产品责任保险风险问询表及投保单

1、产品责任保险风险问询表及投保单 s Liability Insurance Questionnaire And Proposal 投保人声明 Statementof Applicant(s) 我/我们在此声明以下的陈述和详情是真实和准确的，我们并没有谎报或隐瞒任何实质性的 事实。我们同意把此风险问询表及投保单和我们提供的任何其他 资料作为由此而产生的任 何保险合同的基础。 I/We herebydeclarethat the statementsand particulars in what followsare true and correct that we have not missta

2、ted or suppressedany material facts. We agree that this Questionnaireand Proposal,togetherwith any information supplied by us, shall form the basisofany contractof insuranceaffectedthereon. 一、被保险人信息 请附单位简介和年度报告) INSURED S INFORMATION ( Pleaseattach company profile/annual report) 1.被保险人 Policy Holder

3、 全称 Full Name 成立日期 Date of Establishment 地址 Principal Address 业务性质 Busin ess 制造商口经销商 Manu facturerDistributor 贸易公司其他 Trading CompanyOther 2.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 Relati on ship to In sured 1 经销商其他 DistributorOther 2 经销商其他 Distributo

4、rOther 3 经销商其他 DistributorOther (如果有人要求 贵公司投保本 产品责任保险，请附上他们的书面请求。If anyone require you to have this product liability in sura nee, pleaseattach a copy of their agreeme nt.) 二、投保产品信息 请提供关于列名 产品的简介、使用手册、样 品图片) INSURED PRODUCTS INFORMATION (Please attach brochures, instruction manuals, pictures of samp

5、les 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。 Pleaseprovide the expected/previous salesto 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 20 Domestic Sales USA/Ca nada Sales Europe Sal

6、es Others Sales 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。 Pleasegive details of new products of the in sured to be in troduced duri ng the in sura nee period of the policy. 3. 贴牌产品 OEM s 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

7、 product shipped under another label/brand or manufactured by others. 这些贴牌产品的制造是根据公司的设计要求或他方的设计要求？ Are such OEM s products made followingyour 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？否 Are any of your products/services known to be usedin connection with aircraft/missiles

8、/watercraft?Yes No 贵公司的产品销售给消费者制造商发商？ Are your products purchased byconsumersmanufacturers 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?5years 三、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

9、 险人都分别有质量控制体系？ 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？ Are your products subject to any mandatory or voluntary standards? 若是，请列出贵公司的产品达到哪个标准？ Yes No If so, Please advise which standardsyour products should comply with? (例口:TUV、ASTM、CSA、CE、UL

10、、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？ Are record keeping procedures being kept onyour products? 如有，保存几年？ Yes No If yes, how many years are those records kept? 4. 贵公司有产品召回计划吗？ Do you have any products recall programme? 如有，请附上。 If so, please attach it. 5. 贵公司产品是否有使用 说

11、明和警示标志？ Are instructions and warning labels attached to your products? 6. 贵公司能否识别出投保产品？ Can you identify the insured products? 如是，请描述如何识别 If yes, pleaseexplain 7. 贵公司是否要求供货 Do you require certificates of in sura nee from your suppliers? 如是，请说明要求的最低限额 If so, pleaseindicate minimum limit acceptable Ye

12、s No YesNo 否 YesNo 否 Yes No 四、损失记录 LOSS EXPERIENCE 1. 贵公司产品是否曾被强令回收或停止使用？否 Have you ever experieneed a mandatory recall or discontinuationYesNo of any product? 2. 贵公司是否曾 经或正在考 虑自市场回收任何已知或可能有缺陷的产品是否 Have you ever recalled or are you considering recalling any known orYesNo suspecteddefective products

13、from the market? 3. 贵公司曾因你们的产品（无论是否被承保）造成身体伤害或财产否 损失而被索赔吗？ Has anyoneeven required for payment of damagesfor bodily injury orYesNo property damage caused by your products, whether insured or uninsured? 若是，请提供过去5年的详细损失记录： If yes, pleaseprovide total incurred losseslast5 years: A.损失合计 Total aggregatel

14、osses 年份 Year 索赔次数 No. of Claims 已付赔款 In dem nity Paid 预估赔款 Indemnity Reserved B.损失金额超过10000美元的个案 In dividual Losses greaterthan $10,000 索赔日期 Date of Claim 出1险产品 Product In volved 总赔款 Total In dem nity 未结案/已结案 Open or closed 事故原因 Origin of Accident 五、保险需求 INSURANCE REQUIRMENTS 1. 是否有保险公司曾经取消、限制或不予续

15、保贵公司的产品责任险? 是 Has a ny in surer ever ca ncelled, restricted or refused to accept/re newyour Yes No products liability in sura nee? 若是，什么时间，为什么？ If yes, when and why? 2. 目前，贵公司的产品责任险向谁投保？ With whom are you currently insured for products liability? 保单形式： 事故发生式(报告期年) Policy Form:Occurrenee (Reporting T

16、ime _ ears) 赔提出式(追溯日) Claim-Made (Retroactive Date ) 每次事故赔偿限额：累计赔偿限额： Limit of any oneaccident:Limit of aggregate: 保险费：司法管辖： Premium:Jurisdict ion: 免赔额: Deductible/Self Insured Retention: (如果方便请提供保单复印件) 3. (Pleasefeel free to attach a copy of your policy schedule) 新保/续保计划： New/Re newal In sura nee Programme: 保单形式：事故发生式(报告期 年) Policy Form:Occurrenee (Reporting time years) 赔提出式(追溯日) Claim-Made (Retroactive Date) 赔偿限额需求：每次事故赔偿限额 累计赔偿限额 Limit Required: Limit of anyone accidentLimit of aggregate 司法管辖需求：免赔额需求： Jurisdicti