雇主责任险风险问卷调查表.doc

雇主责任保险Employers Liability Insurance风险调查问卷Risk Evaluation Questionnaire概 况General Information1投保人名称Name of Insured _2总部地址Address of Head Office in P.R.China _3工作地点Work-place(若包含多个附地址清单If more than one place are included, please attach list) _4企业性质Nature of Enterprise 国营state-owned 集体collective 私营private-owned 股份制shared 中外合资joint 外商独资，请告知外方的国籍：foreigner-owned, please advise nationality of the owner _5行业性质与经营范围Nature & Scope of Business 是否属于危险品生产Is your business to manufacture hazardous products？ 是Yes 否No 请详述：Please describe _6普通汽车数量Number of regular automobiles：_ 是否拥有特种工程车？Do you possess engineering vehicles for specialized operation 是Yes 否No 若有，请说明：If so, please specify 车辆类型type 数 量quantity _ _ _ _ _ _雇员情况condition of employee1员工人数No. of Employee: _ 其中，人事/人力资源部员工数Amidst above, No. of Employees in the personnel/human resource department: _ 女性员工占比Percentage of Female Employee： _% 30岁以下员工占比Percentage of Employee below 30： _% 3050岁员工占比Percentage of Employee between 30 and 50： _% 50岁以上员工占比Percentage of Employee over 50： _%2是否为本单位雇员缴纳四金？Do you pay to legal welfare funds for all of your employees 是Yes 否No 除本保险外，是否还为雇员购买其他商业保险？ Is there any other welfare commercial insurance policy purchased for your employee besides this insurance 是Yes 否No 请简单评述本单位的福利和收入水平在同行业中的所处地位： Please give comment in respect of your employees welfare and salary 领先superior 高于平均水平above average 一般水平average 低于平均水平below average3请按下表填写雇员的情况: Please fill in the following blank雇员工种Classification Of Work人 数Number of Employee平均年收入Average wage &other earningsyearly是否需出差Business tripFrequently?_行业风险防范Loss Control1是否设有安全生产管理部门Do you have special department dealing with the management of safety production？ 是否有安全检查制度并得到能切实的落实Are all inspection systems for the purpose of safety fully implemented and performed？是Yes是Yes否No否No2员工是否经过专业技术培训Have all of your staff been trained in professional technique courses？ 员工是否能遵守各项制度和纪律Could your staff oblige all the disciplines and system made by the management board？是Yes是Yes否No否No3生产过程中是否有特殊危险的作业Is there any dangerous operation involved in the course of production？ 若有，请说明危险的来源If Yes, please advise the source of such danger： _ 上述操作属于the operation is： 带电in electrification 高温in high temperature 爬高in high altitude 操作高速高压机械装置handling high-speed, high pressure mechanical machinery 其他，请说明others, please describe：_ 从事上述操作的工人数No. of labor engaged in the above-said job：_ 有无防护措施、应急抢救措施和安全制度Do you have sufficient protection measures, safety system, and first aid plan against the harm brought by such pollutants？是Yes是Yes否No否No4生产过程中是否会产生影响雇员身体健康的污染物Are there any hazardous or poisonous wastes which will possibly harm the health of employee produced in the course of production？ 若有，请说明污染物的性质及其可能对人体导致的危害后果If Yes, please advise the nature of such hazardous pollutants： _ 若无防护措施，将对人体导致的后果please describe the potential negative effects brought to the human body by such pollutants in case that no protection measures are implemented： _ 有无防护措施、应急抢救预案和安全制度Do you have sufficient protection measures, safety system, and first aid plan against the harm brought by such pollutants？是Yes是Yes否No否No5生产过程中是否有使用到危险品Do you handle hazardous material during the manufacturing？ 若有，请说明危险品的性质或名称If Yes, please advise the nature/name of these hazardous materials： _ 上述危险品属于the above-said dangerous products are： 易燃combustible 易爆explosive 有毒poisonous 辐射radioactive 有无防护措施、应急抢救预案和安全制度Do you have sufficient protection measures, safety system, and first aid plan against the harm brought by such hazardous materials？ 危险品是否放置在专门的仓库内并有专人保管Are these materials under custody of designated personnel all the time？ 危险品在厂区内运送是否有专门路线Do you prescribe special route for hazardous material transportation in plant？ 危险品集中放置处和仓库周围有无设立危险警示标志Do you set warning signs around the storehouse or the stack？ 有无应急措施Do you have any written emergency plans？