公众责任保险风险问卷调查-公共场所.doc

公众责任保险Public Liability Insurance风险调查问卷Risk Evaluation Questionnaire本表适用于公共场所的场所公众责任险投保。This form shall be applied to on premise cover of Public Liability Insurance for public place.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企业性质Nature of Enterprise 国营state-owned 集体collective 私营private-owned 股份制shared 机关事业government 中外合资joint 外商独资，请告知外方的国籍：foreigner-owned, please advise nationality of the owner4保险地址Location under Cover(连锁店请附地址清单Please attach list if you are operating a chain firm) _5请在左栏选择被保险人所经营管理的场所的主要性质，然后选择或回答对应的右栏中的有关问题。 Please make choice on the left handside first, then, if applicable, choose Yes or No or answer the relevant question on the right handside. 大卖场/超市/百货商场shopping mall/supermarket/department store： 是否设有儿童游乐区Are pleasure ground for children included？ 是Yes 否No 是否有铺位或柜台向第三方出租 Are there any business areas leased to third parties？ 是Yes 否No 商务楼/公寓business office/apartment 公园/游乐场park/amusement centre 医院/诊所hospital/clinic 宾馆hotel：是否是星级宾馆，多少星级No. of Stars if you are qualified？_ 若上述场所含有以下服务内容，则也须选择和回答Please complete the rest part if you provide the services as described below: 饭店/餐厅restaurant/snack bar 旱地溜冰场skating rink：请告知何种地面 please advise what kind of ground :_ 舞厅、卡拉OK disco room, karaoke private： 是否供应酒精度超过15的饮料Do you provide beverage with alcohol level above 15 degree？ 是Yes 否No 酒吧pub 影剧院、放映厅cinema/theatre 游泳馆/池swimming pool ：换水频度frequency of changing water？_；值班救生员人数No. of life guard？_ 采用何种措施保证水质way to guarantee quality of water？_ 健身中心fitness club： 有无配备专业教练指导Instructed by professionals？ 是Yes 否No 器材定期保养维护regular maintenance on equipment？ 是Yes 否No 美容中心beauty parlor &/or hair dresser 沐浴中心bathe & sauna 网球场tennis court：是否禁止儿童进入场地Are child allowed in the premise？ 是Yes 否No 高尔夫球场golf court 游艺厅game room：请说明主要活动项目please specify major project_ 是否主要面向儿童开放mainly toward children？ 是Yes 否No 停车服务parking services：是机械化立体库Do you manage a mechanical hangar？ 是Yes 否No 综合娱乐总汇 night club 其他others：请具体说明please specify _6员工总人数No of Staff：_， 其中保安员人数No of security staff amidst：_， 汽车数量No. of vehicle：_7营业/活动场所面积business area in square meters：_m28过去12个月的营业收入turnover during the last 12 months：_， 开业日期date of opening：_9平均客流情况average number of visitors：_ （例如：月均客流量=门票月收入/门票平均单价 eg: average monthly number of visitors = monthly income from tickets/ average price of each ticket）管理Management1有无提供临时医疗救助服务Is first aid service included？ 若有，专业人员资质情况If so, what are qualifications of these professional staff_是Yes否No2有无提供按摩或美容服务Massage or hairdressing？ 若有，专业人员资质情况If so, what are qualifications of these professional staff _是Yes否No3有无食品小卖部等类似的服务Are there any cafeteria / canteen related services？ 若有，请问是被保险人自营还是向第三方转包 If Yes, is it managed by the Insured or by a third party？ 若为转包，被保险人是否与其签订事故免责的协议 If managed by third parties, has Insured signed a contract to immunize the responsibility of such a third party？是Yes自营 By Insured是Yes否No转包 By Third Party否No4有无提供餐饮服务Are meal facilities provided？ 若有，有无通过政府卫生部门的检查If Yes, is it authorized by the food health & hygiene regulatory department of government？ 若是，最近检查日期_If Yes, last inspection date_ 请问是被保险人自营还是向第三方转包 Are the facilities managed by the Insured or by a third party？ 若为转包，被保险人是否与其签订卫生事故免责的协议If managed by third parties, has the Insured signed a contract to immunize the responsibility of such a third party？ 若为自营，有无建立各连锁店统一的关于控制食品或食品原料进货渠道和更换过期食品的 专门制度If self managed, has the Insured established a systematic prescription for collective purchase of foods from standard suppliers and to keep all foods valid and safe？