出口產(chǎn)品責(zé)任險投保書

1、出口產(chǎn)品責(zé)任險投保書EXPORT PRODUCTS LIABILIT Y INSURANCE APPLICATION本公司對問卷各項填寫內(nèi)容，除作為核保及其它保險程序上的參考外，不另為其它用途，并予以保密。The information provided here will be used for insurance underwriting and related processing only, and will be kept confidential.1.投保人/被保險人名稱及注冊地址Name & address of applicant /insured (including

2、 all subsidiaries):2. 被保險人成立形式 The Legal Form of the Insured 獨資 In dividual 合伙 Part nership 公司 Corporati on 合資 Joi ntventure3. 請選岀被保險人的經(jīng)營性質(zhì)Please tick the business nature of the Insured: 制造商 Manufacturer 經(jīng)銷商 Distributor 貿(mào)易公司 Trading Company 其它(請說明)other (please state)4. 投保公司從事該行業(yè)幾年？如果有的話，請?zhí)峁┕揪W(wǎng)址How

3、long has the Insured been in this business? Please provide company web address, if there is one.5. 被保險人在美國或加拿大有分支機構(gòu)或代表處？如有，請?zhí)峁┮韵沦Y料Does the Insured have any subsidiaries, affiliates or representative office in the USAand/orCanada?IfYES,pleasegivethefollowingdetails: Yes No公司名稱 Name of Company:公司性質(zhì) Bu

4、siness Nature: 地址 Address:與被保險人關(guān)系 Relationship with the Insured:1. 1 請簡要說明貴公司目前所生產(chǎn)或銷售的所有產(chǎn)品，并說明所需承保的產(chǎn)品Please list all products produced and/or distributed by you and specify the products to be insured.2)貴公司從事生產(chǎn)或銷售這些產(chǎn)品多長時間？How many years have you been manufacturing or distributing these products?2. 預(yù)期

5、產(chǎn)品的生命期限What is the life expectancy of your product?3. 最近五年內(nèi)是否有已停止生產(chǎn)或銷售的產(chǎn)品？如有，請簡要說明4. Are there any products that are no longer manufactured or distributed by you during the past five YES NOyears? If YES, please describe.5未來一年內(nèi)是否預(yù)計推出新的產(chǎn)品？如有，請說明。Are any new products proposed for introduction during th

6、e ensuing year? If YES, please specify: YES NO*請注意：任何新增加的產(chǎn)品必須通知本公司，并經(jīng)本公司書面同意后才能受本保險保障。*Note: Any additional product must be reported to the Company and will be covered only uponwritten acceptance by the company.6. 產(chǎn)品是否全部由貴公司自行設(shè)計？Areallofyourproductsdesignedbyyourself? YES NO6. 貴公司的產(chǎn)品是否作為其它產(chǎn)品的零組件？假設(shè)是

7、，請指明Are there any products sold as component parts for other products? If YES, please specify:YES NO7. 1 )貴公司所售的產(chǎn)品是否有以其它名稱來銷售？如有，請說明并提供其所占比例。Are any of your products sold under another name or label? If YES, please describe and give YES NOPercentage.2)如有，請 問 此 產(chǎn)品 是由 貴 司 設(shè) 計還 是買方 設(shè)計 ？ YOUR COMPANYAre

8、suchproductsmadetoyourspecificationorthoseofthebuyer? BUYER8. 貴公司是否向他人購置原料或零組件？9. Do you purchase materials or components from others? YES NO9. _貴公司的產(chǎn)品是否用于以下工程或與其有關(guān)Could any of your products or services be used on or in connection with:*航空器/飛彈/太空方面aircraft/missile/aerospace? YES NO*水上或海上交通工具/、waterc

9、raftoroffshore? YES NO*內(nèi)陸交通運輸transportation/transit? YES NO*維生、復(fù)健設(shè)備lifesupportservice? YES NO如有，請說明：If YES, please specify:請列岀投保產(chǎn)品下一年度預(yù)期銷售額及過去四年的實際銷售額(美元)Please provide estimated turnover for the products to be insured and past 4 years actual turnover in each region (in USDollars)a.美加地區(qū) USA/Canada1_

10、年度 Year產(chǎn)品Product20212021202120072006b.澳洲和新西蘭 Australia & New Zealand年度 Year產(chǎn)品 Product20212021202120072006c.歐洲 Europe''年度Year產(chǎn)品 Product20212021202120072006d.其它地區(qū) Rest of the World一一一年度 Year產(chǎn)品 Product20212021202120072006 YES NOIs there a written Quality Control Procedure in place?2)是否有書面的產(chǎn)

11、品回收計劃？ YES NOIs there a written product recall plan?2. 產(chǎn)品是否到達或超過相關(guān)國家政府與行業(yè)所訂的標(biāo)準(zhǔn)？如是，請列舉適用的標(biāo)準(zhǔn)及其影本3. Are your products designed to meet or exceed the respective government and industry ' s standards? YESNOIf YES, please list all applicable standards and attach copies.4. 產(chǎn)品測試 Product Testing1) 有無書面的產(chǎn)

