chestionar-drumuri-&-cai-ferate-ccb-8e-7-25.08.2010-v1

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Societate de asigurare – reasigurare

Anexă la poliţa seria E /Nr. ………………, din …/…/……

Chestionar suplimentar privind construcţia de drumuri şi căi ferate Additional Questionnaire for the construction of roads and railway facilities

1. Titlul contractuluiTitle of contract

2. Amplasamentul lucrarilorSite

zona de ses zona de deal zona montana

flat hilly mountainouszona construita zona semi-construita

built-up area semi-built-up area

teren liber/open area

Daca proiectul este intr-o zona construita sau semi-construita, specificati distanta pana la proprietatile existente si tipulacestora. / If project is in built-up or semi-built-up area, state minimum distance to and type of neighbouring structures

3. Defalcarea valorilor Breakdown of alues

Tipul lucrariiItem

Valoare (valuta)!alue "currency#

Oranizare de santier si lucrari cu caracter temporarSite installations and temporary work

Ateliere, maazii, etc.$orkshops, stores, camps, etc

!xcavatii%arthwork

"olectoare tubulare, pasa#e subterane si pasa#e superioare&ulerts, underpasses and oerpasses

$trat de leatura/balastBase course'ballast

$uprafata de uzura/cale de rulare$earing course'track system

!c%ipamente electromecanice%lectromechanical e(uipment

Alte lucrari)ther work

TOTA& / Total alue

4.Tipul drumului

Type of road

autostrada / highway drum in zona rurala / country road drum municipal / municipalroad

'umar de benzi/cai de rulare feroviara

*umber of lanes'tracks

arte carosabila dubla/+ual carriageway Da/ yes 'u/no

fara covor asfaltic /unsurfaced cu covor asfaltic /surfaced numai covor asfaltic /surfacing

CCB-8E-7-25.08.2010-V1 CITY INSU!NCE "agi#a 1 di# $





only

5. Date te%niceTechnical data

&unime / lengthm&atime / width.m*nclinare maxima/a. gradient ..+

. "olectoare tubulare, pasa#e subterane si pasa#e superioare&ulerts, underpasses and oerpasses'umar/*umber..............

prefabricate / precast turnate in santier / cast in site

din metal / steel

Des%idere maxima/a. span.................m*n cazul constructiei de poduri, trebuie completat "%estionarul suplimentar corespunzator //or bridges, complete additional (uestionnaire for the construction of bridges

. ambleuri/0ills&unimea totala/Total length.......................1m*naltimea max. a unui sinur rambleu...........ma. height of single fill

*nclinatia pantei/Inclination of slope................2aterialul folosit la umplere/aterial to be filled in.................

.3 Debleuri / &uts&unimea totala/Total length.......................1mAdancimea max. a unui sinur debleu...........m0olositi explozibili/4lasin 5or16 Da/ yes 'u/no

$e executa sfaramare mecanica/0ock crushing1 Da/ yes 'u/no

2ateriale ce vor fi inlaturate/aterials to be remoed

.7 $uprastructura / Superstructure

0undatieSub-base

$trat de leaturaBase course

$trat de uzura$earing course

2aterial/ aterial

8rosime/Thicknes cm

"ompactat/&ompacted

$tabilizat/Stabili2ed

Traverse/Sleepers

c%erestea/ timber otel/steel

beton/concrete

'ivelul apei freatice / 3eel of ground water min. .m

6. 8raficul de executie&onstruction schedule

Tip lucrare &omponent

Datele de executie%ecution dates

!xcavatii%arthwork

"olectoare tubulare, pasa#e subterane si pasa#e superioare&ulerts, underpasses and oerpasses

0undatii/oundations

iloni4iers and abutments

$trat de leatura/balastBase course'ballast

$uprafata de uzura/cale de rulare$earing course'track system

Alte lucrari)ther work

CCB-8E-7-25.08.2010-V1 CITY INSU!NCE "agi#a 2 di# $





&unimea max. a unui tronson in lucru la un moment dat..................................1ma. length of road under construction any one time

7. Trebuie mentinut traficul in perioada constructiei drumului6

ust traffic be maintained during construction of the road1

Da/ yes

'u/no8. Va fi desc%is noul drum traficului inaintea turnarii stratului de uzura6$ill the new road be open to traffic before completion of wearing course1

Da/ yes

'u/no

. rocentul in care lucrarea poate fi distrusa ca urmare a unui sinur evenimentTo what etent might the contract work be destroyed in one loss eent1

1!. $pecificati lucrarile care sunt executate de catre subcontractori (in cazul in care acestiaexista)$hat work will be done by subcontractors1

11. 9nde sunt amplasate birourile, depozitele, atelierele6

9nde sunt stocate ec%ipamentele si materialele de constructii6$here are the offices, stores, workshops, camps, etc. located1$here are construction plant and e(uipment and construction materials stored1

12. Daca contractual prevede ca lucrarile sa fie predate pe sectiuni, in functie de finalizareaacestora, va ruam sa mentionati numarul sectiunilor, perioada de executie a fiecareia si datade finalizare.If contract proides for completed sections to be handed oer indiidually, please indicatenumber of sections, their lengths and anticipated dates of handing oer.

Afirm:m c: declara;iile f:cute mai sus de c:tre noi <n acest "%estionar, sunt, dup: cuno=tin;a noastr:, complete =i adev:rare, fiind

de acord ca acest "%estionar s: fac: parte interant: din poli;a emis: <n le:tur: cu riscurile de mai sus. !ste convenit c:Asiur:torul este r:spunz:tor <n concordan;: cu termenii poli;ei numai =i dac: Asiuratul nu va adresa nici un fel de cerere de oricealt: natur:. Asiur:torul se ana#eaz: s: trateze aceste informa;ii confiden;ial.$e hereby declare that the statements made by us in this Questionnaire are, to the best of our knowledge and belief, complete and true, and we hereby agree that this Questionnaire forms the basis and is part of any policy issued in connection with the aboe risk.It is agreed that the Insurers are liable in accordance with the terms of the policy only and that the Insured will not lodge any other claims of whateer nature. The Insurers undertake to deal with this information in strict confidence.

"ompletat la> Data> $emnatura%ecuted at5 +ate5 Signature

CCB-8E-7-25.08.2010-V1 CITY INSU!NCE "agi#a $ di# $

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