Questionnaire for Products Liability Insurance
产品责任险 风险调查问卷
INSTRUCTIONS 填写说明 Plea ... 1. Print clearly or type 请清楚填写或打印本表 2. Answer all questions completely 请完整地回答本表的全部问题 3. If space is insufficient to answer any question fully, continue on a parate sheet of your firm’s letterhead indicating the number of the question. 如果空格不够您完整的回答某些问题，请您继续用贵公司的信纸另外填写，并标明问题的序号。 4. If the answer to any question is ”none” state ”NONE”. 如果某个问题的答案是“无”，请填“无”。 初中半命题作文5. Application must be signed and dated by owner, partner or officer. 此表必须由雇主、合伙人或有关负责人填写并注明日期。 | | IMPORTANT NOTICE 重要提示 It is your duty to disclo all material facts to Company. A material fact is one that is likely to influence an Underwriter’s judgement and acceptance of your proposal. If your proposal is a renewal, it should also include any change in facts previously advid to Underwriters. If you are in any doubt about facts considered material, disclo them. FAILURE TO DISCLOSE could prejudice your rights to recover in the event of a claim or allow Underwriters to void the Policy. 您有责任将所有重要的信息告知我们公司。重要的信息是影响承保者判断和接受您投保的一个可能的因素。如果您是续保，也应该告知一些原来承保者考虑过但改变的情况。如果您对一些重要的信息不能确定也告知我们。告知上的疏忽可能会导致如果发生索赔，您将损失获得赔偿的权利，或者让承保人注销保单。 |
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Section A - General Information 基本信息
1. NAME OF COMPANY: 公司名称
2. Principal Adress: 男士秋装搭配总公司地址
3. Does applicant have subsidiaries or divisions? YES NO
申请人是否还有其他附属机构?
If ”YES”, plea specify. 如果有，请详细说明
请在申请人及其附属公司的营业性质上打√
| Applicant 申请人 | Sub./Assoc. 附属机构 |
Manufacturer 制造商 | | |
Distributor 经销商 | | |
Importer 进口商 | | |
Other (plea specify) 其他（请详细说明） | | |
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5. How long has the Insured been in business? 被保险人从事该行业多久
Other detailed background information of the Insured, is there any website ？
被保人的详细背景资料，是否有网址可查阅？
6. Has any insurer ever cancelled or declined your products liability? YES NO
以往是否有保险公司取消或降低贵司的产品责任保险？
If ”YES”, plea explain. 如果有，请详细解释
7. Does the Insured in the USA/Canada have a Subsidiary Affiliate 吉祥物英文Reprentative Others
被保险人在美国或加拿大是否有 附属公司 分公司 联络处 其他
If yes, plea give name(s), address(es), telephone(s), fax(es) and operation:
若有，请列出名称、地址、电话、传真及经营性质
8. Areas to be covered: 承保区域
USA/Canada Europe Australia Asia ROW Plea Specify______________
美国/加拿大 欧洲 澳大利亚 亚洲 世界其他地区 （请详细说明）
9. Policy period desired: 希望保险期限
From 从________________________________to至_______________________________________
10. Limit of liability desired ________________________CSL(occurrence/aggregate)
保险责任限额 合并单一责任额(每一事故 / 保险期间累积金额)
11. Deductible per occurrence USA/Cda 每次事故免赔额（美国/sheep复数形式加拿大）_______________________
Deductible per occurrence excl. USA/Cda 每次事故免赔额（美国/加拿大除外）________________________
12. Policy Trigger desired？ 希望的保单承保方式？colombiana
□ Claims made basis 索赔发生制 □ Occurrence basis 尼古丁英文事故发生制
13. Do you require ”Vendors Liability”? 是否需要投保“销售商责任”？ YES NO
If ”YES”, plea provide the list of vendor(s) and address(es). ( If there is more than one vendor, plea indicate sales breakdown of each vendor: 如果需要，请提供销售商的名称及地址（如果多于一个销售商，请提供每个销售商的销售额:）
Vendor 销售商 | Address 地址 | Telephone 电话 | Fax 传真 | Product 产品名称 | Brand 品牌名称 | Sales 销售额 |
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Section B – Product and Sales Data 产品及销售数据
2. List any product for which cover is required and tick its current status, where:
请列出所有被保险产品并在其目前的状态上打√
(A) All products discontinued or recalled within the last five years (plea shortly explain for each).
近五年内已经停止销售或曾被召回过的产品 （请逐一加以简要说明）
(B) All products that have been introduced during the last three years.
过去三年内推出的产品
(C) All new products propod for introduction during the ensuing year.
来年将推出的新产品
Note: any additional product will be covered only from the date on which it is reported to the Company.
备注：所有新增产品仅在向保险人报备之日后方可被承保
angel girlProducts in Chine 产品中文名称 | Products in English 产品英文名称 | Marketing Area销售区域 Plea tick. 请打√ | Current Status目前状态 Plea tick请打√ |
Home Market 国内市场 | Europe/ Australia 欧洲/澳大利亚 | USA/
Canada 美替代品英文/加 | Asia Including Japan 亚洲包括日本 | Other 其他 | (A) | (B) | (C) |
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3. Plea give territorial split of your turnover by product lines for 请分区域给出被保险产品年销售额
改错题 a. Next year (est.) 下一年（预计）____________
(Currency) 货 币____________
Products in Chine 产品中文名称 | Products in English 产品英文名称 | Turnover 年销售额 | Home Market 国内市场 | Europe/ Australia 欧洲/澳大利亚 | USA/Canada 美国/加拿大 | Asia Including Japan 亚洲包括日本 |
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b. Current year 今年____________
