保单大型企业综合风险调查表-上海星达保险经纪有限公司

上海星达保险经纪有限公司

UNISTAR INSURANCE BROKERAGE&

CONSULTING(SH)LTD.

P age 1

INSURANCE QUESTIONNAIRE

Thisform has beencompleted by填表人__________________________________

Position职务____________________________________

Company公司___________________________________

Telephone No.电话_______________________________

Currency:Values shown in this Questionnaire shal l be in RMB.

币种:本问卷中所填金额的币种为人民币。

Declaration声明

We hereby declare that the information provided in this questionnaire is true andcomplete to the best of our knowledge.We agree that this questionnaire shal l be thebasis of the i nsurance contract between us and the insurer.

我们在此声明本问卷中提供的信息系我们所知的真实、完整的情况。我们同意本问卷成为保险人与我们之间达成保险合同的基础。

Date日期__________________________Signature签名_____________________

Please return this form completed TO:

请填写该调查问卷并发至

Account Manager&Email Address

Insurance Broker:UNISTAR Insurance Brokerage&Consulting(Shanghai)Ltd.

上海星达保险经纪有限公司

Address of Broker:上海浦东新区东方路989号中达广场1002A室

TELEPHONENO :021-68762600*666

FACSIMILE NO :021-68767730

P age 2

IMPORTANT NOTICE CONCERNING DISCLOSURE告知义务

It is your duty to disclose al l material facts to underwriters.A material fact is onewhich mayinfluence an underwriter's judgement in his consideration of your risk asto whether to provide insurance and on what terms. It is l ikely thatany change infacts previously advised wi l l be material and such changes should therefore benotifi ed.

您有责任将所有重要事实告知保险公司。所谓重要事实是指任何足以影响保险公司作出是否承保风险以及以何种条件承保风险的信息。如已告知的重要事实发生变化您仍需要将该变化通知保险公司。

This duty places a responsibi l ityon you to disclose al l material facts. The questionsinthis questionnaire provide a helpful way of enquiry,but should not be taken asl imiting the duty of disclosure. If you are in anydoubt as to whethera fact is materialyoushould disclose it.

这一义务赋于您告知所有重要事实的责任。该调查问卷只是帮助询问重要事实这并不意味您的告知义务仅限于此。如果您无法确定某一事实是否属于重要事实请将该事实告知我们。

FAILURE TO DISCLOSE could prejudice your right to recovery in the event of aclaim oral low underwriters to avoid the pol icyfrom its inception.

未履行告知义务会影响您的索赔权利或使保险公司有权自保单生效之日起取消保单。Appropriate enquiries should be made to ensure that the answers set forth hereinare true and complete and that no material fact has been omitted.Any change in theanswers given and any material change in the risk arising before inception of yourpol icy must be advised to us and should therefore be notified immediately.

在填写调查问卷时应保证答案是正确完整的重要事实没有被忽略。在保单正式生效前如已填写的有关情况发生变化或有关风险的重要事实发生变化请立即通知我们。

UNDERINSURANCE不足额保险

Many pol icies containa Co-insurance(orAverage)provision wherebyyou mayberequired to beara rateable proportion of the loss inthe event that the sum insured isless than the value of the insured property at the commencement of the insurance.大多数保单都包括共保或比例分摊条款该条款规定如果保险金额小于保单生效时的保险财产的价值您需承担一定比例的损失。

UTMOST GOOD FAITH最大诚信原则

Everycontract of insurance is based on“Utmost good faith”which requires eachparty(i .e.you and the insurer) to act towards the other party in respect of any matterarising underthe contract,with the utmost good faith. If you fai l to do so you mayprejudice any claim.