12、品 YES NOAre written testing procedures in place for your products?請附復(fù)印本2) 產(chǎn)品是否經(jīng)過專業(yè)機構(gòu)監(jiān)測合格 YES NODo you apply any third-party laboratories/testing centers? If yes, please attach copy of the reports.4. 關(guān)于產(chǎn)品的潛在危險、誤用或濫用，貴公司是否警告最終消費者？如有，說明以下何種方式Are hazards inherent in the final product, and warnings again

13、st foreseeable misuse and abuse made YES NOknown to the ultimate user? If YES, please specify how:在產(chǎn)品危險部位標(biāo)示警告事項warning labels at the poi nt of hazard?提供文字說明writte n instructions?其它方式(請說明)other means (attach details)?5. 對已售產(chǎn)品，貴公司能否能確定：Can you determine based on available records for all products you

14、have sold:產(chǎn)品的制造日期？ YES NOWhen any given product item was manufactured?產(chǎn)品銷售的對象及岀售日期？ YES NOTo whom it was sold, and the date of sale?零件及材料的供貨商？ YES NOSuppliers of the parts and materials?7. 貴公司是否留存有關(guān)產(chǎn)品的舊的使用說明，操作手冊或廣告資料？Do you maintain copies of old instruction or operation manuals and advertising mat

15、erial? NO YES1.您是否需要“經(jīng)銷商責(zé)任是否作為附加被保險人？假設(shè)是，請?zhí)顚懸韵滦畔?Do you require any Vendor Liability cover (to be additional insured or not ) ? If yes, please provide the followinginformation:經(jīng)銷商名稱地址產(chǎn)品名稱使用品牌名稱銷售額Vendor' s NameAddressProduct NameBrandSales2. 您是否與經(jīng)銷商簽定任何形式的免責(zé)協(xié)議或其他類似的協(xié)議?Have you ever entered into

16、any hold harmless or other similar contractual agreements with vendors?女口是，請?zhí)峁┰旀毿畔f yes, please provide details:3. 經(jīng)銷商是否對產(chǎn)品實施質(zhì)量管理工作？Does the vendor perform any quality control work on the product?4. 您如何從相同或類似的產(chǎn)品中辨識您的產(chǎn)品How do you identify you products from similar products?5. 經(jīng)銷商是否對產(chǎn)品提供維修工作？Does th

17、e vendor perform any repair work on the product?1.貴公司是否曾因產(chǎn)品可能不平安而將產(chǎn)品收回？假設(shè)有，請說明并告知回收比率2.Have you ever recalled products because of a potential product safety hazard? NO YESIf YES, please attach details and indicate percent of recovery.3.貴公司產(chǎn)品 無論是否被承保是否曾造成他人的醫(yī)療費，身體傷害或財產(chǎn)損失？如果有,公司最近五年的損失紀(jì)錄。請?zhí)峁?YES NO年度Y

18、ear損失金額Incurred Loss Amount事故描述Incident DetailsIf YES, please provide yourHas anyone ever requested payment of damages for medical expense, bodily injury or Property damage caused by your product (whether insured or uninsured)?company s loss history for the last 5 years:1.以往有無保險公司退保或拒保貴司產(chǎn)品責(zé)任險？假設(shè)有，請說

19、明Has any insurer ever cancelled or declined your products liability? If YES, please explain.2. 請?zhí)峁┵F公司目前產(chǎn)品責(zé)任險承保情況(之前已投保)3. Please provide current product liability insurance information:保險公司：保險期限Insurer:PolicyPeriod責(zé)任限額每次事故限額保單期限累計限額Limitsof Liability: Anyone occurrenceAggregate per Policy Period免賠額D

20、eductible保單形式事故發(fā)生制索賠發(fā)生制追溯日Coverage Form: Occurre nee Claims-made (Retroactive Date)4. 最新/續(xù)保需要的產(chǎn)品責(zé)任保險要求5. New /Renewal requested product liability insurance保險期限PolicyPeriod責(zé)任限額每次事故限額保單期限累計限額Limitsof Liability:Anyone occurrenceAggregate per Policy Period免賠額Deductible保單形式事故發(fā)生制索賠發(fā)生制追溯日Coverage Form: Occ

21、urrence Claims-made (Retroactive Date)1.本人填寫本投保單之前，保險人已就本投保單及所附保險條款的內(nèi)容，尤其是就保險人免除及減輕責(zé)任的條款、投保人和被保 險人義務(wù)條款及本投保單中的特別約定條款向本人作了明確說明，本人對該保險條款及保險條件已了解并同意接受。l/we have read and understood the Insurer ' s Terms & Conditions of Insurance and agree to be bound by these termsand conditions.? I/we understan

22、d that the Policy is issued strictly on the basis of my/our agreement to these termsand conditions as explained to me/us by the Insurer prior to the completion of the Application Form whenmy/our attention was drawn to the duties of the Insured and of the Insurer.? My/our especial attention was drawn to those clauses dealing with exclusion(s) and mitigation(s) who