产品责任险投保单(涉外）.doc

产品责任险情况调查表及投保单Questionnaire and Proposal for Products Liability InsuranceNo.1.投保人名称/地址Name and Address of Applicant: 2.被保险人名称/地址Name and Address of the Insured: 3.被保险人营业性质Nature of Business of the Insured:制造商( ) 零售商( ) 批发商( ) 进口商( ) 出口商( )Manufacturer Retailer Wholesaler Importer Exporter如非以上所列, 请注明如下If not as above-mentioned, please state: 4. 附加被保险人Additional Insured(s): 全称Full Name所属国家Country成立日期Date of Establishment与被保险人关系 Relationship to Insured1经销商 其他 Distributor Other2经销商 其他 Distributor Other3经销商 其他 Distributor Other(如果有附加被保险人要求贵公司投保本产品责任保险，请附上其与贵公司的书面协议。If anyone require you to have this product liability insurance, please attach a copy of their agreement.)5. 投保产品信息（请提供关于列明产品的简介、使用手册、样品图片）INSURED PRODUCTS INFORMATION (Please attach brochures, instruction manuals, pictures of samples etc of all products listed)(1)生产的产品或分销的产品（非被保险人生产的产品）Products Manufactured / Products Distributed (not own manufacture)请列出过去及未来年度贵公司生产的产品在世界范围的年销售额。Please provide the expected/previous sales to worldwide.产品名称 期限 国内销售 出口美加 出口欧洲 出口其他Products Period Domestic Sales USA/Canada SalesEurope Sales Others Sales 20 20 20 20 20 20 （2）新产品New Products请提供被保险人在保险期内拟推向市场的新产品的详细情况。Please give details of new products of the insured to be introduced during the insurance period of the policy. （3）贴牌产品OEMs Products请列出贵公司用其他品牌/商标销售的产品或委托他方生产的产品占全部销售额的比例。Please give sale percentage of total product shipped under another label/brand or manufactured by others. 这些贴牌产品的制造是根据 贵公司的设计要求 或 他方的设计要求？Are such OEMs products made following your design specification or those of others?（4）贵公司的产品或服务是否被使用于航空器/飞弹或船只中？ 是 否Are any of your products/services known to be used in connection withaircraft/missiles/watercraft? Yes No贵公司的产品销售给 消费者 制造商 批发商?Are your products purchased by consumers manufacturers wholesalers?贵公司的产品预期寿命是多少年？ 5年What is the life expectancy of your products? 5years6. 质量控制（请附上贵公司的质量认证、产品检测报告）QUALITY CONTROL（Please attach copies of Quality Certificate, Lab or Testing Reports）（1）是否列名的每一被保险人都分别有质量控制体系？ 是 否Is there any quality control system applied for each insured listed? Yes No（2）贵公司的产品是否遵循法定或强制的标准？ 是 否Are your products subject to any mandatory or voluntary standards? Yes No 若是，请列出贵公司的产品达到哪个标准？ If so, Please advise which standards your products should comply with? （例如：TUV、ASTM、CSA、CE、UL、DOT等等）（Examples: TUV, ASTM, CSA, CE, UL, DOT, etc） （3）贵公司是否保存产品相关记录? 是 否Are record keeping procedures being kept on your products? Yes No 如有，保存几年？If yes, how many years are those records kept? （4）贵公司有产品召回计划吗? 是 否 Do you have any products recall program? Yes No如有，请附上。If so, please attach it.（5）贵公司产品是否有使用说明和警示标志？ 是 否Are instructions and warning labels attached to your products? Yes No（6）贵公司能否识别出投保产品 ？ 是 否 Can you identify the insured products? Yes No如是，请描述如何识别。If yes, please explain. （7）贵公司是否要求供货商提供保险证明？ 是 否 Do you require certificates of insurance from your suppliers? Yes No如是，请说明要求的最低限额。If so, please indicate minimum limit acceptable. （8）投保产品是否有包装? 有 无 Do the products insured have package Yes No如果有, 请列明为何种包装。If so, please give exact description of the package. （9）以往产品与现投保产品能否明显加以区分? 能 否Is there any distinct difference between old products and the products insured？ Yes No如果能, 请列明如何区分If so, please state the difference: 7.以往损失情况Past Loss Record: 有 无Yes No如果有, 请提供过去5年的详细损失记录： If yes, please provide total incurred losses last 5 years: （1）损失合计Total aggregate losses年份Year索赔次数No. of Claims已付赔款Indemnity Paid预估赔款Indemnity Reserved （2）损失金额超过10000美元的个案Individual Losses greater than $10,000:索赔日期Date of Claim出险产品Product Involved总赔款Total Indemnity未结案/已结案Open or closed事故原因Origin of Accident8.预计投保产品本年度销售额Please estimate total insured products sales current year: 9.承保区域Coverage Geographical Area: 10.责任限额Limit of Indemnity:（1）每次事故赔偿额: 人身伤亡: 财产损失For each and every accident Bodily Injury Property Damage （2）累计赔偿限额:Aggregate Limit of Indemnity: 11.免赔额Deductible: 12.保险期限Period of Insurance:自 年 月 日零时起，至 年 月 日二十四时止。From to 。 13.保险责任确定基础Coverage Basis:索赔提出式（追溯期: 自 年 月 日零时起，追溯至 年 月 日二十四时止。） Claim-Made (Retroactive Period: From to 。)事故发生式（报告期 年） Occurrence (Reporting Time years) 14. 需要特别扩展的责任? 有 无Other extension(s) Yes No如果有, 请列明:If so, please state 15.司法管辖权Jurisdiction: 中国司法管辖 世界司法管辖（美加地区除外） Chinese Worldwide (USA & Canada excluded) 16.其他需特别说明的情况:Other conditions which should be specifically stated 17.保险费支付日期Date of Premium Payment: 18.保险合同争议解决方式选择：The way of solution to disputes of contract of insurance 提交 仲裁委员会仲裁； 诉讼。 Refer to the arbitration commission to arbitrate! Lawsuit. 19.特别约定Especially Agreement: 本人(本公司)特此声明, 以上陈述就我们所了解并相信是真实和全面。同时, 我们同意, 本情况调查表及投保单是承保上述风险的保险单的基础和组成部分, 双方同意, 保险人仅按保险单条款规定予以赔偿, 被保险人不得提出任何其他性质的索赔, 保险人须对上述资料绝对保密。We hereby declare that the statements made by us in this Questionnaire Proposal are, to the best of our knowledge and belief, complete and true, and we hereby agree that this Questionnaire and Proposal 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 t