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1、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 QUESTIONNAIREThis 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
2、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
3、this form completed TO:请填写该调查问卷并发至：Account Manager & Email AddressInsurance Broker: UNISTAR Insurance Brokerage & Consulting (Shanghai) Ltd. 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: 021-68762600*666FACSIMILE NO: 021-68767730IMPORTANT NOTICE CONCERNING DISCLOSURE 告知义务It is
4、 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 c
5、hanges 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 limiti
6、ng 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 underwriters to avoi
7、d the policy from its inception.未履行告知义务会影响您的索赔权利或使保险公司有权自保单生效之日起取消保单。Appropriate enquiries should be made to ensure that the answers set forth herein are true and complete and that no material fact has been omitted. Any change in the answers given and any material change in the risk arising before i
8、nception of your policy must be advised to us and should therefore be notified immediately.在填写调查问卷时，应保证答案是正确完整的，重要事实没有被忽略。在保单正式生效前，如已填写的有关情况发生变化或有关风险的重要事实发生变化，请立即通知我们。UNDERINSURANCE 不足额保险Many policies contain a Co-insurance (or Average) provision whereby you may be required to bear a rateable propor
9、tion of the loss in the event that the sum insured is less than the value of the insured property at the commencement of the insurance.大多数保单都包括共保（或比例分摊）条款，该条款规定，如果保险金额小于保单生效时的保险财产的价值，您需承担一定比例的损失。UTMOST GOOD FAITH 最大诚信原则Every contract of insurance is based on “Utmost good faith” which requires each p
10、arty (i.e. you and the insurer) to act towards the other party in respect of any matter arising under the contract, with the utmost good faith. If you fail to do so you may prejudice any claim.每一份保险合同都是建立在最大诚信原则的基础上，这一原则要求合同双方（您和保险公司）在保险合同下的任何行为都应遵循最大诚信原则。如果您没有遵循该原则，这将会影响您的索赔权利。GENERAL INFORMATION4基
11、本情况INSURANCE POLICY INFORMATION4现有保险基本情况企业基本风险保障PROPERTY DAMAGE INSURANCE6财产一切险PROPERTY EXPOSURE DATA10财产保险风险数据BUSINESS INTERRUPTION INSURANCE13利润损失保险BUSINESS INTERRUPTION WORKSHEET16营业中断保险表格(Gross Profit Form)16BUSINESS INTERRUPTION WORKSHEET19营业中断保险表格(Gross Earnings Form)19MACHINERY BREAKDOWN & MA
12、CHINERY BREAKDOWN BUSINESS INTERRUPTION INSURANCE24机损险及机损险营业中断保险MONEY INSURANCE27现金保险OPEN MARINE CARGO INSURANCE30货物运输开口保单INLAND TRANSIT INSURANCE35内陆运输保险EMPLOYERS LIABILITY INSURANCE38雇主责任保险PUBLIC LIABILITY INSURANCE39公众责任保险PRODUCTS LIABILITY INSURANCE43产品责任保险FIDELITY GUARANTEE INSURANCE50雇员忠诚保险企业员
13、工福利保险风险保障EMPLOYEE BENEFIT INSURANCE 员工福利保险企业员特殊保险风险保障DIRCTORS & OFFICIALS LIABILITY INSURANCE董事及高级管理人员责任保险TRADE CREDIT INSURANCE信用保险保险CONSTRUCTION / ERECTION ALL RISKS INSURANCE58建筑及安装工程一切险GENERAL INFORMATION基 本 情 况1. The current Named Insured in terms of your major policies is as follow:目前，贵司保单中的列明
14、被保险人是: 2.List ALL business activities, please provide particular details of any part of the business, where design or advice is provided to customers in the absence of sale or supply of products/services.请列明贵公司所有的营业活动，如贵公司并不是销售产品或提供服务，只是向客户提供设计或专家建议，请提供该营业活动的详情。3. Have you acquired or disposed of an
