產(chǎn)品責任險風險調(diào)查問卷

1、questionnaire for products liability insurance 產(chǎn)品責任險風險調(diào)查問卷instructions填寫說明please 1. print clearly or type譴清楚填寫或打印本表2. answer all questions completely請完整地回答本表的全部問題3. space is insufficient to answer any question fully, continue on a sepaiate sheet of your firm's letterhead indicating the number of

2、 the questio n.如果空格不夠您完整的回答某些問題，請您繼續(xù)用貴公司的信 紙另外填寫，并標明問題的序號。4. if the answer to any question is "none" state "none：如果某個問題的答案是“無”，請?zhí)睢盁o”。5. application must be signed and dated by owner, partner or officer. 此表必須由雇主、合伙人或有關(guān)負責人填寫并注明日期。important notice重要提示it is your duty to disclose all mater

3、ial facts to company. a material fact is one that is likely to influence an underwriter's judgement and acceptance of your proposal. if your proposal is a renewal, it should also include any change in facts previously advised to underwriters if you are in any doubt about facts considered materia

4、l disclose them. failure to disclose could prejudice your rights to recover in the event of a claim or allow underwriters to void the policy.您有責任將所有重要的信息告知我們公司。重要的信息是影 響承保者判斷和接受您投保的一個可能的因素。如果您是續(xù) 保，也應(yīng)該告知一些原來承保者考慮過但改變的情況。如果 您對一些重要的信息不能確定也告知我們。告知上的疏忽可 能會導(dǎo)致如果發(fā)生索賠，您將損失獲得賠償?shù)臋?quán)利，或者讓 承保人注銷保單。section a genera

5、l information基本信息1 name of company:公司名稱2. principal adress:總公司地址yes no3. does applicant have subsidiaries or divisions? 申請人是否還有其他附屬機構(gòu)？9 if "yes： please specify.如果有請詳細說明4. please tick the business nature of applicant and its subsidiaries and associated companies.請在申請人及其附屬公司的營業(yè)性質(zhì)上打7applicant申請人su

6、b./assoc.附屬機構(gòu)manufacturer 制造商distributor 經(jīng)銷商importer 進口商other (please specify)其他(請詳 細說明)5. how long has the insured been in business?被保險人從事該行業(yè)多久other detailed background information of the insured, is there any website ? 被保人的詳細背景資料，是否有網(wǎng)址可查閱？yes no6. has any insurer ever cancelled or declined your pr

7、oducts liability?以往是否有保險公司取消或降低貴司的產(chǎn)品責任保險? > lfnyes please explain.如果有，請詳細解釋7. does the insured in the usa/canada have a subsidiary affiliate representative others 被保險人在美國或加拿大是否有附屬公司 分公司 聯(lián)絡(luò)處其他if yes, please give name(s), address(es), telephone(s), fax(es) and operation:若有，請列出名稱、地址、電話、傳真及經(jīng)營性質(zhì)&a

8、reas to be covered:承保區(qū)域usa/canada europe australia asia row please specify美國/加拿大歐洲澳大利亞 亞洲世界其他地區(qū)(請詳細說明)9. policy period desired:希望保險期限from 從io 至limit of liability desiredcsl(occurrence/aggregate)保險責任限額合并單一責任額(每一事故/保險期間累積金額)11deductible per occurrence usa/cda每次事故免賠額(美國/加拿大)deductible per occurrence ex

9、cl. usa/cda每次事故免賠額(美國/加拿大除外)12policy trigger desired?希望的保單承保方式？ claims made basis 索賠發(fā)生制 occurrence basis 事故發(fā)生制13 do you require "vendors liability”？是否需要投?！颁N售商責任”？yes no if "yes'： please provide the list of vendor(s) and address(es)< (if there is more than one vendor please indicate

10、salesbreakdown of each vendor:如果需要，請?zhí)峁╀N售商的名稱及地址（如果多于一個銷售商，請?zhí)峁┟總€銷售商的銷售額:）vendor銷售商address地址telephone電話fax 傳真product 產(chǎn)品名稱brand 品牌名稱sales銷售額section b - product and sales data產(chǎn)品及銷售數(shù)據(jù)1. please state all products which you at present produce/distribute.請陳述貴司所有目前生產(chǎn)/銷售的產(chǎn)品2. list any product for which cover

