产品责任险风险问卷及投保单

1.投保人名称及地址

Name and Address of Proposer

2.被保险人名称及地址

Name and Address of the Insured

3.被保险人电话及邮编

Telephone No. and Post Code of the Insured

4.被保险人营业性质

Nature of Business of the Insured

制造商（）零售商（）批发商（）进口商（）出口商（）Manufacturer Retailer Wholesaler Importer Exporter

5.保险产品的情况

Description of Insured Products

名称种类性质直接及间接用途销售额销售范围Description Type Nature Direct & Indirect Use Sales V olume Sales Area

合计

Total

6.投保人工厂，商店或仓库的所在地

Location of Insured’s factory, shop or warehouse

7.有无其他分支机构

Is there any other subsidiary

有（）无（）

Yes No

如果有，请列明地址和销售额

If so, please state the address and sales volume

8.投保产品的平均使用寿命

The average life expectancy of the products insured

9.投保产品的销售历史

Sales record

a) 美国/加拿大的产品U.S.A. / Canada Products

请告知过去五年及预估未来年度，贵公司外销美加地区的各项产品销售额

List all products manufactured, sold or distributed by Applicant in or exported to U.S.A./Canada and sales by product for the last 5 years as well as estimated sales for the upcoming year (attach product brochures or other printed material describing products).

b) 其余地区的产品Rest of the World Sales of Products

请告知过去五年及预估未来年度，外销其余地区（不包括美国/加拿大）的各项产品销

售额

List all products manufactured, sold or distributed by Applicant in or exported to Rest of the World (excluding U.S.A./Canada/) and sales by product for the last 5 years as well as estimated sales for the upcoming year (attach product brochures or other printed material describing products).

Do the products insured have package

有（）无（）

Yes No

如果有，请列明为何种包装

If so, please give exact description of the package

11.以往产品与现投保产品能否明显加以区分

Is it possible to distinguish the products insured from the old products

能（）否（）

Yes No

如果能，请列明如何区分

If so, please state the difference

12.投保人的产品或部件是否由其他人生产或提供

Do others manufacture or supply any of Proposer’s products, or any part of Proposer’s products

是（）否（）

Yes No

如果是，请列明

If so, please provide details

13.a) 投保人的产品有没有被作为其他产品的零部件销售？

Are any products sold as components for other products?

有（）无（）

Yes No

如果是，请列明终端产品和用途

If so, please indicate end product and likely use

b)投保人的产品有没有被作为飞机，导弹，航天器或水面船只产品的零部件销售

Are any products sold as components for or use on or with any aircraft, missiles, spacecraft or watercraft 有（）无（）

Yes No

如果是，请提供详细情况

If so, please provide details

14.投保产品是否有使用说明

Are instruction manuals included with the products insured

有（）无（）

Yes No

如果有，是否由除中文以外至少一种以上的语言书写

If so, are the instruction manuals written in at least one foreign language, not including Chinese

15.投保产品是否有明显的警示标志

Are the products insured provided with remarkable warning labels

是（）否（）

Yes No