雇主責(zé)任險(xiǎn)問(wèn)卷新

1、雇主責(zé)任險(xiǎn)風(fēng)險(xiǎn)調(diào)查問(wèn)卷Questionnaire for Employers Liability Insurance基本信息 General Information公司名稱(chēng)： (Name) 建立時(shí)間： (When was the firm established?) 營(yíng)業(yè)性質(zhì)： (Stated Occupation) 業(yè)務(wù)范圍： (Scope of business) 被保險(xiǎn)人是：(Named Insured is)夕卜商獨(dú)資 (Wholly foreign owned enterprises ) 中夕卜合資 (Sino-foreign joint venture )中外合作(Contract

2、ual joint venture/cooperative operation business )涉外貿(mào)易(Foreign trade enterprise)其他(Others)投資夕卜方為( Company/region of the foreign investor )：聯(lián)系地址： (Postal Address) 電話(huà)及傳真： (Telephone Number and Fax Number) 標(biāo)的位置： (Location of Risk) 希望的保險(xiǎn)期限：(When the insurance to commence) 從 (From) 至 (To) 生產(chǎn)狀況 Operation/

3、 Manufacturing Status.生產(chǎn)流程O(píng)peration/ Manufacturing Process.貴公司是否使用酸性物質(zhì)或任何可燃性、易爆、有毒、帶輻射或其他任何有危險(xiǎn)的材料，如有， 請(qǐng)說(shuō)明，并說(shuō)明使用程度：Have you any acids or material which are inflammable, explosive, poisonous, radioactive or in any way dangerous? If so, give full particulars, and specify to what extents:.貴公司是否有機(jī)器通過(guò)蒸汽、燃

4、汽、水、電力或其它機(jī)械動(dòng)力驅(qū)動(dòng)？如有，請(qǐng)?jiān)敿?xì)列明：Have you any circular saws or other machinery driven by steam, gas, water, electricity or other mechanical power? If so, give full particulars:.貴司使用何種類(lèi)型的鍋爐?What boilers have you?工種分類(lèi)與預(yù)計(jì)年收入 Position and Estimated Annual Payroll列舉貴公司給雇員的預(yù)計(jì)年收入。年收入必須包括所有的工資、薪水、獎(jiǎng)金、小費(fèi)、加班費(fèi)或其它 的特殊酬勞

5、或類(lèi)似的津貼。State the estimated annual earnings to be paid to your employees. The earnings declared must include all salaries, wages, bonuses, tips and overtime payments or other special remuneration received by an employee and any other similar allowances.(i)正式員工 FULL-TIME employees雇員情況Description of Em

6、ployees預(yù)計(jì)員工總數(shù)Estimated Number of Employees 預(yù)計(jì)年薪及其它津貼 Estimated annual salaries, wages and other earnings(a)文職人員和管理人員Clerical and Administrative Staff (b)操作工人Employees engaged with woodworkIng machinery including machinists and machinists labourers (c)司機(jī)Driver (d)其它All others (as specified below) 在過(guò)去

7、的12個(gè)月中付給上述員工的工資、薪水及其它津貼的總數(shù)是 The total amount of salaries, wages and other earnings paid by us to the above mentioned employees during the past twelve months was(ii)臨時(shí)員工 PART-TIME employees職位預(yù)計(jì)工人數(shù)目預(yù)計(jì)收入從其他雇主處獲得到收入OccupationEstimated No. of Employees Estimated Earnings Other Earnings to be Receivedto b

8、e paid by youfrom other Employment(iii)若有分承包商，請(qǐng)說(shuō)明 SUB-CONTRACTORS-If you employ any, please state:承包商的姓名Name of Contract-or分包工作性質(zhì)Nature of work sub-let如果僅是提供勞工合同 請(qǐng)列明合同金額In case for which the Contract is for labour only, state amount of contract如果合同是提供勞工和材 料，請(qǐng)列明預(yù)計(jì)的合同金額 If contract is for both labour

9、and materials state estimatedamount of contract.上表是否已包括每個(gè)崗位上的所有正式員工？Do all your full-time employees of every position be included in the above table?是 Yes 否 No.上表是否已包括所有臨時(shí)工？Do all your part-time employees be included in the above table?是 Yes 否 No.貴司是否有外籍員工？如果是，請(qǐng)單獨(dú)列出該員工的職位及工資。Do you hire foreign empl

10、oyees? If Yes, please give details of the Position and show salaries separately.是 Yes 否 No.您在下表中所提供信息僅包括按上海市政府頒布的上海市工傷保險(xiǎn)實(shí)施辦法 有關(guān)規(guī)定參加工傷保險(xiǎn)且為其繳納工傷保險(xiǎn)費(fèi)的員工；不包括參加上海市外來(lái)從業(yè)人員綜合保險(xiǎn)的員工：（繳費(fèi)工資：保險(xiǎn)費(fèi)收繳和理賠支付均以投保人繳納工傷保險(xiǎn)費(fèi)基數(shù)為基礎(chǔ)。該基數(shù)按投保人繳納城鎮(zhèn) 養(yǎng)老保險(xiǎn)費(fèi)或者小城鎮(zhèn)社會(huì)保險(xiǎn)費(fèi)基數(shù)確定。雇員個(gè)人的繳費(fèi)工資即為參照上述方法確定的數(shù)額。）雇員工作種類(lèi)雇員人數(shù)估計(jì)年預(yù)計(jì)繳費(fèi)工資總額.貴司是否要求保單擴(kuò)展“國(guó)內(nèi)差旅擴(kuò)展

11、責(zé)任”？Do you require extend “ Domestic BusinessLlaibiiey under this Policy?是 Yes 否 No.貴司是否要求保單擴(kuò)展“海外差旅擴(kuò)展責(zé)任”？如果是，請(qǐng)給出可能前往的國(guó)家的名稱(chēng)。Do you require extend “ Overseas BusinessJOiaHity under this Policy? If Yes, please give details of countries may involved.是Yes 否No損失記錄Loss Record.貴司以前是否投保過(guò)？Have you previously

12、been insured?是 Yes 否 No.是否曾經(jīng)有保險(xiǎn)公司拒絕您的投保申請(qǐng)，拒絕續(xù)?；蚣由咸厥鈼l件？若有，請(qǐng)?jiān)敿?xì)寫(xiě)明。Has any such insurance ever been declined, has any renewal not been invited or have any special conditions been imposed? If so, please give details是 Yes 否 No.在最近5年內(nèi)是否發(fā)生過(guò)損失事故？若是，請(qǐng)?jiān)斒鲇嘘P(guān)損失情況。Have any loss occurred in the past 5 years? If Yes

13、, please specify the details of loss是 Yes 否 No在過(guò)去的三年內(nèi)曾經(jīng)投保過(guò)的保險(xiǎn)公司及所發(fā)生的賠案Previous Insurers and claims experience during the last three years.年份Year總工資Total Wages由哪一家公司承保Insured with索賠Claims已決部分SettledNo.金額 Cost索賠Claims未決部分OutstandingNo.金額 Cost聲明 Declaration投保人謹(jǐn)此聲明，已就上述問(wèn)卷在自己所了解的范圍內(nèi)進(jìn)行了詳細(xì)、真實(shí)和完備的陳述。并同意將 上述問(wèn)卷作為保險(xiǎn)人評(píng)估風(fēng)險(xiǎn)和出具保單的依據(jù)。保險(xiǎn)人保證對(duì)所了解到的相關(guān)信息嚴(yán)格保守秘 密。We hereby declared that the statements made by us in this Questionnaire is to the best of our knowledge and belief, complete and true, and we hereby agreed