产品责任保险风险问询表及投保单.doc

产品责任保险风险问询表及投保单
Products Liability Insurance Questionnaire And Proposal
投保人声明
Statement of 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 hereby declare that the statements and particulars in what follows are true and correct that we have not misstated or suppressed any material facts. We agree that this Questionnaire and Proposal, together with any information supplied by us, shall form the basis of any contract of insurance affected thereon.

一、被保险人信息（请附单位简介和年度报告）
INSURED’S INFORMATION ( Please attach company profile/annual report )
1. 被保险人
Policy Holder

全称
Full Name

成立日期
Date of Establishment

地址
Principal Address

业务性质
Business
□制造商 □ 经销商
Manufacturer Distributor
□贸易公司 □ 其他
Trading Company Other

2. 附加被保险人
Additional Insureds)

全称
Full Name
所属国家
Country
成立日期
Date of Establishment
与被保险人关系
Relationship to Insured
1

□经销商 □其他
Distributor Other
2

□经销商 □其他
Distributor Other
3

□经销商 □其他
Distributor Other

(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 insurance, please attach a copy of their agreement.)

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 samples 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。
Please provide the expected/previous sales to worldwide.

产品名称
Products

期限
Period

国内销售
Domestic Sales
出口美加
USA/Canada Sales
出口欧洲
Europe Sales
出口其他
Others Sales

20__

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。
Please give details of new products of the insured to be introduced during the insurance 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 product shipped under another label/brand or manufactured by others.

这些贴牌产品的制造是根据 □贵公司的设计要求 或 □他方的设计要求？
Are such OEM’s products made following your 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？ □是 □否
Are any of your products/services known to be used in connection with
aircraft/missiles/watercraft? Yes No
贵公司的产品销售给 □消费者 □制造商 □批发商?
Are your products purchased by consumers manufacturers wholesalers?
贵公司的产品预期寿命是多少年？ □<5年 □=5年 □>5年
What is the life expectancy of your products? < 5years =5years >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险人都分别有质量控制体系？ □是 □否
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？ □是 □否
Are your products subject to any mandatory or voluntary standards? Yes No
若是，请列出贵公司的产品达到哪个标准？
If so, Please advise which standards your products should comply with?
（例如：TUV、ASTM、CSA、CE、UL、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? □是 □否
Are record keeping procedures being kept on your products? Yes No
如有，保存几年？
If yes, how many years are those records kept?
4. 贵公司有产品召回计划吗? □是 □否
Do you have any products recall programme? Yes No
如有，请附上。
If so, please attach it.

5. 贵公司产品是否有使用说明和警示标志？ □是 □否
Are instructions and warning labels attached to your products? Yes No
6． 贵公司能否识别出投保产品 ？ □是 □否
Can you identify the insured products? Yes No
如是，请描述如何识别
If yes, please explain
7．贵公司是否要求供货商提供保险证明？ □是 □否
Do you require certificates of insurance from your suppliers? Yes No
如是，请说明要求的最低限额
If so, please indicate minimum limit acceptable

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？ □是 □否
Have you ever experienced a mandatory recall or discontinuation Yes No
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 or Yes No
suspected defective products 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 □是 □否
损失而被索赔吗？
Has anyone even required for payment of damages for bodily injury or Yes No
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, please provide total incurred losses last 5 years:
A. 损失合计
Total aggregate losses

年份Year
索赔次数
No. of Claims
已付赔款
Indemnity Paid
预估赔款
Indemnity Reserved

B. 损失金额超过10000美元的个案
Individual Losses greater than $10,000

索赔日期
Date of Claim

出险产品
Product Involved

总赔款
Total Indemnity

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、限制或不予续保贵公司的产品责任险？ □是 □否
Has any insurer ever cancelled, restricted or refused to accept/renew your Yes No
products liability insurance?
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: Occurrence (Reporting Time years)
□索赔提出式（追溯日 ）
Claim-Made (Retroactive Date )
每次事故赔偿限额: 累计赔偿限额:
Limit of any one accident: Limit of aggregate:
保险费: 司法管辖:
Premium: Jurisdiction:
免赔额:
Deductible/Self Insured Retention:
(如果方便请提供保单复印件)
3. Please feel free to attach a copy of your policy schedule)
新保/续保计划：
New/Renewal Insurance Programme:
保单形式: □事故发生式（报告期 年）
Policy Form: Occurrence (Reporting time years)
□索赔提出式（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 any one accident Limit of aggregate
司法管辖需求: 免赔额需求：
Jurisdiction Prefered: Deductible/SIR Preferred:

This application must be signed by an officer of the proposer
本投保单须经投保单位负责人签字方为有效
Applicant’s Signature: Date Signed:
投保人签名: 签署日期：
Applicant’s Address:
投保人地址：
Products Liability Insurance Questionnaire and Proposal Page 4
产品责任险风险问询表及投保单