产品责任保险风险问询表及投保单.docVIP

Products Liability Insurance Questionnaire and Proposal Page PAGE 1 产品责任险风险问询表及投保单 产品责任保险风险问询表及投保单 Products Liability Insurance Questionnaire And Proposal 投保人声明 Statement of Applicant(s) 我/我们在此声明以下的陈述和详情是真实和准确的，我们并没有谎报或隐瞒任何实质性的事实。我们同意把此风险问询表及投保单和我们提供的任何其他资料作为由此而产生的任何保险合同的基础。 I/We hereby declare that the statements and particulars in what follows are true and correct that we have not misstated or suppressed any material facts. We agree that this Questionnaire and Proposal, together with any information supplied by us, shall form the basis of any contract of insurance affected thereon. 一、被保险人信息（请附单位简介和年度报告） INSURED’S INFORMATION ( Please attach company profile/annual report ) 被保险人 Policy Holder 全称 Full Name 成立日期 Date of Establishment 地址 Principal Address 业务性质 Business □制造商 □ 经销商 Manufacturer Distributor □贸易公司 □ 其他 Trading Company Other 2. 附加被保险人 Additional Insured(s) 全称 Full Name 所属国家 Country 成立日期 Date of Establishment 与被保险人关系 Relationship to Insured 1 □经销商 □其他 Distributor Other 2 □经销商 □其他 Distributor Other 3 □经销商 □其他 Distributor Other (如果有人要求贵公司投保本产品责任保险，请附上他们的书面请求。If anyone require you to have this product liability insurance, please attach a copy of their agreement.) 二、投保产品信息（请提供关于列名产品的简介、使用手册、样品图片） INSURED PRODUCTS’ INFORMATION (Please attach brochures, instruction manuals, pictures of samples etc of all products listed) 1. 生产的产品或分销的产品（非被保险人生产的产品） Products Manufactured / Products Distributed (not own manufacture) 请列出过去及未来年度贵公司生产的产品在世界范围的年销售额。 Please provide the expected/previous sales to worldwide. 产品名称 Products 期限 Period 国内销售 Domestic Sales 出口美加 USA/Canada Sales 出口欧洲 Europe Sales 出口其他 Others Sales 20__ 20__ 20__ 20__