1.投保人名称及地址
Name and Address of Propor
2.被保险人名称及地址
Name and Address of the Insured
3.被保险人电话及邮编
Telephone No. and Post Code of the Insured
4.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
5.保险产品的情况
Description of Insured Products
名称种类性质直接及间接用途销售额销售范围Description Type Nature Direct & Indirect U Sales V olume Sales Area
合计
Total
6.投保人工厂，商店或仓库的所在地
Location of Insured’s factory, shop or warehou
7.有无其他分支机构
Is there any other subsidiary
有（）无（）
Yes No
如果有，请列明地址和销售额
If so, plea state the address and sales volume
8.投保产品的平均使用寿命
The average life expectancy of the products insured
9.投保产品的销售历史
Sales record
a) 美国/加拿大的产品U.S.A. / Canada Products
请告知过去五年及预估未来年度，贵公司外销美加地区的各项产品销售额
List all products manufactured, sold or distributed by Applicant in or exported to U.S.A./Canada and
sales by product for the last 5 years as well as estimated sales for the upcoming year (attach product brochures or other printed material describing products).
b) 其余地区的产品Rest of the World Sales of Products
请告知过去五年及预估未来年度，外销其余地区（不包括美国/加拿大）的各项产品销
售额
List all products manufactured, sold or distributed by Applicant in or exported to Rest of the World (excluding U.S.A./Canada/) and sales by product for the last 5 years as well as estimated圣诞节的来历
sales for the upcoming year (attach product brochures or other printed material describing products).
Do the products insured have package
有（）无（）
Yes No
如果有，请列明为何种包装
If so, plea give exact description of the package
11.以往产品与现投保产品能否明显加以区分
Is it possible to distinguish the products insured from the old products
能（）否（）
Yes No
如果能，请列明如何区分
If so, plea state the difference
12.投保人的产品或部件是否由其他人生产或提供
Do others manufacture or supply any of Propor’s products, or any part of Propor’s products
是（）否（）
Yes No
如果是，请列明
If so, plea provide details
13.a) 投保人的产品有没有被作为其他产品的零部件销售？
Are any products sold as components for other products?
有（）无（）
Yes No
如果是，请列明终端产品和用途
If so, plea indicate end product and likely u
b)投保人的产品有没有被作为飞机，导弹，航天器或水面船只产品的零部件销售
Are any products sold as components for or u on or with any aircraft, missiles, spacecraft or watercraft 有（）无（）
Yes No
如果是，请提供详细情况
If so, plea provide details
14.投保产品是否有使用说明
Are instruction manuals included with the products insured
有（）无（）
Yes No
如果有，是否由除中文以外至少一种以上的语言书写
If so, are the instruction manuals written in at least one foreign language, not including Chine
15.投保产品是否有明显的警示标志
Are the products insured provided with remarkable warning labels
是（）否（）
Yes No
16.投保产品是否符合销售国家/地区质量标准
Do the products insured comply with the quality standards of the sales country/region
是（）否（）
Yes No
如果是，请列明通过的质量认证
If so, plea state the certificates whi甜柿子
ch have bee医疗补充保险
n obtained
17.投保人是否与经销商（们）订立损害免责协议或类似契约协议
Does Applicant enter into any hold harmless or other similar contractual agreement with any vendor(s) 是（）否（）
Yes No
如果是，请详细说明
If so, plea provide details
18.投保人是否建立了产品召回制度
Has the applicant established the Product Recall plan?
是（）否（）
Yes No
过去5年内是否曾经有产品被召回
Are any products recalled by the Applicant in the past 5 years
19.以往损失情况
Past Loss Record
有（）无（）
Yes No
如果有，请列明
If so, plea state
发生的时间原因受损标的损失金额
Date Cau Item damaged or lost Amount
20.责任限额
Limit of Indem新春致辞
nity
每次事故赔偿限额：
Limit of Indemnity A.O.A
每次事故人身伤亡赔偿限额：
Limit of Indemnity for Bodily Injury A.O.A.
其中每人每次赔偿限额
Limit of Indemnity per person A.O.A.
每次事故财产损失赔偿限额：
Limit of Indemnity for Property Damage A.O.A.
累计赔偿限额：
Aggregate Limit during the Period of Insurance
每次事故免赔额
Deduct风景素描画
ible A.O.A
21.保险期限
Period of Insurance
22.追溯期
Retroactive period
23.承保区域
Coverage Geographical Limit
24.列明要求的特别条款
Give details of any special extension of cover required 25.费率
Premium Rate
26.主险保费
Premium
27.总保险费
Total Premium
28.司法管辖
Jurisdiction
29.付费日期
Date of Payment
30.特别约定、备注
Remarks
投保人声明：本投保单所填各项内容均属实，同意以本投保单作为保险公司签发保险单的依据及保险单的组成部分。投保人确认中意财产保险有限公司已就其产品责任保险条款及特别条款（包括责任免除）的内容向投保人作了明确说明，投保人对保险合同的条款及保险条件已完全了解。保险合同自保险单签发之日成立。
Declarations: I/We (the Propor) do hereby declare that the above statements made by us are to the best of our knowledge, complete and true梦见生双胞胎
, and I/We agree that the Proposal Form shall be treated as proof of issuing the Policy and constitute an integral pa如开头的四字成语
rt of the Policy. I/We confirm that the Products Liability Insurance claus and Special Provisions (including Exclusion claus) ud by Generali China Insurance Co., Ltd. have been explained expressly. I/We have fully understood the contents of all the terms, conditions and claus of this Insurance. This Insurance Contract will go into effect on the date of issuing the Policy.
投保人签章日期
Signature of Propor Date
中国北京市朝阳区建国门外大街乙12号双子座大厦西塔9层邮编：100022 电话：86-10-59601818
9th Floor, West Tower, Twin Towers,B-12 Jianguomenwai Avenue, Chaoyang District, Beijing 100022 China Tel：86-10-59601818