15、y subsidiaries during the year? YES/NO 一年间, 贵司是否开办或关闭任何子公司? 是/否a. If YES please supply details:如果是，请具体说明： b. If you have acquired the liabilities of any company we will need to tailor your insurance program to meet these circumstances, so please advise full details of any such acquisition(s)。如果贵司取得了
16、其他公司的责任或债务，我们需要为您调整保险方案以满足您的具体需要，因此建议您如有上述情况，请将详细情况提供给我们。4. Are any non subsidiary companies to be covered by any of your policies i.e. joint venture or companies where your shareholding is 50% or less etc? YES/NO是否有非贵司子公司的其他公司加入贵司的保单，例如，合资公司或贵司持股等于或少于50%的公司？是/否If YES, please supply details:如果是，请具体说
17、明： 5. Do any of your companies have property, operations or any other U.S domiciled exposures (i.e. incorporated companies etc.) ?YES/NO 贵司在美国是否拥有任何财产、营业机构或者其他存在于美国的风险单位（如在美国组建的公司，等等）？ 是/否6. Some policies contain a provision that has the effect of limiting or excluding the insurers liability in resp
18、ect of a loss if you have entered into an agreement that limits or excludes your right to recover damages from a third party. Therefore, you should not sign any agreement which contains a “hold harmless” or waiver clause without reference to Insurance Broker. 假如贵司签订了发生损失时限制或排除贵公司向第三方求偿的协议，则某些保单也会相应规
19、定限制或排除保险公司的责任。因此，贵司不得在经纪公司未知情的情况下签订任何包含“免责”或“自动放弃”条款的协议。7. 其他公司信息公司信息 Company Information公司全称 (中文)类型 Ownership TypeCompany Name (English)客户编号(key)是否现有客户Existing Customer如选是,选择投保险种 If yes, list products 主地址Main Address选择市总机 Telephone公司网站 Website传真 Fax总经理 GMs Name地址1Address 2中国区总部 China Head Office中国员
20、工人数 Employees in China行业 Industry总资产 Total Assets年销售额 Annual Sales Turnover年出口额 Annual Export Turnover备注关联公司 Affiliated Companies母公司子公司INSURANCE POLICY INFORMATION现有保险基本情况保险保障是否投保承保公司到期日企业基本风险保障1财产一切险2财产保险风险数据3利润损失保险4营业中断保险表格5营业中断保险表格6机损险及机损险营业中断保险7现金保险8货物运输开口保单9内陆运输保险10雇主责任保险11公众责任保险12产品责任保险13雇员忠诚保
21、险企业员特殊保险风险保障14董事及高级管理人员责任保险15信用保险保险16建筑及安装工程一切险企业员工福利保险风险保障17高级管理人员高端医疗保险18团体意外保险19团体人寿险20门急诊21住院医疗22重大疾病23商务旅行保险24牙科体检等其他福利项目* 请提供保险单或保险单明细表，以便进行保单对比及评估。PROPERTY DAMAGE INSURANCE财 产 损 失 保 险It is important that the attached schedule is completed/updated as fully as possible (please see guidance note
22、s for completion below).请尽可能完整填写/更新所附表格（以下 是有关填写该表格的指南）。Buildings:建筑物Values should be given on a reinstatement basis. i.e., the cost of rebuilding as at renewal date including professional fees. Please state if there are any leased/rented properties and confirm who is responsible to insure.该项价值应以重建价
23、值为基础，即在续保日的重建成本，包括专业费用。如有租入或租出财产，请注明，并确定负责购买保险的一方。Machinery, Equipment & Other Contents:机器设备及其它室内财产Values should be the cost of replacement as new and include all contents including property for which you are responsible other than该项价值应以新重置成本为基础，包括您所负责的所有室内财产，以下财产除外：i)Money 现金ii) Stock 库存iii) Other
24、property specifically excluded by policy 保单列明除外财产Computer Equipment:计算机设备Values should be the cost of replacement as new该项价值应以新重置成本为基础。Advertising Signboard:广告牌Values should be the cost of replacement as new该项价值应以新重置成本为基础。Retail Equipment:零售设备Values should be the cost of replacement as new该项价值应以新重置成
