Mosaic
Mosaic Insurance Group JSC
"Aviapark" Business Center · 14 Elbek Str. · Tashkent · 100060 · Uzbekistan
PROPOSAL · v1.0
Language: English Русский O'zbekcha
UNIFIED COMMERCIAL INSURANCE PROPOSAL

One form.
Every line of cover.

Complete the General Information once, then add only the specific sections for the cover you need. Download an interactive fillable PDF, sign, stamp, and submit.

STEP 1 · SELECT COVERS

Tick one or more products. Only ticked sections will appear in the form and PDF.

Property form type:
Recommended for small-to-medium risks; switch off for a full technical questionnaire suitable for large industrial sites.
Optional section:
Tick this only if the cover requires governance/audit disclosure (e.g. D&O, Crime, Cyber, or large risks where insurers ask for it). Hidden by default to keep the form short.
SECTION A

General Information

Common to all covers — complete once.

A.1  Proposer Details

1. Name of Proposer (Company)
2. Date of Incorporation
3. Web site
4. Registered Address
5. Nature of Business / Operations
6. Number of Years in Operation
7. Annual Turnover (USD)
8. Total Number of Employees
9. Total Annual Payroll (USD)
10. Contact Person · Title
11. Telephone
12. E-mail
13. Period of Insurance — From
14. Period of Insurance — To
15. Geographical Coverage Zone

A.2  Regions of Operation & Revenue Split

Includes all subsidiaries and associated companies in which the Proposer retains management control.

Region
Annual Turnover (USD)
Locations
Employees
% of Revenue
Domestic (Uzbekistan)
CIS
European Union
United States & Canada
Rest of World
M&A.Has any merger, acquisition or restructuring in the past 5 years resulted in an employee count change of ±15%?

A.3  Beneficiary / Loss Payee

Complete if different from the Proposer.

1. Name of Beneficiary
2. Relationship to Proposer
3. Address
4. Passport / Registration No.
5. Date of Issue / Issuing Authority

A.4  Previous Insurance

1. Name of Previous Insurer
2. Policy Number & Expiry Date
3.Has any insurer ever declined, cancelled, refused to renew, or imposed special terms on the Proposer?

A.5  Consolidated Loss History — Past 5 Years

All losses (paid, outstanding or notified) across all lines, whether insured or not.

Year
Line of Cover
Gross Amount (USD)
Description / Cause
Paid / Outstanding
Corrective measures taken to prevent similar losses

A.6  Audit & Corporate Governance

1.Do External Auditors audit all operations at least annually?
2.Date of last audit of cash, accounts & inventory:
3.Have all recommendations by External Auditors regarding internal controls been complied with?
4.Is the audit report rendered directly to the Board (or through Audit Committee)?
5.Is the Company in full compliance with the Corporate Governance Code regulating its business?
6.Does the Company have an Internal Audit Department?
7.Does the Company maintain a written manual of operational and systems procedures?
8.Are monthly management reports examined for variances against budget forecasts, and such variances investigated?
9.Does the Company maintain a written anti-fraud policy and Code of Ethics distributed throughout the organisation?
10.Does the Company have a whistle-blowing service accessible to all staff?
SECTION B

Commercial Automobile

Specific to motor risk.

B.1  Fleet Information

1. Total number of vehicles to be insured
2. Average annual mileage per vehicle (km)
3. Composition of fleet by vehicle type
Vehicle Type
Number of Units
Total Sum Insured (USD)
Passenger Cars
Buses / Minibuses
Trucks / Cargo Vehicles
Special / Construction Vehicles
Trailers / Semi-trailers
Other (specify)
4.Are all vehicles registered in the name of the Proposer?
5.Purpose of use of the vehicles:
6.Are vehicles garaged overnight?

B.2  Schedule of Vehicles

Up to 5 vehicles below. For larger fleets, attach a separate schedule.

#
Make & Model
Year
Reg. No.
VIN / Chassis
Insured Value (USD)
Sum Insured (USD)
1
2
3
4
5

B.3  Coverages Requested

A. Own Damage — Sum Insured (USD)
A. Own Damage — Deductible (USD)
B. Motor TPL — Combined Limit (USD)
B. Motor TPL — Bodily Injury Sub-limit (USD)
B. Motor TPL — Property Damage Sub-limit (USD)
C. Personal Accident — Aggregate (USD)
C. Personal Accident — Per-person Limit (USD)
D. Transport Expenses / Replacement Vehicle (USD)
E. Additional Covers Required

B.4  Drivers

Number of authorised drivers
1.Are all drivers holders of valid driving licences appropriate to the vehicle category?
2.Has any driver had a licence suspended, revoked or refused, or any motoring convictions in the past 5 years?

