Chestionar – cerere de asigurare privind raspunderea civila profesionala a arhitectilor si inginerilor

constructori (cod RC101) / Proposal form regarding professional liability of architects and designers
engineers (code RC101)

1. Solicitantul asigurarii (persoana

fizica/juridica) - nume, adresa, tel. fax,
data infiintarii)/Applicant (individual/
legal bodies) – name, address, phone, fax,
establishing date

2. Sunteti memtru in una/mai multe asociatii sau Da/Yes □ Nu/No □

uniuni profesionale?/Are you member of a relevant
professional association?
Daca da, enumerati-le/ If, yes, please specify:

3. Numar total de personal al societatii ……… din care/ Total number of staff …… from which:
a) Directori/asociati/actionari / managers/partners/shareholders
Nr. Numele si prenumele / Name and Calificarea si vechimea in profesie (ani) Pozitia in companie / Position
Crt. surname / Qualification and professional held in compay
experience (years)

b) Personal calificat in cadrul profesiei (arhitecti, ingineri constructori,

proiectanti etc. / Qualified staff (architects, engineers, draughts men, etc.
c) Personal calificat in cadrul altor profesii (ingineri mecanici, chimisti,
metalurgisti, economisti, etc.) / Other qualified staff (mechanical
engineers, chemical engineers, economists, etc)
d) Personal administrative (contabil, secretar, curier, dactilograf, etc.) /
Administration staff (accountants, assistants, typist, etc..)

4. Volumul incasarilor in anul fiscal incheiat / Total

income in the past financial year:
Volumul estimate al incasarilor in perioada
asigurata / Estimated income on the insurance period:

5. Descrierea completa a activitatilor desfasurate /

Complete description of your principal activities:
Ponderea activitatilor de mai sus in total incasari /
Specify the percent of above activities in total incomes:

6. Subcontractati lucrari? / Do you give work with Da/Yes □ Nu/No □

subcontractors?
Daca da, specificati tipul lucrarilor si ponderea
acestora in total incasari / If yes, please state kind of
work and percentage of fees:

7. Solicitati o acoperire anuala pentru toate proiectele

angajate? / Do you request an annual cover for all your
contracts/projects?

Prezentul chestionar face parte integranta din polita de asigurare

Formular D2.1-PL1-CH_RC101 / e/r 1/3 1
 Enumerati valoarea contractelor si beneficiarul pentru
fiecare / Brief description including value and fees for
your projects:

8. Solicitati acoperirea prin asigurare a unui singur contract? / Do

you request cover for one contract/project?
Precizati / Please specify:
- denumirea proiectului, detalii/ title of the project, details
- valoarea totala a proiectului / total price of the project:
- valoarea proiectului de consultanta / the price of consultancy
project:
- beneficiarul / beneficiary:
- locatia / location of project:
data inceperii si durata proiectului / starting date and duration:
- durata raspunderii dvs. referitoare la proiect / the period of
your liability regarding the project:

9. Ati avut, anterior o asigurare de raspundere civila profesionala? / Da / Yes □ Nu / No □

Have you previously been insured for professional liability
insurance?
Daca da, va rugam precizati: Asiguratorul, perioada de asigurare,
limita raspunderii, despagubiri platite: / If so, please specifiy:
Insurer, period of insurance, limit of liability, paid claims:

10. A existat vreun Asigurator care a anulat sau refuzat reinnoirea Da / Yes □ Nu / No □
politelor? / Was it any Insurer that cancelled an insurance policy
concluded with you or that refused conclusion of a policy?

11. Ati avut reclamatii, in activitatea dvs. profesionala, in ultimii trei Da / Yes □ Nu / No □
ani? / Have you had any claims regarding your professional
activity in the last three years?

12. Ati avut cereri de despagubire in ultimii trei ani? / Have you had Da / Yes □ Nu / No □
any indemnity claims in the last three years?

13. Ati platit despagubiri in ultimii trei ani? / Have you paid Da / Yes □ Nu / No □
indemnity in the last three years?
Daca da, mentionati anul, motivele, sumele platite / If yes,
specify the year, the reasons, the paid amounts:

14. Cunoasteti circumstante care pot determina reclamatii/plangeri

impotriva dvs.? / Is your company aware of any circumstances or
incidents which may result in a claim against you/your company?

15. Limita raspunderii solicitata: / Limit of liability:

Limita raspunderii pe intreaga perioada asigurata:
Limita raspunderii pe eveniment:

16. Fransiza solicitata / Requested deductible

Prezentul chestionar face parte integranta din polita de asigurare

Formular D2.1-PL1-CH_RC101 / e/r 1/3 2
 17. Perioada de asigurare / Insurance period

Solicitantul declara ca cele completate în prezenta cerere de asigurare sunt reale si în conformitate cu
documentele pe care le poseda./The Applicant declares that all the information provided in this
questionnaire corresponds to the reality and no circumstance which could influence the risk appreciation
was hidden.
Datele incluse în prezenta cerere de asigurare stau la baza politei ce se va emite si constituie parte
integranta a acesteia./ The Applicant agrees that this questionnaire-proposal form and all the other
declarative documents are the basis of the insurance contract and are integrant part and also complete
the policy.
Data:/Date:

SOLICITANT/ASIGURAT / APPLICANT/INSURED

Prezentul chestionar face parte integranta din polita de asigurare

Formular D2.1-PL1-CH_RC101 / e/r 1/3 3