1999 OVERSEAS RENEWAL QUESTIONNAIRE - 上海星 .doc

INSURANCE RISK EXPOSURE QUESTIONAIRE 保险风险调查表 上海星达保险经纪有限公司 UNISTAR INSURANCE BROKERAGE CONSULTING (SH) LTD. INSURANCE QUESTIONNAIRE This form has been completed by 填表人 __________________________________ Position 职务 ____________________________________ Company 公司 ___________________________________ Telephone No. 电话 _______________________________ Currency: Values shown in this Questionnaire shall be in RMB. 币种: 本问卷中所填金额的币种为人民币。 Declaration声明 We hereby declare that the information provided in this questionnaire is true and complete to the best of our knowledge. We agree that this questionnaire shall be the basis of the insurance contract between us and the insurer. 我们在此声明本问卷中提供的信息系我们所知的真实、完整的情况。我们同意本问卷成为保险人与我们之间达成保险合同的基础。 Date日期__________________________ Signature签名 _____________________ Please return this form completed TO: 请填写该调查问卷并发至： Account Manager Email Address 上海星达保险经纪有限公司 Address of Broker: 上海浦东新区东方路989号中达广场1002A室 TELEPHONE NO : 021666 FACSIMILE NO : 021 IMPORTANT NOTICE CONCERNING DISCLOSURE 告知义务 It is your duty to disclose all material facts to underwriters. A material fact is one which may influence an underwriters judgement in his consideration of your risk as to whether to provide insurance and on what terms. It is likely that any change in facts previously advised will be material and such changes should therefore be notified. 您有责任将所有重要事实告知保险公司。所谓重要事实是指任何足以影响保险公司作出是否承保风险以及以何种条件承保风险的信息。如已告知的重要事实发生变化，您仍需要将该变化通知保险公司。 This duty places a responsibility on you to disclose all material facts. The questions in this questionnaire provide a helpful way of enquiry, but should not be taken as limiting the duty of disclosure. If you are in any doubt as to whether a fact is material you should disclose it. 这一义务赋于您告知所有重要事实的责任。该调查问卷只是帮助询问重要事实，这并不意味您的告知义务仅限于此。如果您无法确定某一事实是否属于重要事实，请将该事实告知我们。 FAILURE TO DISCLOSE could prejudice your right to recovery in the event of a claim or allow unde