产品责任险调查问卷简化版.doc

产品责任险投保书
EXPORT PRODUCTS LIABILITY INSURANCE APPLICATION

T 本公司对问卷各项填写内容，除作为核保及其它保险程序上的参考外，不另为其它用途，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 Information
1. 投保人/被保险人名称及注册地址电话
Name & address of applicant /insured (including all subsidiaries):

2. 被保险人成立形式 The Legal Form of the Insured
□ 独资 Individual _________ □ 合伙Partnership _________ □ 公司Corporation _ _________ □ 合资Joint venture________

3. 请选出被保险人的经营性质
Please tick the business nature of the Insured:
□ 制造商 Manufacturer __ ________ □ 经销商 Distributor _________ □ 贸易公司 Trading Company _________
□ 其它(请说明) other (please state) _________________

4. 投保公司从事该行业几年？如果有的话，请提供公司网址
How long has the Insured been in this business? Please provide company web address, if there is one.

5. 被保险人在美国或加拿大有分支机构或代表处？ 如有, 请提供以下资料
Does the Insured have any subsidiaries, affiliates or representative office in the USA
and/or Canada? If YES, please give the following details: □ Yes □ No

公司名称 Name of Company: _______________________________________________
公司性质 Business Nature: _________________________ ___________________
地址 Address: ______________________________________________ _________
与被保险人关系 Relationship with the Insured: _____________ ___

PARTII - 产品信息 PRODUCT(s) INFORMATION (请附产品说明书、产品目录、测试报告、用户使用手册。Please attach Product Brochures, Catalogue, Testing Reports, User Manuals)
1. 1）请简要说明贵公司目前所生产或销售的所有产品, 并说明所需承保的产品。
Please list all products produced and/or distributed by you and specify the products to be insured.

___________________________________________________________________________

2）贵公司从事生产或销售这些产品多长时间?
How many years have you been manufacturing or distributing these products?

________ ______________________________________________________________________

2. 预期产品的生命期限
What is the life expectancy of your product?

3. 最近五年内是否有已停止生产或销售的产品？ 如有，请简要说明
Are there any products that are no longer manufactured or distributed by you during the past five □ YES □ NO
years? If YES, please describe.

4. 未来一年内是否预计推出新的产品？如有，请说明。
Are any new products proposed for introduction during the ensuing year? If YES, please specify: □ YES □ NO
*请注意：任何新增加的产品必须通知本公司, 并经本公司书面同意后才能受本保险保障。
*Note: Any additional product must be reported to the Company and will be covered only upon
written acceptance by the company.

5. 产品是否由贵公司自行设计?
Are all of your products designed by yourself? □ YES yes □ NO

6. 贵公司的产品是否作为其它产品的零组件?若是，请指明
Are there any products sold as component parts for other products? If YES, please specify: □ YES □ NO

7. 1）贵公司所售的产品是否有以其它名称来销售? 如有，请说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 □ NO
Percentage.
__________________________________________________________________
2）如有，请问此产品是由贵司设计还是买方设计？ □ YOUR COMPANY
Are such products made to your specification or those of the buyer? □ BUYER

8. 贵公司是否向他人购买原料或零组件?
Do you purchase materials or components from others? □ YES □ NO

9. 贵公司的产品是否用于下列项目或与其有关
Could any of your products or services be used on or in connection with:

* 航空器/飞弹/太空方面 aircraft/missile/aerospace? □ YES □ NO
* 水上或海上交通工具 watercraft or offshore? □ YES □ NO
* 内陆交通运输 transportation/transit? □ YES □ NO
* 维生、复健设备 life support service? □ YES □ NO

如有，请说明：If YES, please specify: ___________________________________
10. 贵司任何一种产品其自身或与其它材料结合后是否具有爆炸性、易燃或有毒 □ YES □ NO
Are any of your products explosive, flammable, or poisonous, either by itself
or in combination with other materials?
如有，请说明：If YES, please specify: ___________________________________
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Part III - 产品销售额 TURNOVER

请列出投保产品下一年度与其销售额及过去四年的实际销售额 (美元)
Please provide estimated turnover for the products to be insured and past 4 years actual turnover in each region (in US Dollars)
a. 美加地区 USA/Canada
年度Year
产品 Product
下一年(Next Year)
今年(This Year)
上年(Last Year)

合计（Total）

b. 国内市场 Home Market
年度Year
产品 Product
下一年(Next Year)
今年(This Year)
上年(Last Year)

合计（Total）

c. 欧洲/澳大利亚 Europe/Australia
年度Year
产品 Product
下一年(Next Year)
今年(This Year)
上年(Last Year)

合计（Total）

d. 其它地区 Rest of the World
年度Year
产品 Product
下一年(Next Year)
今年(This Year)
上年(Last Year)

合计（Total）

PART IV – 产品质量及安全控制 PRODUCT QUALITY AND SAFETY CONTROL

1. 1) 贵公司是否有书面的产品质量控制措施？ □ YES □ NO
Is there a written Quality Control Procedure in place?
2) 是否有书面的产品回收计划？ □ YES □ NO
Is there a written product recall plan?

2. 产品是否达到或超过相关国家政府与行业所订的标准? 如是，请列举适用的标准及其复印件
Are your products designed to meet or exceed the respective government and industry’s standards? □ YES □ NO
If YES, please list all applicable standards and attach copies.