11、is required and tick its current status, where:請列出所有被保險產(chǎn)品并在其目前的狀態(tài)上打(a) all products discontinued or recalled within the last five years (please shortly explain for each).近五年內(nèi)已經(jīng)停止銷售或曾被召回過的產(chǎn)品(請逐一加以簡要說明)(b) all products that have been introduced during the last three years.過去三年內(nèi)推岀的產(chǎn)品(c) all new product

12、s proposed for introduction during the ensuing year 來年將推出的新產(chǎn)品note: any additional product will be covered only from the date on which it is reported to the company. 備注：所有新增產(chǎn)品僅在向保險人報備之日后方可被承保products inchinese 產(chǎn)品中文名稱products inenglish產(chǎn)品英文名稱marketing area 銷售區(qū)域 刁 please tick.請打 vcurrent status 目前狀態(tài) 9pl

13、ease tick 請打 jeurope歐洲australia/new zealand 澳大利亞/新西亠usa/ canada 美/加other其他(a)(b)(c)3. please give territorial split of your turnover by product lines for 請分區(qū)域給出被保險產(chǎn)品年銷售額a. next year (esl.)下一年(預(yù)計)(currency) 貨幣products inchinese 產(chǎn)品中文名稱products inenglish產(chǎn)品英文名稱turnover 年銷售額europe 歐洲australia/newzealand澳

14、大利亞/新西蘭usa/canada 美國/加拿大other其他%b. current year 今年(currency)貨 幣products inchinese 產(chǎn)品中文名稱products inenglish產(chǎn)品英文名稱turnover年銷售額europe歐洲australia/newzealand澳大利亞/新西蘭usa/canada美國/加拿大other其他%c. last year上一年(cuircncy)貨幣products inchinese 產(chǎn)品中文名稱products inenglish產(chǎn)品英文名稱turnover年銷售額europe歐洲australia/newzealand

15、澳大利亞/新西蘭usa/canada美國/加拿大other其他%4. full description of all products to be insured (supported by brochures and illustrations):對所有被保產(chǎn)品的詳盡描述（提供產(chǎn)品指南和說明）:products 產(chǎn)品名稱brand name 品牌function 功能use 用途*physical composition 物質(zhì)構(gòu)成manners of distribution 分銷方式*length of time on the market is 放市場時間*use finished co

16、nsumer products? bulk products? ingredients? components for consumer product? or oem products? or for industrialequipments? complete industrial equipments? etc.用途完整消費產(chǎn)品？散裝貨品？配料？消費產(chǎn)品的零部件？ oem產(chǎn)品？工業(yè)設(shè)備的零部件？或成套工業(yè)設(shè)備？等distribution products sold direct to consumers? to wholcsalcrs/importcrs? to retailers vi

17、a insured's own import/salcs subsidiary? or to nlanufacturcrs who integrate the insureds product into their products?分銷方式-產(chǎn)品是否直接銷售給消費者？批發(fā)商/進口商？通過被保險人自己的進口 /銷售分支機構(gòu)售給零售商?；蚴叟c其他制造 商用做配件？5suppliers and distributors of your products貴司產(chǎn)品的供應(yīng)商和銷售商yes no 口口a. is any product sold as component parts for oth

18、er products?是否有產(chǎn)品是以零件方式銷售？b. could any of your products or services be used on or in connection with:貴司產(chǎn)品或服務(wù)是否會用于 aircraft/missile/aerospace?飛機 / 導(dǎo)彈 / 航空 watercraft or offshore?船舶或海洋c. are any of your products explosive, flammable, or poisonous, either by itselfor in combination with other materials

19、?貴司任何一種產(chǎn)品其自身或與其它材料結(jié)合后是否具有爆炸性、易燃或有毒d. could any of your products be classified as:貴司是否有產(chǎn)品被歸類為：- pharmaceuticals?藥品 cosmetics? 化妝品e. are any of your products sold under another name or label ?貴司產(chǎn)品是否有以其他品牌或商標進行銷售f. do you purchase materials or components from others?貴司是否從他處購買原材料或商品零配件9 please explain a

