产品责任险询问表

1、PRODUCTS LIABILITY INSURANCE QUESTIONNAIRE产品责任险询问表PLEASE TYPE OR PRINT 请以打字或正楷填写Applicants Instructions 申请人注意事项：1. Answer all questions and please do it in English , if possible.请回答下列问题，并尽可能以英文回答。2. If space is insufficient to answer any questions fully, attach separate sheet.若作答空间不够，请另附其它纸张回答。3. If

2、 the answer to any question is none, state NONE.若回答问题的答案为无的话，请答无字。4. Application must be signed and dated by owner, partner or officer.本问卷需公司所有人、合伙人、或部门主管签章及注明填写日期。1. APPLICANT 要保人a) Full Name：全名b) Principal address：住所地Website：网址c) Subsidiaries or Divisions：分支机构If you have a subsidiary, affiliate or

3、 representative in the USA/Canada, please give names(s) and address(s)：若贵公司在美国加拿大有分支机构联络处请详列名称及地址11/11d) Individual独资Partnership合伙Corporation公司Other其它e) Manufacturer制造商Wholesaler批发商Retailer零售商Importer进口商Exporter出口商Assembler零件组合商f) Years in business under present name：以目前公司名称从事该行业之年数g) Prior experien

4、ce in this business under another name： 以前有无以其它之公司名称商号从事该行业之经验2. PRODUCTS AND SALES DATA 产品及销售数据Describe your products, Include and identify, those acquired via acquisition or merger, those planned for introduction in next 12 months, and those previously discontinued. Show number of years involved w

5、ith each products; indicate which products you install, service or repair：请叙述贵公司之产品，在叙述中请包括并指明藉由并购或合并而取得之产品及在未来12个月内计划生产之产品，以及可能中止生产之产品。请按产品及年度，分项说明贵公司所生产、装配及修理之产品。a) List the turnover figures for the past 5 years as well as the estimated Turnover for the forthcoming year. Indicate the approximate p

6、ercentage split in turnover per territory.列出过去五年之销售金额及预估年度预计投保之销售金额，同时依下列不同地区填写其所占之比率。Year年份Turnover销售金额(US$)各地区比例USA/Canada美加Japan/Australia/Europe日本澳洲欧洲Other其它地区Est. 20142013201220112010Please indicate the approximate percentage of overall turnover for the year relating to each Insured product and

7、 the number of anticipated units.请列出各产品占投保销售金额之比率及各单位量。Products & Services(or Specific Categories)产品和服务 (或特别项目)Applicant Acts As A/An:申请者是No. of Years for sale经营此产品几年% of Gross Sales占总销售额之%Products Sold To产品售予MWMRRIWRMRCOM manufacturer 制造商R retailer 零售商MR manufacturer rep. 制造商代表W wholesaler 批发商I imp

8、orter 进口商C consumer direct 直接销至消费者O other (describe) 其它请说明:Do you sell to one distributor/wholesaler or direct to retail outlet(s)? 贵公司仅针对单一批发商销售或是直接销售至各零售商？b) Suppliers and Distributors of your products：产品之供应者及经销商i. Do you hold them harmless or insure them?YesNo贵公司是否与供应者或经销商订立损害免责协议免除其法律责任或以保险承保其责任

9、？ii. Do they hold you harmless or insure you?YesNo供应者或经销商是否与贵公司订立损害免责协议免除贵公司法律责任或以保险承保其责任？If yes in either i, or ii, above, please explain.若第i项或第ii项之答案为是时，请加以说明。c) Do you purchase materials or components from others?YesNo贵公司是否向他人购买原料或零组件？d) Do you import products or component parts?YesNo贵公司是否进口成品或零件

10、？e) Do you export products or have foreign operations?YesNo贵公司是否输出产品或于国外提供服务？f) Could any of your products or services be used on or in connection with：贵公司之产品或服务是否用在下述项目或与下述项目有关?i. aircraft/missile/aerospace?YesNo航空飞行器/飞弹/太空方面？ii. watercraft or offshore?YesNo水上或海上交通工具及离岸设施？iii. transportation/transi

11、t?YesNo内陆交通运输？iv. life support service?YesNo维生、复健医疗设备或服务？g) Do you make or handle any product that is explosive,flammable or poisonous either by itself or in combinationwith other materials?YesNo贵公司是否制造或经营产品本身或是与其它物质结合后会有害人体、或易燃、易爆之产品？h) Could any of your products be classified as：贵公司之产品是否归类于下项产品i.