每一份保险合同都是建立在最大诚信原则的基础上这一原则要求合同双方您和保险公司在保险合同下的任何行为都应遵循最大诚信原则。如果您没有遵循该原则

P age 3

这将会影响您的索赔权利。

GENERALINFORMATION 5基本情况

INSURANCEPOLICYINFORMATION 5现有保险基本情况

企业基本风险保障

PROPERTYDAMAGE INSURANCE 8财产一切险

PROPERTYEXPOSUREDATA 12

财产保险风险数据

BUSINESSINTERRUPTIONINSURANCE 14利润损失保险

BUSINESSINTERRUPTIONWORKSHEET 16

营业中断保险表格

(Gross Profit Form) 16

BUSINESSINTERRUPTIONWORKSHEET 18

营业中断保险表格

(Gross Earnings Form) 18MACHINERY BREAKDOWN&MACHINERY BREAKDOWN BUSINESS

INTERRUPTION INSURANCE 22机损险及机损险营业中断保险

MONEYINSURANCE 24现金保险

OPENMARINECARGOINSURANCE 26货物运输开口保单

INLANDTRANSITINSURANCE 29内陆运输保险

EMPLOYERS'LIABILITYINSURANCE 31雇主责任保险

PUBLICLIABILITYINSURANCE 32公众责任保险

PRODUCTSLIABILITYINSURANCE 35产品责任保险

FIDELITYGUARANTEEINSURANCE 40雇员忠诚保险

企业员工福利保险风险保障

EMPLOYEEBENEFITINSURANCE

员工福利保险

企业员特殊保险风险保障

DIRCTORS&OFFICIALS LIABILITY INSURANCE

董事及高级管理人员责任保险

TRADE CREDIT INSURANCE

信用保险保险

CONSTRUCTION/ERECTIONALLRISKS INSURANCE 63

P age 4

建筑及安装工程一切险

GENERALINFORMATION

基本情况

1 . The current Named Insured in terms of yourmajorpol icies is asfol low:目前贵司保单中的列明被保险人是:

2. ListALL business activities,please provide particulardetai ls of any part of thebusiness,where design oradvice is provided to customers in the absence ofsale orsupplyof products/services.

请列明贵公司所有的营业活动如贵公司并不是销售产品或提供服务只是向客户提供设计或专家建议请提供该营业活动的详情。

3. Have you acquired or disposed of anysubsidiaries during the year? YES/NO一年间,贵司是否开办或关闭任何子公司? 是/否a. If YES please supplydetai ls:

如果是请具体说明

b. If you have acquired the l iabil ities of any companywe wi l l need to tai loryour insurance program to meet these circumstances,so please adviseful l detai ls of anysuch acquisition(s)。

如果贵司取得了其他公司的责任或债务我们需要为您调整保险方案以满足

您的具体需要 因此建议您如有上述情况请将详细情况提供给我们。

4. Are any non subsidiarycompanies to be covered byanyof your pol icies i .e.joint venture orcompanies where your shareholding is 50%or less etc?

YES/NO是否有非贵司子公司的其他公司加入贵司的保单例如合资公司或贵司持股等于或少于50%的公司 是/否If YES,please supplydetai ls:

如果是请具体说明

P age 5

5. Do anyof yourcompanies have property,operations oranyother U.Sdomici led exposures(i .e. incorporated companies etc.)? YES/ NO贵司在美国是否拥有任何财产、营业机构或者其他存在于美国的风险单位如在美国组建的公司等等  是/否

6. Some pol icies contain a provisionthat has the effect of l imiting orexcludingthe insurer’s l iabi l ity in respect of a loss if you have entered into an agreementthat l imits or excludes your right to recoverdamages from a third party.Therefore,you should not sign any agreement which contains a“holdharmless”or waiver clause without reference to Insurance Broker.

假如贵司签订了发生损失时限制或排除贵公司向第三方求偿的协议则某些保单也会相应规定限制或排除保险公司的责任。因此贵司不得在经纪公司未知情的情况下签订任何包含“免责”或“自动放弃”条款的协议。

7. 其他公司信息

P age 6

INSURANCE POLICY INFORMATION

现有保险基本情况

*请提供保险单或保险单明细表 以便进行保单对比及评估。

P age 7

PROPERTY DAMAGE INSURANCE

财产损失保险

It is important that the attached schedule is completed/updated as ful ly aspossible(please see guidance notes for completion below).

请尽可能完整填写/更新所附表格以下

是有关填写该表格的指南 。

Bui ldings:

建筑物 Values should be given on a reinstatementbasis. i .e. , the cost of rebui lding as atrenewal date including professional fees.Please state if there are any leased/rentedproperties and confirm who is responsible toi ns u re.

该项价值应以重建价值为基础 即在续保日的重建成本包括专业费用。如有租入或租出财产请注明并确定负责购买保险的一方。

Machi nery,Equipment&Other Contents:

机器设备及其它室内财产 Values should be the cost of replacementas new and include al l contents includingproperty for which you are responsible othertha n

该项价值应以新重置成本为基础包括您所负责的所有室内财产 以下财产除外i) Money现金i i) Stock库存i i i) Otherpropertyspecifical lyexcludedby pol icy保单列明除外财产

Computer Equipment:

计算机设备 Values should be the cost of replacement asnew

该项价值应以新重置成本为基础。

Advertising Signboard:

广告牌 Values should be the cost of replacement asnew

该项价值应以新重置成本为基础。

Retai l Equipment:

零售设备 Values should be the cost of replacement asnew

P age 8

该项价值应以新重置成本为基础。

Stock&Work i n progress:

库存及在产品 Give the maximum value expected to beheld at anyone time during the pol icy period.Values should be based on'Cost'value.请提供保险期限中任一时点的预计最大库存量。该项价值以成本价为基础。

Others:

其它财产 Value should be the cost of replacement asnew

该项价值应以新重置成本为基础。

P age 9