20、ll of the above "yes” answers below.以上回答如果“是”，請解釋原因a) please provide claims history for the last 3 years (both paid and reserved claims and valuation date)請您提供近三年來索賠的歷史情況（同時包括已決和未決以及估價時間）year日期product產(chǎn)品名稱amount paid賠償金額outstanding amount 未決金額total總計b） describe all losses over $5,000.00（paid or

21、reserved）敘述所有超過五千美元之損失（已決或未決）7. please give a brief description of all claims in the past exceeding 10% of the desired limit of indemnity and/or involving bodily injury in usa/canada.ifi簡單描述一下過去超過預(yù)期賠償限額10%的賠案情況(包括美加地區(qū)人身傷害的賠案)& is there a current carrier?目前有保險公司承保嗎if yes, please indicate the carr

22、ier, the form of the policy and other details 若有，請列出保險公司名稱，并說明保單形式及其他詳細情況section c - processing 包裝/裝配nodo others assemble your product?貴司產(chǎn)品是否由他人裝配yesif "yes'： please indicate dealer, consumer or importer.如果有，請簡要的說明經(jīng)銷商、消費者或進口商2. if assembly is to be done by consumers?產(chǎn)品是否由消費者完成裝配yes no口 口9 i

23、f "yes'： are instructions written in english, or are instructions written in any other language(s)? please specify.如果是，說明書的文 字是英文還是其他語言，請詳細說明。3. do you pack for others?您是否為他人包裝yes no do you pack under trade names other than your own?您是否用他人的商標包裝而非用自己的（兩種情況都有）yes no 9 please indicate percenta

24、ge of total sales rejected by customers due to damage in transit.請您簡要說明由于在運輸過程中損害而導(dǎo)致顧客拒收的商品占整個銷售商品的百分比please describe any written or printed warnings contained on thin film or plastic packaging(or attach them to this questionnaire).請把任何手寫或打印在薄膜或塑膠封帶上的警告寫下來(或把它們貼在該調(diào)查表上)section d - product design 產(chǎn)品設(shè)計

25、1.do you do your own design work?您是否自行設(shè)計yesno2.do you maintain records of design changes and reasons justifying these changes?yesno是否保留有關(guān)設(shè)計變更及設(shè)計變更理由記錄3.are your products designed to meet or exceed government and industry standards?yesno貴司的產(chǎn)品設(shè)計是否符合或超過政府和行業(yè)標準4.do you manufacture your product(s) to the

26、 specifications of your customer?yesno貴司是否會按客戶的指定要求生產(chǎn)section e -quality control and testing 質(zhì)量控制和檢測1.is there a written quality control procedure? 是否有書面質(zhì)量控制程序yesno2.do you have a quality control manager responsible only to top management:yesno貴司是否有僅對最高管理層負責的品質(zhì)控制經(jīng)理3.supplies and components產(chǎn)品材料和零配件yes

27、no are they ordered to your specifications?是否按公司所需的規(guī)格而訂購 have you determined which ones arc critical to the safety of your final product?是否能判斷哪一部分的材料或零部件將影響到貴公司最終產(chǎn)品的安全4. are the warranties obtained from all suppliers? 是否所有供應(yīng)商皆提供品質(zhì)保證final products 成品 is each product subject to and do they confirm wit

28、h applicable safety standards?yesno是否每一項產(chǎn)品均遵循且符合國家標準 what kind of quality certificates has the insured obtained? (attached copy of such certificates) 被保險人已取得何種質(zhì)量認證(請附上證書的復(fù)印件)is09000is09001iso 14000ulcefdaccctuvcsaother certificates 其他認證 what percentage are tested?檢測的百分比are records of results of qual

29、ity control tests kept so that you can identifyyes noat a later date what tests you applied to a given product at a given time?貴司是否記錄了質(zhì)量控制試驗的結(jié)果，以便于在隨后時間里鑒別哪些測試是在既定時間用于既定產(chǎn)品how far back do your records go? (give date)貴司的記錄可以追溯到什么時候(寫明日期)if your products are manufactured to the specifications of your c