________ _______________________________________________________________

3. 产品测试 Product Testing
1) 有无书面的产品测试程序? □ YES □ NO
Are written testing procedures in place for your products?
2) 产品是否经过专业机构监测合格。如有， 请附复印本 □ YES □ NO
Do you apply any third-party laboratories/testing centers? If yes, please attach copy of the reports.
必维测试， Veritas Bureau
____________________________________________________________________________

5. 关于产品的潜在危险、误用或滥用，贵公司是否警告最终消费者？ 如有，说明以下何种方式
Are hazards inherent in the final product, and warnings against foreseeable misuse and abuse made □ YES □ NO
known to the ultimate user? If YES, please specify how:

l 在产品危险部位标示警告事项
warning labels at the point of hazard?_____ _________________________________________
l 提供文字说明
written instructions?_________ ____________________________________________________
l 其它方式(请说明)
other means (attach details)?________ _____________________________________________

6． 对已售产品，贵公司能否能确定：
Can you determine based on available records for all products you have sold:
l 产品的制造日期? □ YES □ NO
When any given product item was manufactured?
l 产品销售的对象及出售日期? □ YES □ NO
To whom it was sold, and the date of sale?
l 零件及材料的供货商? □ YES □ NO
Suppliers of the parts and materials?
l 如果贵司产品是按照客户要求的规格制造的，他们是否在收货时进行检测
If your products are manufactured to the specifications of your customers, □ YES □NO
do they test the product upon receipt?
l 贵司客户是否签字验收
Do you receive an acceptance sign-off from your customer? □ YES □ NO

贵公司是否留存有关产品的旧的使用说明，操作手册或广告资料? 如有， 请附复印本

Do you maintain copies of old instruction or operation manuals and advertising material? □ YES □ NO

Part V – 经销商责任Vendor’s Liability
1. 您是否需要“经销商责任”？若是，请填写以下信息：
Do you require any Vendor Liability cover? If yes, please provide the following information:
经销商名称 地址 产品名称 使用品牌名称 销售额
Vendor’s Name Address Product Name Brand Sales

______________ _____________ ______________ _____________ _____________
______________ _____________ ______________ _____________ _____________

2. 您是否与经销商签定任何形式的免责协议或其他类似的协议？
Have you ever entered into any hold harmless or other similar contractual agreements with vendors?
如是，请提供详细子信息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 deems 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 claims and payment of all premiums when due. It is a requirement that all goods sold by Vendor to Buyer be covered by said insurance. It is Vendor’s responsibility to provide its insurance company at all times with a current listing of goods to be covered under the terms of this Agreement.

3. 经销商是否对产品实施质量管理工作？Does the vendor perform any quality control work on the product?

4．您如何从相同或类似的产品中辨识您的产品How do you identify you products from similar products?

4. 经销商是否对产品提供维修工作？Does the vendor perform any repair work on the product?

Part V - 损失纪录 LOSS EXPERIENCE

1. 贵公司是否曾因产品可能不安全而将产品收回? 若有，请说明并告知回收比率
Have you ever recalled products because of a potential product safety hazard? □ YES □ NO
If YES, please attach details and indicate percent of recovery.

2. 贵公司产品 （无论是否被承保）是否曾造成他人的医疗费,身体伤害或财产损失？如果有， 请提供
公司最近五年的损失纪录。 □ YES □ NO
Has anyone ever requested payment of damages for medical expense, bodily injury or
Property damage caused by your product (whether insured or uninsured)? If YES, please provide your
company’s loss history for the last 5 years:

年度
Year
损失金额
Incurred Loss Amount
事故描述
Incident Details

PART VI – 保险要求 INSURANCE REQUIREMENT

1. 以往有无保险公司退保或拒保贵司产品责任险? 若有，请说明
Has any insurer ever cancelled or declined your products liability? If YES, please explain.

2. 请提供贵公司目前产品责任险承保情况
Please provide current product liability insurance information:
(1) 保险公司: 保险期限
Insurer: Policy Period
(2) 责任限额 每次事故限额 保单期限累计限额
Limits of Liability: Any one occurrence _________________ Aggregate per Policy Period_________________
(3) 免赔额
Deductible_________________
(4) 保单形式 事故发生制 索赔发生制 （追溯日）
Coverage Form: □ Occurrence □ Claims-made (Retroactive Date)___________
3. 最新/续保需要的产品责任保险要求
New /Renewal requested product liability insurance
(1) 保险期限时间
Policy Period ______
(2) 责任限额 每次事故限额 保单期限累计限额
Limits of Liability: Any one occurrence _____ ____________ Aggregate per Policy Period__ ______________
(3) 免赔额
Deductible_______________
(4) 保单形式 事故发生制 索赔发生制 （追溯日）
Coverage Form: □ Occurrence 事故发生制 □ Claims-made (Retroactive Date) ___________
PART VII. –投保人/被保险人声明 THE INSURED/APPLICANT DECLARATION

1.本人填写本投保单之前，保险人已就本投保单及所附保险条款的内容，尤其是就保险人免除及减轻责任的条款、投保人和被保险人义务条款及本投保单中的特别约定条款向本人作了明确说明，本人对该保险条款及保险条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 bound by these terms and conditions.  I/we understand 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 Insurer prior to the completion of the Application Form when my/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) whose implications I/we have fully understood.
2. 本投保单所填各项内容均属事实，同意以本投保单作为保险人评定保险标的风险的基础和签发保险单的依据。
I/we declare that the answers given and the statements made on the Application Form are in every respect true and accurate and that no information has been withheld which the Insurer might reasonably consider relevant to a decision to accept this proposal.  I/we understand that the Insurer is issuing the Policy on the strict basis of the Application Fo