雇主责任险风险问卷调查表

1、雇主责任保险 风险调查问卷employer liability insurancerisk evaluation questionnaire概 况 general information1投保人名称name of insured2. 总部地址 address of head office in p.r.china3. 工作地点work-place（若包含多个附地址清单 if more than one place arc included, please attach list）4, 企业性质 nature of enterprise国营 state-owned 集体 collective 私

2、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 owner5. 行业性质与经营范围naiure & 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 describe6. 普通气车数量 number of regular automobiles: 是否拥有特种工程车？ do you pos

3、sess 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/liuman resource department:女性员工占比 percentage of female employee:%30 岁以下员工占比

4、 percentage of employee below 30:%30-50 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 purchase

5、d 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 employee 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 average 3 请按下表填写雇员的情况：please fill in the following blank雇员工种人数平均年收入是否需出差classificationnumber ofaverage

6、 wage &business tripof workemployeeother earnings yearlyfrequently?行业风险防范loss controli 是否设有安全生产管理部门 do you have special department dealing with the management of safely production?是否有安全检查制度并得到能切实的落实arc all inspection systems for the purpose of safety fully implemented and performed?2.员工是否经过专业技术培

7、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?3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，请说明危捡的来源 if yes, please advise lhe sour

8、ce 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: 有无防护扌昔施.应急抢救措施和安全制度do you have sufficient pr

9、otection measures, safety system, and first aid plan against the harm brought by such pollutants?4. £产过程中是否会p生影响雇员身体健康的污染物arc 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 ad

10、vise the nature of such hazardous pollutants:是 yes是 yes是 yes是 yes是 yes是 yes是 yes否no 否no否no 否no否no否no否no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 suffic

11、ient protection measures, safety system, and first aid plan against the harm brought by such pollutants?5. 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 naturc/namc of these hazardous materials:上述危险品属于 the above-said dangerous pro

12、ducts 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?危险品是否放置在事门的仓库内并有专人保管are these materials under custody of designated personnel all the

13、 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?有无应急扌吿施 do you have any written emergency plans?6. 请描述贵公司操作工人的日常加班情况please give detailed information about the overti

14、me working of your labors:7. 厂区内工作车辆行驶是否有专用道 arc there special pathways for working vehicles in the plant area?是 yes是 yes是 yes是 yes是 yes是 yes是 yes是 yes否no否no否no 否no 否no 否no 否no否no服务与管理 service & management1 有无餐厅或员工食堂 are cafeteria sen ices or meal facilities provided?若有、请回答以下问题 if yes, please an

15、swer 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 par

16、ly?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:是 yes是 yes是 yes否no否no否no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?2.有无员工宿舍 staff dorm

17、itory 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”& sectionbuildings & surroundings: 好 excellent 一般 medium 差 poor3有无医疗室？ do you have medical care facility 若有，医护人员数 if so, no. of su

18、ch professional staff专业人员资质情况 qualification of such professional staff是 yes是 yes否no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? 若冇，请具体说明：if so. please specify是 yes否no)消防安全与风险控制fire prevention & los

19、s control是 yes否no是 yes否no是 yes否no是 yes否no是 yes否no是 yes是 yes是 yes否no 否no 否no是 yes否no是 yes否no是 yes否no是ws否no是 yes否no1.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? 2 有无内部防火阻隔 is there an interna

20、l segregation architecture for protection against fire in the building?3是否安装烟感报警装置 do you have smoke detectors and automatic fire alann system?4. 楼髙超过5层的建筑内有无封闭式紧急楼道do you have fire staircase if no. of floor of your building is in excess of 5 levels?有无烟火道 arc there smoke & fire byways in buildin

21、g?5. 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?6. 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 arc gateways unblocked at all time?疏散通道标志是否明显 arc gateway clearly marked and well lighted?7.是否配备

22、应急电源或应急照明 do you have emergency electric power supplier or illumination?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?有无书面的紧急疏散预案 do you have an emergency evacuation plan in writing?10.楼道内是否配置足够的灭火器 are there sufficient portable extinguis

23、hers provided in corridor?11是否配备中央监控室和监视器 arc you equipped with monitors and have a control center? 如有，监视器数量 if yes, no. of monitors? 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 stmctural repairs been implemented to the building(s)?若是，是否通.过市建筑安全管理局的检查i

24、f yes, have you past through or been qualified by safety regulatory sector of government after the completion?2. 建筑物完工年份year of completion:建筑物设计使用年限 life span estimated or designed: 东而east西 而west是 yes 是 yes北north否no 否no南 而south名称name占用性质occupancy距离distance3. 被保险人营业区周围2()米以内是否有特别危险的因素威胁，请说明：is there

25、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