B.5  Cargo & Hazardous Goods

1.Are any hazardous, flammable, explosive, radioactive or otherwise dangerous goods carried?
2.Are passengers carried for hire or reward?
SECTION C

Property

Buildings, contents, machinery, stock, business interruption.

Mode: Full questionnaire · toggle above to switch.

C.1  Risk Location & Activity

1. Address of the property to be insured
2. Actual occupancy / activity at the location
3. Number of separate buildings
4. Total area of the building(s) (m²)
5. Area occupied by the Applicant (m²)
6. Age of building / date of last capital repair

C.2  Construction Details

External walls (monolithic / reinforced concrete / brick / masonry / wooden / sandwich panels)
Roof framing (columns / load-bearing material)
Roof material (RC plates, metal, wood, thatch, etc.)
Floors / inter-floor structure (beams, frame, girders + material)
Foundation type
Number of floors / storeys
Insulation type in sandwich panels (if any)
Basement / underground parking levels

C.3  Valuation Method

C.4  Sums Insured (USD)

Asset Category
Sum Insured (USD)
Buildings
Other structures
Renovations & fit-out
Machinery & equipment
Electronic & computer equipment
Furniture & office equipment
Stock / inventory / raw materials
Work in progress / finished goods
Cash in safebox
Other (specify in field below)
Other — description
TOTAL SUM INSURED (USD)
Deductible requested (USD)

C.5  Requested Coverages (Perils)

Other perils / sub-limits requested

C.6  Fire Protection & Security

1.Sprinkler system installed?
2.Fire extinguishers — type and total number:
3.Fire alarm system installed?
4.Burglary alarm?
5.Security service / guarding?
6.Nearest fire brigade — type & response time:

C.7  Surroundings & Other Tenants

Surrounding properties (buildings, factories, water bodies, power stations, railways, airports, etc.)
Activity of other tenants in the building

C.8  Hazardous Substances & Utilities

Flammable / hazardous substances stored on site (type and quantity)
Heating system
Energy supply / voltage / transformers
Number of elevators
Description of earthquake resistance

C.9  Business Interruption (if BI cover requested)

Annual net income (USD)
Fixed expenses (USD/year)
Additional / extra expenses (USD)
Indemnity period requested (months)

C.10  Goods in Transit (if GIT cover requested)

Approximate annual shipping volume (USD)
Maximum value per shipment (USD)
Routes / destinations
Packing & mode of transport
SECTION D

General Liability

Public & products liability — premises, operations, contractors, third-party BI & PD.

D.1  Operations Description

1. Materials used in operations
2. Production methods (short description)
3. Safety measures in place
4. In-house emergency / evacuation plan
5. Surrounding third-party property (distances on all four sides + nature)

D.2  Contractors & Subcontractors

List of contractors / subcontractors engaged
Purpose of engagement
Total contract value (USD)
Property on Insured's site belonging to contractors (description + value)
3.Do contractors carry their own liability insurance to required limits?

D.3  Limits Requested (USD)

Combined Single Limit per occurrence
Aggregate Annual Limit
Bodily Injury sub-limit per person
Bodily Injury sub-limit per event
Property Damage sub-limit
Products / Completed Operations sub-limit
Deductible per occurrence (USD)

D.4  Exposure Indicators

1.Are products sold or exported to US/Canada?
2.Does the company manufacture, sell or distribute products to be used in or near aircraft, automotive, pharmaceuticals, or weapons?
3.Hold-Harmless / indemnification agreements signed in favour of others?
SECTION E

Contractors' All Risks

Construction works — material damage & third-party liability during the contract period.

E.1  Project Description

1. Title of contract (and section(s) to be insured, if applicable)
2. Site address — country / province / city / town
3. Name and address of Principal (Employer)
4. Name(s) and address(es) of Contractor(s)
5. Name(s) and address(es) of Subcontractor(s)
6. Consulting engineer
7. Description of contract works (technical detail — dimensions, structure type)

E.2  Period & Construction Method

Commencement of work
Construction duration (months)
Date of completion
Maintenance period (months)
Foundation type & deepest excavation level
Construction method
Construction materials
Work to be done by subcontractors
Q.Is the contractor experienced in this type of work / method?

