Societate de asigurare reasigurare

Anex la polia seria E /Nr. , din //

Chestionar suplimentar privind construcia de drumuri i ci ferate

Additional Questionnaire for the construction of roads and railway facilities
1. Titlul contractului
Title of contract
2. Amplasamentul lucrarilor
Site

zona de ses zona de deal zona montana

flat
hilly
mountainous
zona 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 tipul
acestora. / 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 values

Tipul lucrarii
Item
Organizare de santier si lucrari cu caracter temporar
Site installations and temporary work

Valoare (valuta)
Value (currency)

Ateliere, magazii, etc.

Workshops, stores, camps, etc
Excavatii
Earthwork
Colectoare tubulare, pasaje subterane si pasaje superioare
Culverts, underpasses and overpasses
Strat de legatura/balast
Base course/ballast
Suprafata de uzura/cale de rulare
Wearing course/track system
Echipamente electromecanice
Electromechanical equipment
Alte lucrari
Other work
TOTAL / Total value
4.Tipul drumului
Type of road

autostrada / highway drum in zona rurala / country road drum municipal / municipal
road
Numar de benzi/cai de rulare feroviara
Number of lanes/tracks
Parte carosabila dubla/Dual carriageway Da/yes Nu/no
fara covor asfaltic /unsurfaced cu covor asfaltic /surfaced numai covor asfaltic /surfacing

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CITY INSURANCE

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Societate de asigurare reasigurare

Anex la polia seria E /Nr. , din //

only
5. Date tehnice
Technical data

Lungime / lengthm
Latime / width.m
Inclinare maxima/Max. gradient..%
5.1 Colectoare tubulare, pasaje subterane si pasaje superioare
Culverts, underpasses and overpasses
Numar/Number..............
prefabricate / precast turnate in santier / cast in site
din metal / steel
Deshidere maxima/Max. span.................m
In cazul constructiei de poduri, trebuie completat Chestionarul suplimentar corespunzator /
For bridges, complete additional questionnaire for the construction of bridges
5.2 Rambleuri/Fills
Lungimea totala/Total length.......................km
Inaltimea max. a unui singur rambleu...........m
Max. height of single fill
Inclinatia pantei/Inclination of slope................
Materialul folosit la umplere/Material to be filled in.................
5.3 Debleuri / Cuts
Lungimea totala/Total length.......................km
Adancimea max. a unui singur debleu...........m
Folositi explozibili/Blasing work?
Da/yes Nu/no
Se executa sfaramare mecanica/Rock crushing? Da/yes Nu/no
Materiale ce vor fi inlaturate/Materials to be removed

6. Graficul de executie
Construction schedule

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5.4 Suprastructura / Superstructure

Fundatie
Strat de legatura
Sub-base
Base course
Material/ Material
Grosime/Thicknes cm

Compactat/Compacte
d

Stabilizat/Stabilized
Traverse/Sleepers
cherestea/ timber
otel/steel
Nivelul apei freatice / Level of ground water min. .m
Tip lucrare
Component
Excavatii
Earthwork
Colectoare tubulare, pasaje subterane si pasaje superioare
Culverts, underpasses and overpasses
Fundatii
Foundations
Piloni
Piers and abutments
Strat de legatura/balast
Base course/ballast
Suprafata de uzura/cale de rulare
Wearing course/track system
Alte lucrari
Other work

CITY INSURANCE

Strat de uzura
Wearing course

beton/concrete
Datele de executie
Execution dates

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Societate de asigurare reasigurare

Anex la polia seria E /Nr. , din //

Lungimea max. a unui tronson in lucru la un moment dat..................................km
Max. length of road under construction any one time
7. Trebuie mentinut traficul in perioada constructiei drumului?
Must traffic be maintained during construction of the road?
8. Va fi deschis noul drum traficului inaintea turnarii stratului de uzura?
Will the new road be open to traffic before completion of wearing course?
9. Procentul in care lucrarea poate fi distrusa ca urmare a unui singur eveniment
To what extent might the contract work be destroyed in one loss event?
10. Specificati lucrarile care sunt executate de catre subcontractori (in cazul in care acestia
exista)
What work will be done by subcontractors?

Da/yes

Nu/no

Da/yes

Nu/no

11. Unde sunt amplasate birourile, depozitele, atelierele?

Unde sunt stocate echipamentele si materialele de constructii?
Where are the offices, stores, workshops, camps, etc. located?
Where are construction plant and equipment and construction materials stored?
12. Daca contractual prevede ca lucrarile sa fie predate pe sectiuni, in functie de finalizarea
acestora, va rugam sa mentionati numarul sectiunilor, perioada de executie a fiecareia si data
de finalizare.
If contract provides for completed sections to be handed over individually, please indicate
number of sections, their lengths and anticipated dates of handing over.
Afirmm c declaraiile fcute mai sus de ctre noi n acest Chestionar, sunt, dup cunotina noastr, complete i adevrare, fiind
de acord ca acest Chestionar s fac parte integrant din polia emis n legtur cu riscurile de mai sus. Este convenit c
Asigurtorul este rspunztor n concordan cu termenii poliei numai i dac Asiguratul nu va adresa nici un fel de cerere de orice
alt natur. Asigurtorul se angajeaz s trateze aceste informaii confidenial.
We 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 above 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 whatever nature. The Insurers undertake to deal with this information in strict confidence.

Completat la:
Executed at:

CCB-8E-7-25.08.2010-V1

Data:
Date:

CITY INSURANCE

Semnatura
Signature

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