30、ustomers,yesnodo they test the product upon receipt?如果貴司產(chǎn)品是按照客戶要求的規(guī)格制造的，他們是否在收貨時進行檢測do you receive an acceptance sign-off from your customer?yesno貴司客戶是否簽字驗收section f - instructions / warnings / advertising / warranties 產(chǎn)品說明書/警告事項/產(chǎn)品廣告/產(chǎn)品保證3a.yes no are hazards inherent in the final product, and warn

31、ings against foreseeable misuse and abuse made known to the ultimate user by:制成品固有的危險和可以預(yù)見的由誤用及濫用造成的危險通過下列哪些措施使最后的使用者得知：yesno warning labels at the point of hazard?提示有風險的警告標簽 written instructions書面說明yesno other means (attach details)其他措施(附上細節(jié))are warnings/instructions警告/說明書用哪種語言書寫yesno in english?用英

32、語 in any other language(s)? please specify.用其他語言？ i青指出。2.are instructions, warnings, labels and advertising texts viewed by an attorney to assure that they are complete and understandable to the ultimate user, and avoid overstatement relative to safety or omissions relative to hazards?使用說明、警示、標簽及廣告內(nèi)

33、容是否經(jīng)由律師確認以便可以完整被最終用戶理解.避免對產(chǎn)品的安全性做夸大或遺漏說明9 if 5,no5 please state who reviews such instructions, warnings, etco果“否”,請指出由誰來審查使用名、警示等3b. if you export to the usa/cda are instructions written 如果貴司產(chǎn)品出口到美加，說明書 in english?用英語書寫 in any other language(s)? please specify.用其他語言書寫？請說明。4. do you expressly disclai

34、m or limit warranties for your products?貴司是否明確限制或拒絕保證貴公司的產(chǎn)品5. are all warranties and/or disclaimers reviewed by a legal counsel?是否所有產(chǎn)品保證/拒賠聲明均由法律顧問審核6. do you provide any specific training or instructions for the ultimate user to use your product properly?貴司是否為最終用戶提供專門培訓(xùn)或課程來使他們正確使用貴司產(chǎn)品7. are salesme

35、n and distributors made aware of your desire to be informed of cases where your product is used for a purpose for which it was not designed?銷售商和分銷商是否意識到貴司希望了解您的產(chǎn)品在哪里被用作什么用途section g -loss prevention and control 預(yù)防損失的控制措施l have your products ever been subject to inquiry or investigation relative to p

36、roduct safety by any governmental agency?貴司產(chǎn)品是否被政府機構(gòu)作過有關(guān)產(chǎn)品安全性的質(zhì)詢或調(diào)查yesnoyesnoyesnoyesnoyes no9 if "yes" attach details.如果有，請附上詳細資料。2.do you have a written products recall plan? 您是否有關(guān)于產(chǎn)品召回的書面計劃？yesno今if "yes", please attach.如果有，請附上。3.have you ever recalled products because of a po

37、tential product safety hazard?yesno今貴司是否因為潛在的安全隱患而召回過產(chǎn)品if "yes： please attach details and indicate percent of recovery 如果有，請附上詳細資料和說明召回比例4.do you have a written products safety program for which specific individualsyesnohave responsibility for implementation?貴司是否為那些有執(zhí)行責任的特殊個體準備了書面產(chǎn)品安全計劃 ilyes：

38、please attach.如果有,請附上。5. what is the life expectancy of your products?您產(chǎn)品的預(yù)期壽命是多少？product （產(chǎn)品名稱）life expectancy (預(yù)期壽命)6. explain how you can identify your products and parts from similar competitors5 products and parts. 請解釋如何區(qū)分您和相似競爭者的產(chǎn)品和零件7. can you determine based on available records for all prod

39、ucts you have sold: 貴司是否能基于已出售產(chǎn)品的有效記錄做出決策 when any given product item was manufactured?既定產(chǎn)品的生產(chǎn)時間 to whom it was sold, and the date of sale?銷售給誰及銷售時間 who supplied parts and supplies going into the final products? 誰提供零配件及哪些零配件將最終進入成品8 do you maintain copies of old manuals and advertising material?貴司是否保存了舊說明書和廣告材料的副本yesnoyesno9. person in -charge the insurance matter in your company? 貴司誰負責保險事宜name （姓名）：tel （電話）：title （職務(wù)）：a. do you have a writ