产品责任保险投保单样本

1、产品责任险投保单PROPOSAL FOR PRODUCTS LIABILITY INSURANCE投保单号Proposal 用尊敬的投保人：欢迎您来本公司投保。请您在保险人明确说明本保险的保险条款后，如实填写本投保单及保险标的风险询问表（如有），并特别注意保险条款及投保单中的保险责任、责任免除及投保人、被保险人义务等内容。投保人网址Applicant Website 投保人地址邮编 Address of ApplicantPostCode联系人电话电子信箱ContactTelephoneE-mail被保险人网址Insured被保险人地址Address of Insured联系人Contact营

2、业性质Nature of Business保险期限Period of Insurance 电话TelephoneWebsite 邮编 Post Code电子信箱E-mail8/ 6序号No.个月自年_日时起，至年_日时止Months From at Toat 投保产品情况Information of the Insured Products销售额 Sales 产品名称型号规格单价上一年本年明年Name of Product Standard of Type PriceLast year This year next year （estimate洛称 Name 供应商 Supplier 原料及零

3、部件Raw Materialsand / or Parts直接及间接用途Direct &Indirect Use质量标准Standard of Quality获得何种 xxAny License（ s）销售地区Market Area投产时间Put Into Production in产品的包装Description of the Products产品的历史History of The Products发生时间Time of Occurrence 事故原因Cause of Accident 损失金额 Loss Amount Limits of Indemnity免赔额/ 率Deducti

4、ble赔偿基础追溯期费率（o） Indemnity Basis Retroactive Rate预收保险费：币种（大写）（小写）Deposit Premium Currency最低保险费：币种（大写）（小写） Minimum Premium Currency年_月_日保险费缴付日期Date of Payment承保区域司法管辖Coverage territory Jurisdiction其它保障 Other Extensions：是否已向其他保险公司投保与本保险标的有关的保险？如是,请列明保险公司名称、保险种类、保险金额和主要保险条件：特别约定 Special Agreement：1. 本保险

5、合同适用中国保险监督管理委员会1998 年 12 月 2 日保监发【1998】 3 号颁布的财产险2000 年问题除外责任条款。The Contract of Insurance will be subject to those exclusions in respect of property damage arising from the Y2K issue (Millennium Bug), as promulgated by the Chinese Insurance Regulatory Commission (CIRC), December 2nd1998.2.本保险合同自保险人核

6、保并签发保险单后成立，自投保人依约缴费后生 效，保险人自本保险合同生效后开始承担保险责任。3.本保险合同一律采用书面形式，双方不认可其他形式的约定。Only the written form contract will be operated, any other form will be not approved.4. 因履行保险合同发生争议的，一方可向仲裁委员会依该会届时有效的仲裁 规则申请仲裁。In the event of any dispute arising from its implementation or enforcement,either of the parties t

7、o the Contract of Insurance may make application to the Arbitration Committee, whose judgements shall be given inaccordance with such rules of arbitration as are then in effect.随附产品资料Together With The Following Documents1）产品说明书 2）质量合格证书3）安全警告标记ManualCertification of QualitySafety Warning Mark（ 5）质量检

8、验报告（ 6）销售合同（ 7）设计图纸 Quality Inspection Report Contract of Sale Design Drawin我 人限额 Limits of Person ：累计赔偿限额Aggregate Limits of Indemnity ：（ 4） xx（ 8）其他License（s）Else投保人声明：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。2 .本投保单及保险标的风险询问表（如有

9、）所填各项内容均属事实，同意以本投保单及保险标的风险询问表（如有）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 and in the Schedule of Declared Risks 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 Po