出口产品责任险投保书

1、华泰财产保聆有限公司Huatai Properly & CasualtyInsurance Co,r Ltd.出口产品责任险投保书EXPORTPRODUCTSLIABILITYINSURANCEAPPLICATION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。Theinformationprovidedherewillbeusedforinsuranceunderwritingandrelatedprocessingonly,andwillbekeptconfidential.PartI-基本信息BasicInformation1-sSSW

2、"Name&addressofapplicant/insured(includingallsubsidiaries):2 .被保险人成立形式TheLegalFormoftheInsured独资Individual合彳PPartnership口司Corporation匚昌资Jointventure3 .请选出被保险人的经营性质PleasetickthebusinessnatureoftheInsured:制造商Manufacturer经销商Distributor贸易公司TradingCompany其它(请说明)other(pleasestate)4 .投保公司从事该行业几年？如

3、果有的话，请提供公司网址HowlonghastheInsuredbeeninthisbusiness?Pleaseprovidecompanywebaddress,ifthereisone.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DoestheInsuredhaveanysubsidiaries,affiliatesorrepresentativeofficeintheUSAand/orCanada?IfYES,pleasegivethefollowingdetails:DYesDNo公司名称NameofCompany:公司性质BusinessNature:地址Ad

4、dress:与被保险人关系RelationshipwiththeInsured:PARTII-产品信息PRODUCT(s)INFORMATION(请附产品说明书、产品目录、测t报告、用户使用手册。PleaseattachProductBrochures,Catalogue,TestingReports,UserManuals)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。Pleaselistallproductsproducedand/ordistributedbyyouandspecifytheproductstobeinsured.2)贵公司从事生产或销售这些

5、产品多长时间？Howmanyyearshaveyoubeenmanufacturingordistributingtheseproducts?2 .预期产品的生命期限Whatisthelifeexpectancyofyourproduct?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ArethereanyproductsthatarenolongermanufacturedordistributedbyyouduringthepastfiveYESNOyears?IfYES,pleasedescribe.4 .未来一年内是否预计推出新的产品？如有，请说明。Areanynewp

6、roductsproposedforintroductionduringtheensuingyear?IfYES,pleasespecify:YESNO*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:AnyadditionalproductmustbereportedtotheCompanyandwillbecoveredonlyuponwrittenacceptancebythecompany.5. 产品是否由贵公司自行设计？Areallofyourproductsdesignedbyyourself?口YESNO口6. 贵公司的产品是否作为其它产

7、品的零组件？若是，请指明Arethereanyproductssoldascomponentpartsforotherproducts?IfYES,pleasespecify:口YESNO口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。Areanyofyourproductssoldunderanothernameorlabel?IfYES,pleasedescribeandgive口YESNO口Percentage.2）如有，请问此产品是由贵司设计还是买方设计？DYOURCOMPANYAresuchproductsmadetoyourspecificatio

8、northoseofthebuyer?口BUYER8 .贵公司是否向他人购买原料或零组件？Doyoupurchasematerialsorcomponentsfromothers?口YES口NO9 ._贵公司的产品是否用于下列项目或与其有关Couldanyofyourproductsorservicesbeusedonorinconnectionwith:* 航空器/飞弹/太空方面aircraft/missile/aerospace?口YESNO口* 水上或海上交通工具watercraftoroffshore?口YESNO口* 内陆交通运输transportation/transit?口YES

9、NO口* 维生、复健设备lifesupportservice?口YESNO口如有，请说明：IfYES,pleasespecify:PartIII-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）Pleaseprovideestimatedturnoverfortheproductstobeinsuredandpast4yearsactualturnoverineachregion（inUSDollars）a.美加地区USA/Canada年度Year5fc品Product20192018201720162015b.澳洲和新西兰Australia&N

10、ewZealand'年度Year5fc品Product20192018201720162015c.欧洲Europe_年度Year5fc品Product20192018201720162015Page3 of 5华泰财产保聆有限公司Hujtdi Properly & C3sudltyInsurance Co,. Ltd.d.其它地区RestoftheWorld牛Year5fc品Product-一_20192018201720162015PARTIV-产品质量及安全控制PRODUCTQUALITYANDSAFETYCONTROL1 .1）贵公司是否有书面的产品质量控6制措施？Ist

