Authorised Financial Services Provider - FSP NO: 20816
Machine Breakdown Insurance Questionnaire
Fill in Application Form
A. Broker Details
Name of Broker
Contact Person
Tel Number
Fax Number
B. Insured Details
Name
Physical Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Postal Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Tel Number
Business of Insured
VAT No.
C. Business Working Details
Normal Operation
Shift per day
Normal working hours from
Normal working hours to
Days worked per week
Are there any special hazards or circumstances - e.g. the mode of operation (computer controlled)?
Yes
No
If yes, please specify
Is the property insured against fire, explosion etc.?
Yes
No
If yes, which company?
Has the property suffered loss from fire, explosion etc. in the last 3 years?
Yes
No
If yes, please elaborate on the following. Cause, Extent of damage and cost.
D. Machinery Insurance Details
Description of machinery (In the following order. Item, Premises, Value and Excess) - If the space of items exeed given space please provide with a detailed list of Machinery
Note. 1) If the Insurance is extended to include foundations and masonry then the description of machinery must state this and its value must be calculated within the Sum Insured. 2) The value of the Refrigeration or Air-conditioning Machinery should include the cost of Refrigerant or Coolant.
Is the property currently insured against machinery breakdown?
Yes
No
If yes with which company?
Has the insured property suffered loss or damage by machinery breakdown in the last 3 years?
Yes
No
If Yes, please specify the following. (Item, Date and Cause)
Are any machines or installations still under manufacturers guarantee?
Yes
No
If Yes, please specify the following. (Item, Date of Expiry)
Maintenance of the machinery: Comment briefly on the maintenance in force,: e.g planned, weekly..
E. Deterioation Of Stock Following Machinery Breakdown
Machinery and Technical information
Please supply information / schedule of machines as per attached Annexure II. Is the electrical equipment fitted with automatic restart facility ie:
Following a power failure will machinery re-activate when power is re-established?
Yes
No
Number of cold rooms / number of deep freeze rooms?
Are the cold rooms fitted with external temperature monitoring gauges?
Yes
No
What are the normal temperatures of the cold rooms / deep freeze rooms?
How long could rooms hold temperature before deterioration of stock commences?
Detail the extent of the maintenance:
agreement in force:
Yes
No
what is affected? Ie motor, electrical only or complete installation
Name of Maintenance Company:
Tel Number
Email
F. Security
Is there always personel on site, ie: security guards who would be aware of a machine failure?
Yes
No
Is there an alarm system in place to warn of plant malfunction?
Yes
No
How often is it tested?
G. Products/Stock Information
Type of stock, ie Seafood:
Split in value of stock type showing max holding at any time:
What is the turnaround time of stock stored?
What alternative arrangements can be made in the event of a breakdown?
Removal to another premises
Yes
No
If Yes, details to where
Removal to another cold room / freezer on premises
Yes
No
Is the product / stock of a seasonal nature, i.e fuit
Yes
No
If Yes, please give details on high and low seasons.
H. General
Give details of loss / breakdown history with approximate repair costs and stock losses.
Give general impression of risk ie, clean, dusty, excessively hot running motors
I. Declaration
Form Completed by
Date
/
DD
/
MM
YYYY
By completing and submitting form you declare the forgoing particulars to be true in every respect
Broker to mail to:
