机器损坏险保险合同.doc
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1、机器损坏险保险合同机器损坏险投保单MACHINERY BREAKDOWN INSURANCE APPLICATION保单号:_Policy No. _本投保单由投保人尽可能如实地、详细地填写并签章后作为向本公司投保机器损坏险的依据。本投保单为该机器损坏险保险单的组成部分。 The Applicant is required to fill in the following items with utmost faith and as detailed as pos-sible. and affix signature to this application, which shall be th
2、e basis of application to the Company for Machinery Breakdown Insurance and constitute an integral part of the Machinery Breakdown In-surance Policy. 1.被保险人名称和地址Name and Address of the Insured:2.营业性质Nature of Business:3.被保险机器所在地Location of Machinery to be Insured:4.保险期限:个月,年月日零时起至年月日二十四时止Period of I
3、nsurance:Months, from 0:00 ofto 24:00of5.被保险项目及保险金额Insured Items and Sum Insured项目 保险金额每次事故免赔额 Insured Items Sum Insured Deductible for Any One Accident* 5.1 保险财产(详见背面) Property Insured(Look Overleaf)5.2 附加费用Additional Expenses 清除残骸费用Debris Removal Expenses 灭火费用Fire Extinguishment Expinses 专业费用 Prof
4、essional Expenses其他费用 Other Expenses6.总保险金额Total Sum Insured:7.保险费率Premium Rate:8.保险费Premium:每次事故指不论一次事故或一个事件引起的一系列事故 The words ANY ONE ACCIDENT chall mean any one accident or series of accident arising out of one event. 被保险机器的详细说明Specification of Machinery to be Insured项目 型号 数量 主要技术参数 制造商Manufa 制造年
5、份 保险金额 维护及保用期情况Item Model Qty. Major Tech. Parametercturer Year of Manu.Sum InsuredMaintenance & Un-expiredGuarantee Perio说明:(1)主要技术参数指机器的输出功率、速度、容量、负荷等,如属电器设备,应说明电压、电流量、转速,如属蒸气设备,应说明燃料、压力和温度。 (2)维护情况指自行维护(A)、由指定厂家维护(B)、由生产厂家维护(C)。 Note:(1)Major Technical Parameter:Output, Speed, Capacity, Loading e
6、tc. and for Electrical Equipment, Voltage, Amperage, Cycles. and for Steam Equipment, Fuel, Pressure and Temperature. (2)Maintenance: By Insured(A), By Contractor(B), By Manufacturer(c). 9.以前这些机器发生是否发生过损坏?(以往5年) 是否Previous Losses Experience(Last 5 Years) Yes No 项目Item 损坏时间Breakdown Timed 损失金额Loss Am
7、ount10.有无制定操作规程? 是 否Any Operating System? If Yes, Please State.YesNo11.操作人员Operator:11.1 新员工上岗前是否进行岗位教育和培训? 是 否Were the New Operator Trained before Taking up New Post? YesNo11.2 操作人员是否持证上岗? 是 否Are the Operator Working With Qualitication Certificate? YesNo11.3 平均上岗时间是 否The Average Time of Employment
8、in this Post YesNo12.维修情况Condition of Maintenance? 12.1 有无配置专业维修人员? 是 否Any Trained Maintenance Worker?YesNo12.2 是否进行日常的维修和保养? 是 否Any Daily Maintenance?YesNo12.3 大修每隔个月进行一次Ovrhaul EveryMonths是 否YesNo12.4 是否按照生产厂家的要求和规定进行维修和保养? 是 否Procedures Comply with the Requirement of Manufacturer? YesNo13.特别条款Spe
9、cila Provisions:14.备注Remarks: 投保人及被保险人兹声明所填上述内容属实,对贵公司就安装工程一切险条款及附加内容(包括责任免除部分)的说明已经了解,同意按照该条款和附加内容投保安装工程一切险。 I/We(the Applicant & the Insured) to hereby declare that the above contents are truly filled in, and that I/Wehave understood the Companys explanation on the clauses of Erection All Risks In
10、surance and its additionalcontents (including exclusions), and that I/We agree to apply for Erection All Risks Insurance subject to the above-mentioned clauses and its additional contents. 投保人及被保险人(签章) 电话 Signatures of the Applicant & the Insured Telephone地址 日期 AddressDate以下内容由保险公司填写For Office Use O
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