11、hereawrittenQualityControlProcedureinplace?2）是否有书面的产品回收计划？Isthereawrittenproductrecallplan?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影本AreyourproductsdesignedtomeetorexceedtherespectivegovernmentandindustryIfYES,pleaselistallapplicablestandardsandattachcopies.3 .产品测试ProductTesting1）有无书面的产品测试程序？Arewrit

12、tentestingproceduresinplaceforyourproducts?2）产品是否经过专业机构监测合格。如有，请附复印本4.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 YESNO口 YESNO口s standards?NO YES YESNO口 YESNO口Doyouapplyanythird-partylaboratories/testingcenters?Ifyes,pleaseattachcopyofthereports.Page6 of 5 YESNO口Arehazardsinherentinthefinalproduct,andw

13、arningsagainstforeseeablemisuseandabusemadeknowntotheultimateuser?IfYES,pleasespecifyhow:在产品危险部位标示警告事项warninglabelsatthepointofhazard?提供文字说明.writteninstructions?其它方式（请说明）othermeans（attachdetails）?5.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:产品的制造日期？Whe

14、n any given product item was manufactured?产品销售的对象及出售日期？To whom it was sold, and the date of sale?零件及材料的供货商？Suppliers of the parts and materials? YES YES YESNO 口NO 口NO 口6.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？Do you maintain copies of old instruction or operation manuals and advertising material? YESNO口Part V

15、 -经销商责任 Vendor' s Liability1.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Vendor' s Name地址Address产品名称Product Name使用品牌名称Brand销售额Sales2.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？Haveyoueverenteredintoanyholdharmlessorothersimilarcont

16、ractualagreementswithvendors?如是，请提供详细子信息Ifyes,pleaseprovidedetails:3.经销商是否对产品实施质量管理工作？Doesthevendorperformanyqualitycontrolworkontheproduct?4.您如何从相同或类似的产品中辨识您的产品Howdoyouidentifyyouproductsfromsimilarproducts?5.经销商是否对产品提供维修工作？Doesthevendorperformanyrepairworkontheproduct?PartV-损失纪录LOSSEXPERIENCE1 .贵公

17、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Haveyoueverrecalledproductsbecauseofapotentialproductsafetyhazard?YESNODIfYES,pleaseattachdetailsandindicatepercentofrecovery.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。YESNdHasanyoneeverrequestedpaymentofdamagesformedicalexpense,bodilyinjuryorPropertyd

18、amagecausedbyyourproduct(whetherinsuredoruninsured)?IfYES,pleaseprovideyourcompany'slosshistoryforthelast5years:年度Year损失金额IncurredLossAmount事故描述IncidentDetailsPARTVI保险要求INSURANCEREQUIREMENT1.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Hasanyinsurerevercancelledordeclinedyourproductsliability?IfYES,pleaseexplain.

19、2 .请提供贵公司目前产品责任险承保情况Pleaseprovidecurrentproductliabilityinsuranceinformation:(1)保险公司：保险期限Insurer:PolicyPeriod(2)责任限额每次事故限额保单期限累计限额LimitsofLiability:AnyoneoccurrenceAggregateperPolicyPeriod(3)免赔额Deductible(4)保单形式事故发生制索赔发生制(追溯日)CoverageForm:OccurrenceClaims-made(RetroactiveDate)3 .最新/续保需要的产品责任保险要求New/

20、Renewalrequestedproductliabilityinsurance(1)保险期限PolicyPeriod_(2)责任限额每次事故限额保单期限累计限额LimitsofLiability:AnyoneoccurrenceAggregateperPolicyPeriod(3)免赔额Deductible(4)保单形式事故发生制索赔发生制(追溯日)CoverageForm:OccurrenceClaims-made(RetroactiveDate)会华泰保隙tjVInsuranceGrvucPARTVII.登保人/被保险人声明THEINSURED/APPLICANTDECLARATION

21、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/wehavereadandunderstoodtheInsurer'sTerms&ConditionsoainSagreeetobeboundbythesetermsandconditions.I/weunderstandthatthePolicyisissuedstrictlyonthebasisofmy/ouragreementtothesetermsandconditionsasexplainedtome/usbytheInsurerpriortothecompletionoftheApplicationFormwhenmy/ourattentionwasdrawntothedutiesoftheInsuredandoftheInsurer.My/ourespecialattentionwasdrawntothoseclausesdealingwith