雇主责任险问卷新

1、雇主责任险风险调查问卷Questionnaire for Employers Liability Insurance基本信息 General Information公司名称： (Name) 建立时间： (When was the firm established?) 营业性质： (Stated Occupation) 业务范围： (Scope of business) 被保险人是：(Named Insured is)夕卜商独资 (Wholly foreign owned enterprises ) 中夕卜合资 (Sino-foreign joint venture )中外合作(Contract

2、ual joint venture/cooperative operation business )涉外贸易(Foreign trade enterprise)其他(Others)投资夕卜方为( Company/region of the foreign investor )：联系地址： (Postal Address) 电话及传真： (Telephone Number and Fax Number) 标的位置： (Location of Risk) 希望的保险期限：(When the insurance to commence) 从 (From) 至 (To) 生产状况 Operation/

3、 Manufacturing Status.生产流程Operation/ Manufacturing Process.贵公司是否使用酸性物质或任何可燃性、易爆、有毒、带辐射或其他任何有危险的材料，如有， 请说明，并说明使用程度：Have you any acids or material which are inflammable, explosive, poisonous, radioactive or in any way dangerous? If so, give full particulars, and specify to what extents:.贵公司是否有机器通过蒸汽、燃

4、汽、水、电力或其它机械动力驱动？如有，请详细列明：Have you any circular saws or other machinery driven by steam, gas, water, electricity or other mechanical power? If so, give full particulars:.贵司使用何种类型的锅炉?What boilers have you?工种分类与预计年收入 Position and Estimated Annual Payroll列举贵公司给雇员的预计年收入。年收入必须包括所有的工资、薪水、奖金、小费、加班费或其它 的特殊酬劳

5、或类似的津贴。State the estimated annual earnings to be paid to your employees. The earnings declared must include all salaries, wages, bonuses, tips and overtime payments or other special remuneration received by an employee and any other similar allowances.(i)正式员工 FULL-TIME employees雇员情况Description of Em

6、ployees预计员工总数Estimated Number of Employees 预计年薪及其它津贴 Estimated annual salaries, wages and other earnings(a)文职人员和管理人员Clerical and Administrative Staff (b)操作工人Employees engaged with woodworkIng machinery including machinists and machinists labourers (c)司机Driver (d)其它All others (as specified below) 在过去

7、的12个月中付给上述员工的工资、薪水及其它津贴的总数是 The total amount of salaries, wages and other earnings paid by us to the above mentioned employees during the past twelve months was(ii)临时员工 PART-TIME employees职位预计工人数目预计收入从其他雇主处获得到收入OccupationEstimated No. of Employees Estimated Earnings Other Earnings to be Receivedto b

8、e paid by youfrom other Employment(iii)若有分承包商，请说明 SUB-CONTRACTORS-If you employ any, please state:承包商的姓名Name of Contract-or分包工作性质Nature of work sub-let如果仅是提供劳工合同 请列明合同金额In case for which the Contract is for labour only, state amount of contract如果合同是提供劳工和材 料，请列明预计的合同金额 If contract is for both labour

9、and materials state estimatedamount of contract.上表是否已包括每个岗位上的所有正式员工？Do all your full-time employees of every position be included in the above table?是 Yes 否 No.上表是否已包括所有临时工？Do all your part-time employees be included in the above table?是 Yes 否 No.贵司是否有外籍员工？如果是，请单独列出该员工的职位及工资。Do you hire foreign empl

10、oyees? If Yes, please give details of the Position and show salaries separately.是 Yes 否 No.您在下表中所提供信息仅包括按上海市政府颁布的上海市工伤保险实施办法 有关规定参加工伤保险且为其缴纳工伤保险费的员工；不包括参加上海市外来从业人员综合保险的员工：（缴费工资：保险费收缴和理赔支付均以投保人缴纳工伤保险费基数为基础。该基数按投保人缴纳城镇 养老保险费或者小城镇社会保险费基数确定。雇员个人的缴费工资即为参照上述方法确定的数额。）雇员工作种类雇员人数估计年预计缴费工资总额.贵司是否要求保单扩展“国内差旅扩展

11、责任”？Do you require extend “ Domestic BusinessLlaibiiey under this Policy?是 Yes 否 No.贵司是否要求保单扩展“海外差旅扩展责任”？如果是，请给出可能前往的国家的名称。Do you require extend “ Overseas BusinessJOiaHity under this Policy? If Yes, please give details of countries may involved.是Yes 否No损失记录Loss Record.贵司以前是否投保过？Have you previously

12、been insured?是 Yes 否 No.是否曾经有保险公司拒绝您的投保申请，拒绝续保或加上特殊条件？若有，请详细写明。Has any such insurance ever been declined, has any renewal not been invited or have any special conditions been imposed? If so, please give details是 Yes 否 No.在最近5年内是否发生过损失事故？若是，请详述有关损失情况。Have any loss occurred in the past 5 years? If Yes

13、, please specify the details of loss是 Yes 否 No在过去的三年内曾经投保过的保险公司及所发生的赔案Previous Insurers and claims experience during the last three years.年份Year总工资Total Wages由哪一家公司承保Insured with索赔Claims已决部分SettledNo.金额 Cost索赔Claims未决部分OutstandingNo.金额 Cost声明 Declaration投保人谨此声明，已就上述问卷在自己所了解的范围内进行了详细、真实和完备的陈述。并同意将 上述问卷作为保险人评估风险和出具保单的依据。保险人保证对所了解到的相关信息严格保守秘 密。We hereby declared that the statements made by us in this Questionnaire is to the best of our knowledge and belief, complete and true, and we hereby agreed