E.3  Site Conditions & Special Risks

Ground water level below grade (m)
Nearest river/lake/sea — name & distance
Rainy season — from / to
Max rainfall (mm/hour or mm/day)
1.Have earthquakes been observed in this area?
2.Is the design based on regulations for earthquake-resistant structures?
3.Special risks at the site:

E.4  Sums Insured (Section I — Material Damage)

Item
Sum Insured (USD)
1. Contract works (contract price)
1.1. Materials/items supplied by Principal
2. Construction plant & equipment
3. Construction machinery
4. Clearance of debris
Total Section I

Section II — Third-Party Liability

Bodily Injury — any one person
Bodily Injury — total
Property Damage limit
Earthquake / Volcanism / Tsunami sub-limit
Storm / Flood / Landslide sub-limit
SECTION F

Directors & Officers Liability

Personal liability of directors, officers and senior management for wrongful acts in their managerial capacity.

F.1  Corporate Structure

1. Country of registration
2. How long continuously in business (years)?
3. Business activities of the Company and its subsidiaries
4.In the last 5 years, has any of the following occurred?
(a) Parent company name change
(b) Acquisition or merger
(c) Subsidiary sold or ceased trading
(d) Capital structure changed
5.Any acquisition, tender offer or merger pending or under consideration?
6.Is the Company aware of any proposal for its acquisition by another company?
7.Does the Company intend a new public offering of securities (Uzbekistan or abroad) in the next 12 months?

F.2  Ownership & Listing

Tick all that apply.

Total shareholders
Total shares issued
Shares held by D&O
Holdings ≥15% — name the holders and the percentage held by each

F.3  Key Financials (latest audited)

Item (USD)
Last FY
Prior FY
Projected
Total assets
Total equity
Revenue / Turnover
Net profit / (loss)

F.4  Claims History & Limits Requested

1.Is any D&O Liability Insurance currently in force?
2.Has any claim ever been made against any director, officer or the company under a D&O policy?
3.Is the Company aware of any fact or circumstance which may give rise to a claim?
Aggregate Limit requested (USD)
Retention / Deductible (USD)
SECTION G

Professional Indemnity

Liability arising from professional advice, design, or services provided to clients.

G.1  Firm Details & Principals

1.Is the firm a member of a Professional Association?
2.Subsidiaries / associated companies requiring cover?
3.In the past 3 years, name change or M&A activity?
Partners / Principals / Directors of the Proposer
Name
Qualifications
Date Qualified
Years as Principal
Total Partners / Principals / Directors
Qualified staff
Clerical / Admin staff

G.2  Professional Activities & Revenue

Clear description of the firm's business activities (last 2 years)
Estimated split of gross fees / revenue by geography
Region
Past FY
Current
Projected
Domestic (Uzbekistan)
European Union
Central / Eastern Europe (non-EU)
US / Canada
Other
TOTAL Gross Fees
1.Is 40% or more of gross fees / revenue generated from a single client?
2.If US/Canada business — describe services provided and major contracts:

G.3  Internal Risk Management

1.Quality Assurance / Risk Management procedures always followed?
2.Are satisfactory employee references obtained:
3.Standard written contracts used with all customers?
4.All contracts contain an exclusion for indirect / consequential / economic loss?
5.Does the firm use sub-contractors?
(a) Always use written sub-contracts
(b) Sub-contractors required to maintain their own PI?

G.4  Claims & Current Cover

1.Is PI insurance currently purchased?
Limit (USD)
Retention (USD)
Premium (USD)
Expiry & Retroactive dates
2.Has PI cover ever been declined, cancelled or non-renewed?
3.Any claim made (or pending) for actual / alleged breach of professional duty?
4.Aware of any circumstances which may give rise to a future claim?
5.Any disciplinary action, fine, penalty, or inquiry against firm or principals?
Limit of Liability Requested (USD)
Retention Requested (USD)
SECTION H

Fidelity & Crime

Employee dishonesty, funds-transfer fraud, computer crime, third-party crime.

C.1  Internal Financial Controls

1.Are wages / salaries independently checked against personnel records for unusual or excessive payments?
2.Are duties segregated within the finance function so no individual can control any of the following from start to finish:
(a) Signing cheques / authorising payments above USD 2,000
(b) Issuing funds-transfer instructions
(c) Opening new bank accounts / amending signatory details
(d) Refund of monies above USD 5,000
(e) Appointing new suppliers / awarding contracts
3.Is all supporting documentation validated before signing cheques / authorising payments above USD 2,000?
4.Are bank statements independently reconciled at least every 30 days by persons not authorised to deposit / withdraw funds?