是Yes是Yes是Yes是Yes是Yes是Yes否No否No否No否No否No否No6请描述贵公司操作工人的日常加班情况Please give detailed information about the overtime working of your labors： _7厂区内工作车辆行驶是否有专用道Are there special pathways for working vehicles in the plant area？是Yes否No服务与管理Service & Management1有无餐厅或员工食堂Are cafeteria services or meal facilities provided？ 若有，请回答以下问题If Yes, please answer following question： 就餐人数average No. of staff being serviced per day：_ 是否通过有关部门的卫生检查If Yes, is it authorized by the food health & hygiene regulatory department of government？ 若是，则最近一次检查日期是If Yes, the latest inspection date：_ 是否转包给第三方Are the facilities managed by the Insured or by a third party？ 若为转包，承包人的资质情况If managed by third parties, please give the information regarding the qualification of the contractor： _ 若为自营，采购渠道及如何进行食品来源质量管理If self-managed, please describe your measures in management of sources supply and quality supervision of the food？ _是Yes是Yes是Yes否No否No否No2有无员工宿舍Staff dormitory or residence？ 请对照以下“消防安全”和“建筑物状况及周围环境”两表对宿舍 楼状况作总体自我评价Self appraisal to the building as follows refer to the Section “Fire Prevention & Loss Control”& Section“Buildings & Surroundings”： 好Excellent 一般Medium 差Poor是Yes否No3有无医疗室？Do you have medical care facility 若有，医护人员数 If so, No. of such professional staff _ 专业人员资质情况 qualification of such professional staff _是Yes否No4员工上下班方式？To and from work place 自行by oneself 厂车by bus of Insured（车型type_，数量quantity_）5有无其他员工福利设施或项目Any other welfare facilities for staff？ 若有，请具体说明：If so, please specify_是Yes否No消防安全与风险控制 Fire Prevention & Loss Control1是否通过消防局年检Have you been inspected by the local Fire Prevention Department？ 若是，则请告知最近一次检查的时间If Yes, please advise the date of latest qualified inspection？_是Yes否No2有无内部防火阻隔Is there an internal segregation architecture for protection against fire in the building？是Yes否No3是否安装烟感报警装置Do you have smoke detectors and automatic fire alarm system？是Yes否No4楼高超过5层的建筑内有无封闭式紧急楼道Do you have fire stair case if no. of floor of your building is in excess of 5 levels？ 有无烟火道Are there smoke & fire byways in building？是Yes否No5是否在关键单元安装喷淋头或其他自动灭火装置？ Do you have an automatic sprinkler system or other automatic fire extinguishing system？是Yes否No6有无足够的太平门或疏散通道Are emergency exits or evacuating gateways located on all floors？ 通道内是否畅通Are gateways unblocked at all time？ 疏散通道标志是否明显Are gateway clearly marked and well lighted？是Yes是Yes是Yes否No否No否No7是否配备应急电源或应急照明Do you have emergency electric power supplier or illumination？是Yes否No8员工是否经过消防知识和紧急疏散培训或演练Have the staff practiced or been trained for fire extinguishing or emergent evacuations？是Yes否No9有无书面的紧急疏散预案Do you have an emergency evacuation plan in writing？是Yes否No10楼道内是否配置足够的灭火器Are there sufficient portable extinguishers provided in corridor？是Yes否No11是否配备中央监控室和监视器Are you equipped with monitors and have a control center？ 如有，监视器数量If Yes, No. of monitors？_是Yes否No建筑物状况及周围环境Buildings & Surroundings1建筑物内部结构是否经过翻修改建？ Has any alterations, additions or structural repairs been implemented to the building(s)? 若是，是否通过市建筑安全管理局的检查If Yes, have you past through or been qualified by safety regulatory sector of government after the completion？是Yes是Yes否No否No2建筑物完工年份Year of Completion：_ 建筑物设计使用年限Life span estimated or designed：_东 面East西 面West北 面North南 面South名 称Name_占用性质Occupancy_距 离Distance_3被保险人营业区周围20米以内是否有特别危险的因素威胁，请说明： Is there any special exposure factors around the business location of Insured within the periphery of 20 meters radius, please specify: _被保险人对未提及的风险的补充：Additional statement about exposure not mentioned_既往保险史 / 过去索赔个案Previous Insurance / Loss Experience1 投保人过去是否在其他保险公司购买过保险？ Have you previously been Insured with other Insurer(s)?若是，请说明具体情况：If so, please specify:是Yes否No保险公司名称Name of Insurer保单期限Policy Period赔偿限额Limit of Indemnity2 过去五年中是否有索赔记录？Has anyone requested for payment for bodily injury or property damage by your products during the past five years? 若是，请告之具体情况：If Yes, pl