Report an Incident

Section 1 - General details

Name and address of main contractor	:
Name and address of employer:
Address of contract site:
Defects liability (or maintenance) period:
Under which conditions of contract is the work to be carried out?
If subject to JCT Clause 21.2.1 Conditions (or similar), please state which version of the conditions applies e.g. JCT 1980 with/without the 1986 amendments? Please forward a copy of the contract conditions if they are not standard
Please describe fully the works to be carried out. Please supply specifications and plans to support this
Description of ground conditions at the contract site:
Contract start date:
Period of contract:
Contract value:	£
Limit of indemnity required:	£

Section 2 - Existing property

If the existing property is being completely demolished or the contract site has already been cleared, please proceed to SECTION 3. Otherwise, please answer the questions below:

What are the approximate age and the general condition of the existing property?
Is the property currently occupied and if so, for what purpose?	YesNo
Will any work on the existing property require temporary propping or support? If so, please provide details:	YesNo

Section 3 - Surrounding property

Please give a description of all surrounding property not forming part of the Contract Works:

Please state the address of each property and its approximate distance from the site, give a description including age, condition and occupation and attach a copy of location plan, if available: e.g. Property 1 Address: Occupation: Condition: Approximate age: Approximate distance from site:
Have any Schedules of Conditions/Schedules of Dilapidations been drawn up for the property being worked upon or surrounding property?	YesNo If Yes, please forward a copy of this to dahlia.osuoha@consortinsurance.com
Please confirm that the contractor will prepare/take photographs and/or video and/or schedule of conditions of all adjoining or surrounding third party property that could reasonably be expected to be affected by the works?	YesNo

Section 4 - Construction and extensions

Please complete DEMOLITION Section if applicable (where such demolition forms part of a contract for erection, reconstruction, alteration or repair by the insured):

Demolition

Is the demolition to be carried out by your own direct employees? If No, please provide details of the sub-contractor e.g. name, address, number of years' experience in business etc.	YesNo
a) Please provide full details of property to be demolished, including age, condition and number of storeys b) What is the method of demolition?
Is any demolition below ground level? If Yes, please state: a) Maximum depth b) Minimum distance from nearest property c) Will shoring and/or propping be required? If Yes, please provide details	YesNo
Is any excavation work to be undertaken? If Yes, please state: a) To what depth b) Minimum distance from nearest property c) Means to be adopted to support the excavation	YesNo
Is any piling work to be undertaken? If Yes, please state: a) Type/method of piling b) Number of piles and maximum depth c) Minimum distance from nearest property	YesNo
Is any underpinning work to be undertaken? If Yes, please state: a) Overall length involved b) Maximum depth c) Maximum length any one bay	YesNo
Is any dewatering work to be undertaken?	YesNo
Is any ground stabilisation work to be undertaken? If Yes, please state: a) Method b) Minimum distance from nearest property	YesNo

Section 5 - Declaration

The undersigned declares on behalf of all parties proposing for insurance that to the best of his/her knowledge and belief, the statements provided herein are true and complete and all material facts or circumstances have been fully disclosed. The undersigned declares and agrees that the proposal form together with any other information supplied shall form the basis of any subsequent contract of insurance and undertakes to inform the insurer of any material alteration to those facts occurring before completion of the contract of insurance.

Declaration Made By:
Company Title:
Date:

Client Name / Policy Holder

Policy Type

Current Insurer

Policy Number

Contact Name

Contact Number

Date & Time of Incident

Description of Incident

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JCT clause 21.2.1 (or equivalent) insurance