C.2  Recruitment Procedures

1.When recruiting or promoting employees, do you obtain written references covering at least 3 years of previous employment?
2.Are independent checks into criminal record and financial history undertaken?
3.Are mid-employment background checks performed when staff are promoted to managerial or sensitive positions?
Number of employees in each function (with money/securities access where relevant)
Function
Headcount
Executive Management
Management
Accounts / Finance — with access to money / securities
Accounts / Finance — without access
Purchasing & Sales
IT — Analysts / Programmers / Operators
Stock & Warehousing
Security Personnel
Other

C.3  Stock & Physical Security

1.Is there controlled access to all locations?
2.Are all premises containing money, securities or stock connected to an intruder alarm linked to a central / police station?
3.Is the transfer of money / securities above USD 10,000 made by a professional cash-carrying company?
Max value of money / securities at one location — during business hours (USD)
Max value of money / securities at one location — outside business hours (USD)

C.4  Funds Transfer

"Funds Transfer" means any instructions (other than cheques) given to pay or deliver funds.

Monthly average INTERNAL transfers (USD)
Monthly average EXTERNAL transfers (USD)
1.Are all funds-transfer instructions subject to a verification and authentication process?
2.Can payment instructions only be made to pre-approved beneficiaries?
3.Do you have transfer limits per transaction?

C.5  Third Parties / Vendors

1.Does the Company maintain a documented approved-vendor list with background checks (financials, ownership, address, tax ID)?
2.Does the Company use a purchase-order / payment-requisition system requiring dual signatures?
3.Are employee records cross-referenced against vendor data to detect unusual matches?
SECTION I

Cyber Shield

Data breach response, cyber extortion, network interruption, media liability.

D.1  Desired Coverage

Aggregate Limit Requested (USD)
Deductible Requested (USD)

D.2  Data Protection Procedures

a.Is there a written data-protection and privacy policy applicable to the Company?
b.Are all employees provided with a copy / updates of the policy and required to confirm compliance?
c.When was the data-protection policy last reviewed, and by whom?
d.Does the policy comply with all applicable data-protection legislation in jurisdictions of operation?
e.Does the Company employ a Chief Compliance Officer / Data Protection Officer / In-house Counsel responsible for DP matters?

D.3  Data Access & Recovery

a.Are firewalls used to prevent unauthorised access from external networks?
b.Are anti-virus / anti-malware protections deployed on all desktops, e-mail systems and mission-critical servers?
Update frequency:
c.Procedures in place to identify and detect network security weaknesses (penetration testing, vulnerability scans)?
d.Does the Company monitor its network and computer systems for breaches of data security (SIEM, IDS)?
e.Are there physical security controls protecting computer systems and data centres?
f.Does the Company collect, store, maintain or distribute sensitive data?
If Credit Card data — PCI-DSS compliant?
g.Does the Company process payments / eCommerce transactions on behalf of others?
h.Are there encryption requirements for data in transit and data at rest (incl. laptops, USB, backup media)?
i.Are backup & recovery procedures maintained for all mission-critical systems and data assets?
Backups encrypted?
j.Are background checks performed on all employees and independent consultants?
k.Are remote users authenticated (MFA) before being allowed to connect to internal networks?

D.4  Outsourcing Activities

a.Does the Company outsource any network, computer-system or information-security function?
b.Does the Company outsource any data collection / data processing?
c.Are outsourcers required to maintain their own data-protection liability insurance?
d.Is indemnification required from outsourcers for any attributable liability?
e.Are outsourcers required to comply with the terms of the Company's data-protection policy?

D.5  Cyber Claims Information

a.Has the Company been the subject of any investigation or audit by a Data Protection Authority or regulator?
b.Has the Company ever been subject to a Data Subject Access Request?
c.Has the Company ever been subject to an Enforcement Notice by a DPA or other regulator?
d.Is the Company aware of any actual or alleged fact or circumstance which may give rise to a claim under this policy?
SECTION J

Declaration & Signature

I/We declare that the statements and particulars contained in this proposal are true and complete to the best of my/our knowledge and belief, and that no material facts have been mis-stated or suppressed. I/We agree that this proposal, together with any other information supplied, shall form the basis of and be an integral part of any contract of insurance issued. I/We undertake to inform the Insurer of any material alteration to those facts occurring before the completion of the contract of insurance.

Signing this proposal does not bind the Proposer to complete this insurance, nor does it oblige the Insurer to accept this proposal. The Insurer will issue the policy only upon the Proposer's acknowledgement of the terms and conditions of the quotation.

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Title / Position
Place
Date
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