PDF《公众责任保险投保书》

甲部 投保人资料 Part A Details of The Proposer 保户名称 Name of the Proposer 通讯地址 Mailing Address 行业 Business 电邮地址 联络电话 E-mail Address Contact No.

乙部 投保责任项目 Part B Indemnity Required 保单生效日期 由至(起讫两日均包括在内) Period of Insurance (dd/mm/yy) From To (Both dates inclusive) 投保人对第三者之人身伤亡及财物损失责任 投保人对第三者之人身伤亡责任 Death of or Bodily Injury to Third Party & Damage to Third Party Property Death of or Bodily Injury to Third Party Only 港币 每宗事故之最高赔偿额 投保金额 HK$ for any one Accident Amount of Indemnity 港币 全年之最高赔偿额 HK$ for any one Period 丙部 投保地点资料 Part C Details of Premises to be Insured

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13 14 保户全年营业额 Annual Turnover Number of Hoists or Cranes employed, if any No. of clerical staff/workers who work at the Premises 在投保围外工作之员工数目 No. of workers who work outside the Premises 在投保地点使用或存放之化学品、爆炸品或带有幅 射之物品资料,如有 Details of Chemicals or Explosives or Radioactive Materials used or stored, if any 公众责任保险投保书Public Liability Insurance Proposal Form 合约总额,如涉及合约工程 坐位数量 (只适用於学校、教堂、酒楼或相关行业) Seating Capacity, if the occupation is a school, church, restaurant or the like 会员人数 (只适用於会所) No. of Members, if the occupation is a club 投保会涉及之承办商,如有 Sub-contractor for which cover is required, if any Contract Price, if a contract exists 投保地点 Situation of Premises 在投保围内进行之活动 Occupancy/Activities being carried out in the Premises 投保地点的总面积 Floor Area of the Premises 在投保围内工作之员工数目 机器或其他机械设备之资料,如有 Details of Machinery, Electrical or other Mechanical Appliances, if any 起重机之数量,如有 房间数量 (只适用於酒店) No. of Bedrooms, if the occupation is a hotel

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16 阁下是否在申请上述保险或续保时被拒绝p撤回p取消或附加特别条款? Have you ever been declined, cancelled, refused or imposed special terms when you apply or renew the above mentioned Insurance?

17 在过去三年内o阁下是否向保险公司索取赔偿? Have you make any claims during the past

3 years? 阁下如在上述第16项或第17项回答 "是", 请详述之. If your answer is "Yes" in Question

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17 above, please give details. 丁部 付款方式 Part D Payment Method 支票付款 Cheque 划线支票抬头人请填写"中国太平洋保险(香港)有限公司" Please cross your cheque and make it payable to "CHINA PACIFIC INSURANCE CO., (H.K.) LTD." 现金付款 Cash 请亲临中国太平洋保险(香港)有限公司 地址 : 香港湾仔港湾道18号中环广场4301室Address : 收集个人资料声明 阁下提供的资料,为本公司提供保险业务所需,并可能使用於下列目的: ?任何与保险或财务有关的产品或服务或该等产品或服务的任何更改、变更、取消或续期 Personal Data Collection Statement The information you provide to us is collected to enable us to carry on insurance business and may be used for the purpose of ?any insurance or financial related product or service or any alternations, variations, cancellation or renewal of them. ?any claim or analysis of it. 声明 本人/公司申请投保资料於上所述,本人/公司现声明以上资料俱属真实,并无虚报事情. 本人/公司保证遵守政府机构所公布之一切有关各项规章条例及任何通告. 本人/公司同意本声明及上述所签各节应为本人/公司与中国太平洋保险(香港)有限公司立约之基础,并同意根５ド纤丶八⒅蹩,接受该公司保单. Declaration I/We undertake that all statutory requirements and all bye-laws and regulations imposed by any public anthourity are duly observed and complied with . I/We agree that this proposal and declaration and the answers given above shall be the basis of the contract between myself/ourselves and China Pacific Insurance Co., (HK) Ltd. Rate and Excess Suite 4301, 43/F., Central Plaza,