12、pharmaceuticals?YesNo药品ii. cosmetics?YesNo化妆品i) Are any of your products sold under anothers name or label?YesNo是否有产品以他人之名义或标示销售（即 OEM 之产品）？If yes in either i, or ii, above, please explain.若第i项或第ii项之答案为是时，请加以说明。3. PRODUCT DESIGN 产品设计a) Do you do your own design work?YesNo产品是否由贵公司自行设计？b) Do you maint

13、ain records of design changes and reasons justifying these changes?YesNo是否留存有关设计变更及设计变更理由之记录？c) Are your designs subject to independent external review,testing or certification?YesNo贵公司之设计是否曾经由他人审核、测试或合格证明？If so, attach details and dates.若是，请附明细及日期d) Are your products designed, tested, labeled and m

14、anufactured：产品之设计、测试、标示及制造是否符合：i. to meet or exceed all government and industry standards?YesNo政府及工业标准ii. for optimum safety in spite of misuse or abuse?YesNo尽管误用或滥用仍具良好的安全性4. PROCESSING 制造过程a) Do other assemble your products?YesNo贵公司产品是否由他人装配？if assembly by others, do you supervise?YesNo若由他人装配，是否由贵

15、公司监督？b) If installation by others, do you supervise or furnish instruction as to installation?YesNo若由他人安装，是否由贵公司监督或指示其安装？c) If you maintain and service your products, attach a copy of your standard service contract.若贵公司对于产品提供维修或服务，请附贵公司维修服务契约之影本。d) Who packages your products?贵公司之产品由谁包装？e) Who design

16、s your packaging?贵公司之包装由谁设计？f) Who supplies the packaging materials?贵公司包装之材料由谁提供？g) How are they packed when sold?产品出售时如何包装？h) Is any sterile packaging involved?是否有用到无菌包装？i) Do you package for others?贵公司是否为他人包装？5. QUALITY CONTROL AND TESTING 质量管理及测试a) Are written testing procedures followed?YesNo是否依

17、据书面测试程序作业？b) Do you have a quality control manager responsible only to topmanagement?YesNo是否有品管控制经理对最高管理单位负责？c) Supplies and components 产品材料与零组件：i. Are they ordered to your specifications?YesNo是否按贵公司所需之规格而订购？ii. Have you determined which ones are critical to thesafety of your final product?YesNo能否判别

18、那一部份之材料或零组件将影响到贵公司产品的安全性？iii. List those particle items, indicating whether testing ison a sample basis or on all units?YesNo列出易发生危险之零组件并说明是否对该零组件采取抽样或全盘测试？iv. Are warranties obtained from all suppliers?YesNo是否所有供货商皆提供品质保证？d) Final Products 最后成品：i. Briefly describe tests applied before sales：简述产品售前测

19、试ii. What percentage are tested?%测试产品所占之比率？iii. Are records of results quality control tests kept sothat you can identify at a laterdate what tests youapplied to a given products at a given time?YesNo是否有存留测试结果报告以便日后也能确定测试之项目及时间iv. How far back do your records go? (give date)所做之纪录可回溯到多久以前（请提供日期）v. If

20、 your products are manufactured do the specificationof your customers do they test the product upon receipt?YesNo如果产品是依客户要求之规格制造，是否客户于收货时做产品测试？vi. Do you receive an acceptance sign-off from your customer?YesNo是否客户签字验收？6. Instructions/Warnings/Advertisings/Warranties 产品说明/警告事项/产品广告/产品保证a) Are hazards

21、 inherent in the final product, and warnings against foreseeable misuse and abuse made known to the ultimate user by：贵公司以下列何种方式警示最终使用者产品因为误用、滥用所可能发生之潜在危险i. warning labels at the point of hazard?YesNo在产品危险之部位警告标示之ii. written instructions?YesNo提供文字说明iii. other means? (attach details)YesNo其它方式（请说明）b) A

22、re warnings/instructions in English?YesNo警告用语或产品说明书是否以英文书写？（如有使用其它语言文字者，请说明之。）c) Are instructions, warnings, labels, and advertising texts subject to review, to assure that they are complete and understandable to the ultimate user, and avoid overstatement relative to safety, or omissions relative to

23、 hazards by：使用说明、警示、标签及广告内容是否经由下列有关单位审核，以确定最终消费者完全了解，避免对产品安全性做夸大或遗漏之说明。i. legal counsel?YesNo法律顾问ii. top management?YesNo最高管理阶层iii. other? (attach details)YesNo其它（附明细）d) Do you expressly disclaim or limit warranties for your products?YesNo贵公司是否明示其限制保证或拒绝赔偿贵公司之产品e) Are all warranties and/or disclaime

