產(chǎn)品責(zé)任險調(diào)查問卷簡化版VIP

1、產(chǎn)品責(zé)任險投保書EXPORT PRODUCTS LIABILITY INSURANCE APPLICATIONT本公司對問卷各項(xiàng)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.Part I -基本信息 Basic Information1 .投保人/被保險人名稱及注冊地址電話 Name & address

2、of applicant /insured (including all subsidiaries):2 .被保險人成立形式 The Legal Form of the Insured獨(dú)資 Individual 合彳P Partnership 匚幺司 Corporation I p 資 Joint venture3 .請選出被保險人的經(jīng)營性質(zhì) Please tick the business nature of the Insured:制造商 Manufacturer dfe銷商 Distributor 貿(mào)易公司 Trading Company其它(請說明)other (please stat

3、e)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 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(jī)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 USA and/or Canada? If YES, please give the following

4、details:DYes DNo公司名稱 Name of Company:公司性質(zhì) Business Nature: 地址 Address: 與被保險人關(guān)系 Relationship with the Insured: PARTII -產(chǎn)品信息 PRODUCT(s) INFORMATION (附附產(chǎn)品說明書、產(chǎn)品目錄、測t報告、用戶使用手冊。Please attach ProductBrochures, Catalogue, Testing Reports, User Manuals)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

5、 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Are there any products that are no

6、 longer manufactured or distributed by you during the past five YES NOyears? If YES, please describe.4 .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 the 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

7、must be reported to the Company and will be covered only upon written acceptance by the company.5 .產(chǎn)品是否由貴公司自行設(shè)計？Are all of your products designed by yourself? YESyes NO6 .貴公司的產(chǎn)品是否作為其它產(chǎn)品的零組件？若是，請指明Are there any products sold as component parts for other products? If YES, please specify: YESNO 7 . 1)貴

8、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 YESNO Percentage.2)如有，請問此產(chǎn)品是由貴司設(shè)計還是買方設(shè)計？DYOUR COMPANYAre such products made to your specification or those of the buyer? BUYER8.貴公司是否向他人購買原料或零組件Do you purchase materials or c

9、omponents from others? YES NO9._貴公司的產(chǎn)品是否用于下列項(xiàng)目或與其有關(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? YESNO 口*水上或海上交通工具 watercraft or offshore? YESNO 口* 內(nèi)陸交通運(yùn)輸 transportation/transit? YESNO 口* 維生、復(fù)健設(shè)備 life support service? YESNO 口如有， 請說明

10、：If YES, please specify:10.貴司任何一種產(chǎn)品其自身或與其它材料結(jié)合后是否具有爆炸性、易燃或有毒 YESNOAre any of your products explosive, flammable, or poisonous, either by itself or in combination with other materials?如有， 請說明：If YES, please specify:Part III -產(chǎn)品銷售額 TURNOVER請列出投保產(chǎn)品下一年度與其銷售額及過去四年的實(shí)際銷售額(美元)Please provide estimated turnov

11、er for the products to be insured and past 4 years actual turnover in each region (in US Dollars) a.美加地區(qū) USA/Canada年度 Year5fc 品 Product下一年(Next Year)今年(This Year)上年(Last Year)合計（Total ）b.國內(nèi)市場 Home Market"_ 年度 Year5fc 品 Product下一年(Next Year)今年(This Year)上年(Last Year)合計（Total ）c.歐洲 /澳大利亞Europe/Au

12、stralia年度Year5fc 品 Product下一年(Next Year)今年(This Year)上年(Last Year)合計（Total ）d. 其它地區(qū) Rest of the World-一_年度 Year5fc 品 Product _一/_下一年(Next Year)今年(This Year)上年(Last Year)合計（Total ）PART IV 產(chǎn)品質(zhì)量及安全控制 PRODUCT QUALITY AND SAFETY CONTROL1 .1)貴公司是否有書面的產(chǎn)品質(zhì)量控制措施？口 YES NtrnIs there a written Quality Control P

13、rocedure in place?2)是否有書面的產(chǎn)品回收計劃？口 YESNCOIs there a written product recall plan?2 .產(chǎn)品是否達(dá)到或超過相關(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)及其復(fù)印件Are your products designed to meet or exceed the respective government and industrystandards ? s YES NCEIf YES, please list all applicable standards and attach copies.3 .產(chǎn)品測試 Pr

14、oduct Testing1)有無書面的產(chǎn)品測試程序 ？Are written testing procedures in place for your products?2)產(chǎn)品是否經(jīng)過專業(yè)機(jī)構(gòu)監(jiān)測合格。如有，請附復(fù)印本Do you apply any third-party laboratories/testing centers? If yes, please attach copy of the reports. 必維測試，Veritas Bureau5 .關(guān)于產(chǎn)品的潛在危險、誤用或?yàn)E用，貴公司是否警告最終消費(fèi)者？如有，說明以下何種方式Are hazards inherent in t

