专业人员职业责任保险投保申请书.docVIP

Specified Professional Liability Proposal Form 专业人员职业责任保险投保申请书 Note: This Policy does not cover any insured event occurred in the following countries: Syria, Iran, Cuba, Burma and Sudan. 注意： 本保险不承保于以下国家发生的保险事故：叙利亚伊朗、古巴、缅甸和苏丹。 I. APPLICANT DETAILS 投保人的基本资料 Name of Applicant/Insured: 投保人/被保险人名称： Applicant’s Organization Code投保人的机构代码: Address(es):地址： Web Site Address: 网址 Establishment Date: 成立日期： II. BUSINESS ACTIVITIES业务活动 2. Please state the following details: 请提供以下详细资料： Number of Partners/Directors/Principals: 合伙人/董事/负责人的人数： Number of Professional Employees: 专业人员的人数： Number of Other Technical Staff: 其他技术人员的人数： Number of Trainee Staff: 受训员工的人数： Number of Non-Technical Staff (i.e. administration, clerical, typists etc.): 非技术人员的人数（如行政、文员、打字员等） 3. Please give the following details of all Partners/Directors/Principals: 请提供所有合伙人/董事/负责人的以下详细资料： Name姓名 Qualifications职位 Years in Industry从业时间 Years as Partner /Director/Principal担任合伙人/董事/负责人的时间 If a Partner/Director/Principal has been working in the relevant industry for less than 3 years, we will require a brief resume outlining career details. 若贵公司上述合伙人/董事/负责人中有从事该行业不足三年者，请提供其个人工作简历。 4. Please provide a full description of the activities of Insured: 请详细描述贵公司的业务活动： 5. Please state, during the past 5 years: 过去5年中， (a) has the name of the Insured(s) been changed? 贵公司是否变更过公司名称？ ?Yes是 ?No否 (b) has any other business(es) been purchased, merged or consolidated with the Insured? 贵公司是否发生过并购或整合？ ?Yes是 ?No否 If “yes”, please provide details on a separate sheet. 如果“是”，请单列一页详细说明。 6. Please provide details of any major new operations undertaken during the last 12 months or planned for the next 12 months. 如果贵公司在过去12个月或拟在将来12个月增设任何重大新业务，请提供详细说明。 7. Please approximate the business activities by percentage of fee income derived.请提供贵公司营业收入的具体业务分类及百分比 Brief Description of Work 业务类别 Percentage (%) 占总收入的百分比 8. Please give names of any professional