电话号码 /传真号码
Telephone Number / Fax Number _______________________________________________________________
被保险人营业执照的注册地址是否在浦东？
Is the registered address on the Assured's Business License
in Pudong? 是Yes o 否No o
保险期限 从 至
Period of Insurance From ______________________________ To
________________________________
1
明细表中是否包含Does the Schedule include
(i) 每个岗位上的所有正式员工All your full-time employees of every
description?
(ii) 所有的临时工All part-time employees?
(i) 是Yes
否No
(ii) 是Yes
否No
2
贵公司是否要求保单扩展承保公司员工到国外出差?如果有,请给出具体的国家名称,单独列出该员工工资Do
you require the geographical area of the policy extended
beyond Shanghai in respect of employees working abroad?
If so, please give details of countries involved and show
wages separately on next page.
是Yes
否No
细节Details ___________________
3
(a) 贵公司是否有机器通过蒸汽、燃汽、水、电力或其它机械动力驱动?如有,请详细列明Have
you any circular saws or other machinery driven by steam,
gas, water, electricity or other mechanical power? If
so, give full particulars.
(b) 贵公司是否能合理地维护和看管机器设备、厂房和道路，并使其处在良好状态下Are your machinery,
plant and ways properly fenced and guarded and otherwise
in good order and condition?
请列明贵公司使用何种酸性、可燃性、化学性或易爆炸材料，并说明使用程度State
what acids, gases, chemicals or explosives will be used
and to what extent
6
(a) 贵公司是否曾申请过此类保险Have you ever
proposed for this kind of insurance?
(b) 是否曾经有过保险公司拒绝您的投保申请,拒绝续保或加上特殊条件吗? 若有,请详细写明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
在过去的三年内曾经投保过的保险公司及所发生的索赔记录Previous
Insurers and claims experience during the last three years
年份Year
由哪一家公司承保Insured With
索赔 Claims
已决部分Settled
未决部分Outstanding
No.
金额Amount
No.
金额Amount
8. 列举贵公司付给雇员的预计年收入。年收入必须包括所有的工资、薪水、加班费、奖金及其它津贴
State the estimated annual earnings to be paid to your employees.
The earnings declared must include all salaries, wages, overtime
payments, bonuses and other allowances payable by the insured
to his employees.
(i) 正式员工
FULL-TIME employees
雇员情况DESCRIPTION OF EMPLOYEES包括所有正式员工,并单独给出在上海以外工作的员工详情Include
all full-time employees and give separatedetails for those
working outside Shanghai
预计员工总数Estimated Number of Employees
预计年薪及其它津贴Estimated annual salaries, wages and other
earnings
(a) 文职人员和管理人员Clerical and Administrative Staff
(b) 销售人员Sales Person
(c) 操作工人Machinists and Machinists Laborers
(d) 司机Drivers
(e) 其它All others (as specified below)
(ii) 临时员工
PART-TIME employees
贵公司须申报该员工所有的收入,包括从贵公司雇佣合同中或从其它雇主那知道的这些情况
You should declare here the TOTAL earnings received by such
employees, both from their employment with you and from their
other employers if information on such other employment has
been supplied to you
临时员工详情
Description of Part-time Employees
职位Occupation
预计工人数Estimated Number of Employees
预计收入Estimated Earnings to be Paid
by you
从其他雇主处获得的收入Other Earnings to be Received
from other Employment
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
声明事项 Declaration
我们声明根据我们所知及所信在本投保书内填报的资料为真实的,且所有会影响风险评估的细节均已填报。如隐瞒任何重要事实,均可导致本保险单失效。我们同意将本投保书及声明事项作为我们与皇家太阳联合保险公司订立保险合约的基础。
We declare the information given is true to the best of our
knowledge and belief and that all particulars affecting the
assessment of risk have been disclosed. Failure to disclose
all material information could invalidate the insurance. We
further agree that this proposal and declaration shall be
the basis of the contract between us and the Company.
投保人签名 日期
Signature of Proposer ___________________ Date__________________
以下仅供保险公司使用 Insurers Use Only
Occupation __________________ U/W Category ________________
EML______________________
本投保书需经保险人正式接纳或正式的暂保单签发后,保险人的保险责任才正式生效。
The liability of the Insurers does not begin until the Proposal
has been formally accepted by the Insurers or official cover
note issued.