15、he final product, and warnings against foreseeable misuse and abuse made known to the ultimate user? If YES, please specify how:在產(chǎn)品危險部位標(biāo)示警告事項(xiàng)warning labels at the point of hazard?提供文字說明written instructions?其它方式(請說明)other means (attach details)?6 .對已售產(chǎn)品，貴公司能否能確定：Can you determine based on available r

16、ecords for all products you have sold:產(chǎn)品的制造日期？When any given product item was manufactured?產(chǎn)品銷售的對象及出售日期 ？To whom it was sold, and the date of sale?零件及材料的供貨商？Suppliers of the parts and materials?如果貴司產(chǎn)品是按照客戶要求的規(guī)格制造的，他們是否在收貨時進(jìn)行檢測If your products are manufactured to the specifications of your customers,

17、 do they test the product upon receipt?貴司客戶是否簽字驗(yàn)收Do you receive an acceptance sign-off from your customer?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？如有，請附復(fù)印本Do you maintain copies of old instruction or operation manuals and advertising material? YESNd YESN。 YES NCE YESNCE YES 口NO YESN3YESCNOYES口NO YESN OPart V -經(jīng)

18、銷商責(zé)任 Vendor' s Liability1.您是否需要“經(jīng)銷商責(zé)任”？若是，請?zhí)顚懸韵滦畔ⅲ篋o you require any Vendor Liability cover? If yes, please provide the following information: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 any hold harmless or other simi

19、lar contractual agreements with vendors? 如是，請?zhí)峁┰敿?xì)子信息 If yes, please provide details:As a condition to doing business with Buyer, Vendor agrees to provide proof of insurance underwritten by an insurance company with a Best Rating acceptable to Buyer, in such amount and with such coverage as Buyer dee

20、ms necessary, which insurance shall also be endorsed to name Buyer as an additional insured. Vendor agrees to maintain said insurance without a reduction in coverage and further agrees to comply with all terms and conditions of said insurance, including without limitation, prompt notification of cla

21、ims and payment of all premiums when due. It is arequirement that all goods sold by Vendor to Buyer be covered by saidinsurance. It is Vendor' s responsibility to provide its insurance company at all times with a current listing of goods to be coveredunder the terms of this Agreement.3.經(jīng)銷商是否對產(chǎn)品實(shí)

22、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?4.經(jīng)銷商是否對產(chǎn)品提供維修工作？Does the vendor perform any repair work on the product?Part V - 損失紀(jì)錄 LOSS EXPERIENCE1 .貴公司是否曾因產(chǎn)品可能不安全而將產(chǎn)品收回？若有，請說明并告知回收比率Have you ever

23、recalled products because of a potential product safety hazard? YESNODIf YES, please attach details and indicate percent of recovery.2 .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(fèi)，身體傷害或財產(chǎn)損失？如果有，請?zhí)峁┕咀罱迥甑膿p失紀(jì)錄。 YESNdHas anyone ever requested payment of damages for medical expense, bodily injury orProperty damage cause

24、d by your product (whether insured or uninsured)? If YES, please provide yourcompany ' s loss history for the last 5 years:年度Year損失金額Incurred Loss Amount事故描述Incident DetailsPART VI 保險要求 INSURANCE REQUIREMENT1 .以往有無保險公司退?；蚓鼙ＹF司產(chǎn)品責(zé)任險？若有，請說明Has any insurer ever cancelled or declined your products li

25、ability? If YES, please explain.2 .請?zhí)峁┵F公司目前產(chǎn)品責(zé)任險承保情況Please provide current product liability insurance information:(1)保險公司：保險期限Insurer:Policy Period(2)責(zé)任限額每次事故限額保單期限累計限額Limits of Liability: Any one occurrence Aggregate per Policy Period(3) 免賠額Deductible(4)保單形式事故發(fā)生制索賠發(fā)生制(追溯日)Coverage Form: Occurrence

26、 Claims-made (Retroactive Date)3.最新/續(xù)保需要的產(chǎn)品責(zé)任保險要求New /Renewal requested product liability insurance(1)保險期限時間Policy Period (2)責(zé)任限額每次事故限額保單期限累計限額Limits of Liability: Any one occurrence Aggregate per Policy Period(3)免賠額Deductible(4)保單形式事故發(fā)生制索賠發(fā)生制 (追溯日)Coverage Form: Occurrence 事故發(fā)生制 Claims-made (Retroa

27、ctive Date)PART VII. 加保人 /被保險人聲明 THE INSURED/APPLICANT DECLARATION1 .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。I/we have read and understood the Insurer's Terms & Conditions of Insurance and agree to be bouitermy and conditions. I/weerunderstand that the Policy is issued strictly on the basis of my/our agreement to these terms and conditions as explained to me/us by the Ins prior to the completion of the Application Form when my/our attention was drawn to the duties of the Insured