25、本为基础。Stock & Work in progress:库存及在产品Give the maximum value expected to be held at any one time during the policy period. Values should be based on Cost value.请提供保险期限中任一时点的预计最大库存量。该项价值以成本价为基础。Others:其它财产Value should be the cost of replacement as new该项价值应以新重置成本为基础。LOCATION 保险地址(Full Address)（详细地）BUILD
26、ING建筑物EQUIPMENT机器设备COMPUTER计算机设备SIGN BOARDS广告牌RETAILEQUIPMENT零售设备STOCK存货OTHERS其它财产* Location: Please list all locations where you have property to insure.保险地址：请列出所有放置投保资产的地址。PROPERTY EXPOSURE DATA财产风险状况(Separate sheet to be completed for each major location)（请就每一主要地点财产风险状况单独填写）Location地点: Building 1
27、Building 2Building 3建筑物甲建筑物乙建筑物丙Usage of Building建筑物用途(i.e. office, manufacturing,warehousing, etc.)（如办公、生产、仓库等） _ Size of Building建筑物大小Number of floors层数 Area occupied per floor每层面积 Construction of Building建筑物结构(i.e. concrete, asbestos, zinc, timber. If others,please specify.)（如混凝土、石棉、锌木材等。其他请注明）Wa
28、lls墙壁 _ Floors地板 _ Roofs屋顶 _ Year of Construction建筑年份 _Building Protection保护设施情况Yes有 No无 Fire Extinguishers灭火器 Indoor Fire Hydrant室内消防水龙 Outdoor Fire Hydrant室外消防水龙 _Public Fire Hydrant公用消防水龙 _ Automatic Sprinkler System自动喷淋装置 _ Smoke/Heat Detectors/Alarm System烟/热监测报警系统 Water Pump solely for fire pr
29、otection消防水泵 Burglary Alarm System防盗报警系统 24 hour Watchman Service24小时保安服务 Trained in-house Fire Brigade内部消防人员 Public Protection公共保护措施If a fire breaks out, estimate the time the Public/Volunteer Fire Service will take to arrive: minutes若发生火灾，估计消防人员将用多长时间到达现场？_分钟。Plot Plans图示Please attach roughly scal
30、ed plot plans of premises and property.请附上房屋与财产的大致草图。Mortgagee (specify name of bank and specify property mortgaged)抵押权人（银行名称及抵押财产情况 ） 5 Years Loss Experience (Insured and Uninsured) 五年来损失记录（保险及未保险的）Date日期 Details详情 Amount金额 BUSINESS INTERRUPTION INSURANCE营 业 中 断 险Insured Value保险金额1.Gross Profit毛利润:
31、 2.Wages工资: (Ordinary Payroll)普通直接工资3.Auditors Fee审计师费用: (The worksheet attached shows the recommended method of computing the insured values.)（所附工作表将列明计算保险金额的方法。）Interruption Period中断期间This represents the maximum period during which your business could be affected as a result of a serious damage.即损
32、害发生后贵司业务被迫中断的最长时间。When a major loss happen (consider the worst case scenario): 当一个重大损失发生时（请考虑最坏情况）：1. How long will it take to reinstate the building following a major loss? 修复建筑物需要多长时间？ Months个月2. How long will it take to replace key machinery following a major loss?重置主要机器设备需要多长时间？ Months 个月3. How
33、long will it take to reinstate the sales position following a major loss?恢复到灾前的销售水平需要多长时间？ Months个月4.In the event of a major loss or damage to the plant/premises, what contingency plans have been made for use of substitute facilities or equipment?若工厂/房屋遭受重大损失，将采用何种计划以使用备用的设施及设备？ 5.Please identify key machinery. 请注明主要机器设备。 Contingency Cover对其他意外的保障Please list the major Suppliers and Customers where the loss at their premises would affect 20% or more of the Insureds sales.请列明将影响被保险人销售业绩20%或更多的主要供货商及顾客的有关情况。Supplier/% SalesNameCustomerProductCountryAffected名称 供货商/顾客 产品国家销售受影响的比例1 2 3