24、rs reviewed by U.S.legal counsel?YesNo所有产品保证拒赔声明是否都经美国的法律顾问审核f) Do you provide any specific training or instructions forthe ultimate user in the proper use of your product?YesNo公司是否有提供最终使用者正确使用本产品之指导或训练If yes, please describe.若有，请叙述g) Are salesmen and distributors made aware of yourdesire to be info

25、rmed of cases where your product isused for a purpose for which was not designed?YesNo配销商或售货员是否了解须通知贵公司任何产品使用不当之案件。7. LOSS PREVENTION 损失防阻a) Have your products ever been subject to inquiry or investigationrelative to product safety by any governmental agency?YesNo贵公司之产品是否曾因其安全性被政府机关要求调查？If yes, atta

26、ch details.若为是，请附详细资料说明之。b) Do you have a written products recall plan?YesNo是否有不良产品回收书面计划？If yes, please attach.若为是，请附件。c) Have you ever recalled products because of a potential productsafety hazard?YesNo是否有产品因潜在安全性危险之考量而回收？If yes, attach details and indicate percent of recovery.%若为是，请说明详情及回收比率(%)d)

27、 Has your management issued a written policy statement onproduct safety which has been communicated to all employees?YesNo贵公司主管是否曾对于产品安全性有一书面说明并告知所有员工？If yes, please attach.若为是，请附件。e) Do you have a written products safety program for whichspecific individuals have responsibility for implementation?Y

28、esNo贵公司是否有贵产品使用安全之文字说明书好让使用人能确实遵守?If yes, attach copy or outline.若为是，请附影本或简述之。f) Explain how you can identify your products and parts from similar competitors products and parts：请说明贵公司如何能从其它厂商之类似产品中办认出自己之产品g) Can you determine, based on available records for all products you have sold：根据已售产品现有之数据，贵公

29、司能否确定下项：i. when any given product item was manufactured?YesNo任何指明产品项目之制造日期ii. to whom it was sold, and the date of sale?YesNo产品销售之对象及出售日期iii. who supplied parts and supplies going into thefinal products?YesNo最后成品之零组件及材料的供货商h) Do you maintain copies of old instruction or operation manualsand advertis

30、ing material?YesNo贵公司是否有存留旧的使用说明、操作手册或广告数据i) Accident procedure：处理意外事故之程序i. Do you have a written procedure for obtaining informationabout product complaints, accidents and injuriesinvolving your products?YesNo贵公司是否有书面程序来受理产品所致意外事故及产品申诉抱怨事宜？ii. Have you made distributors aware of your desire forprom

31、pt notice of all complaints, accidents and injuriesinvolving your product?YesNo是否了解经销商须立即通知贵公司有关产品所致之不满、意外事故、或体伤案件？iii. Does your procedure provide for examining and preservingany allegedly defective product with the results of suchexamination record?YesNo贵公司处理程序是否提供瑕疵品之检验及存留瑕疵品和其检验结果？iv. Do reports

32、 on complaints, accidents, injuries, and theexamination of products involved go to the personresponsible for product safety?YesNo客户不满、意外事故、体伤及出险产品检验报告是否会送交负责产品安全之人员？v. Are results used for improving the product/processprocedures?YesNo处理的结果今后是否会用于产品与制造过程之改进？8. INSURANCE REQUESTED 要求之保险a) Limits desir

33、ed 所要求之保险金额：$ Per Occurrence，$ Aggregate per policy periodb) Deductible desired 所要求之自负额：$ Per Occurrencec) Form 理赔基础：Occurrence formClaim-made form，Retroactive Date：d) Present insurer 目前之保险公司：e) What insurers have provided your products liability for the past three year?请列出曾提供贵公司产品责任险之保险公司名称InsurerP

34、olicy Period保险公司保险期间InsurerPolicy Period保险公司保险期间InsurerPolicy Period保险公司保险期间f) Has any insurer ever cancelled, restricted or refused torenew your liability insurance?YesNo是否有保险公司注销或拒绝续保贵公司之产品责任保险？If yes, please attach.若为是，请附件。g) Proposed effective date for this insurance：本保险预订之生效日期9. CLAIM HISTORY - 5 years or more 损失纪录最近五年或更久以前a) Total aggregate losses, from the ground up, including defense costs：请依年份列出全部累积损失，包括诉讼费用Policy Period保险期间No. of Claim出险次数Total Amounts PaidBI