/RON

11. Modalitatea de plat a primei de asigurare/Payment of insurance premiumsIntegral/ In full In rate/ In installments

Solicitantul declar c datele incluse n aceast cerere sunt reale i n conformitate cu documentele i informaiile de care dispune,fiind de acord s stea la baz i s fie parte a poliei emise.We declare that the statements in this proposal are true and according to all documents and all information supplied by me/us. We

agree that this proposal shall form the basis of any contract of insurance affected thereon.

ASIGURAT/INSURED________________________

(numele, semntura, tampila)(name, signature, stamp)

ncheiat polita nr(Se completeaz de ctre reprezentantul Asigurtorului.)

Anexa 3 Cerere Chestionar- Acoperire Activitate Si Proiect

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