是Yes是Yes自营 By Insured是Yes是Yes否No否No转包 By Third Party否No否No5遇雨天门厅内是否配有地面除湿设备或有专人对地面除湿？Do you have floor dehumidifier or designate special serviceman to do this job?是Yes否No6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No724小时专人值班Is there a personnel on duty 24 hours？是Yes否No消防安全 Fire Prevention1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内部分隔和装潢材料是否大量使用阻燃材料 Did you substantially adopt fire resistance material for partition or decoration？是Yes否No3有无内部防火阻隔 Is there an internal segregation architecture for protection against fire in the building？是Yes否No4是否安装烟感报警装置Do you have smoke detectors and automatic fire alarm system？是Yes否No5若楼高超过5层，楼内有无封闭楼梯Do you have fire stair case when 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是Yes否No否No6是否安装喷淋系统或其他自动灭火装置 Do you have an automatic sprinkler system or other automatic fire extinguishing system in crucial areas？是Yes否No7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？ 关键地点有无贴有疏散程序和疏散通道指引图 Are guide maps showing emergent evacuation ways put on all the room-doors？是Yes是Yes是Yes是Yes否No否No否No否No8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No9工作人员是否经过消防知识和紧急疏散培训 Have the staff practice or been trained for fire extinguishing or emergent evacuations？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No建筑装潢 Building & Decoration1建筑物内部结构是否经过改建 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 inspection or been qualified by safety regulatory sector of government？是Yes是Yes否No否No2建筑物完工年份Year of completion of building structure_3楼梯和台阶是否采用防滑材料或经过防滑处理 Are the stairs and steps processed with anti-skip design？是Yes否No4门厅入口是否有玻璃转门Do you have revolving door at the entrance of lobby？是Yes否No5营业场所内是否有锐角的器具？比如废物箱、装饰台等 Are there any furniture with metal acute angle within the business premises, such as litter-bin?是Yes否No6有无落地玻璃弹簧门Do you have plated glass door？ 若有，玻璃门的包角是否有脱落或产生锐角If Yes, are there any detachment？ 玻璃门底部、包角和其他地方有无保护 Do the bottom, angle or other position of the door adopt protection design？是Yes是Yes是Yes否No否No否No7有无停车库/场Do you have garage or car parking lots？ 如有，请告知If yes，please advise： 地面on the ground 地下under the ground 层数No. of storage_；车位数No of unit _； 面积Square meters_；进出和出口数No. of inlets and outlets _ 24小时专人值班Is there a personnel on duty 24 hours？ 车道是否规定单向行驶Are signs directing vehicles sufficiently installed and marked？ 车道宽度Broadness of driving path _m是Yes是Yes是Yes否No否No否No8有无自动扶梯Do you have escalators in business premises？ 若有，则是否通过有关部门的检查 Have they been inspected by governmental regulatory department？ 楼层交角处有无警告标志或采用保护措施？ Are there any warning signs or protection devices at the corner of inter-floor ?是Yes是Yes是Yes否No否No否No9电梯是否经过年检Have the Lifts or elevators been inspected？ 若是，则最近年检的日期If Yes, please advise the latest date of inspection_是Yes否No周围环境 Surroundings1被保险人的营业场所是否与第三方位于同一建筑物内或与其他建筑物相连Is the insureds business premise located in same one building with other business or in the building attaching to other？ 若为不相连的独立建筑，则周围是否有相距10米以内的建筑物If No, please advise if there is any special exposure factors around the business location of Insured within the periphery of 20 meters radius？ 若有，则请告知下列内容If Yes, please provide the details as follows:是Yes否No是Yes否No东 面East西 面West北 面North南 面South名 称Name_使用性质Occupancy_距 离Distance_2被保险人的营业场所是否位于人流密集的商业中心区？ Is the insureds business premise located in central area of metropolitan with heavy traffic?是Yes否No既往保险史 / 过去索赔个案Previous Insurance / Previous Claims1 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：I