产品责任险问卷

1. 2. 3.

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NAME OF COMPANY: 公司名称

PRINCIPAL ADRESS: 总公司地址 Does applicant have subsidiaries or divisions? 申请人是否还有其他附属机构?

If ”YES”, please specify. 如果有，请详细说明

__________________________________________________________________________________________________________

YES NO ❑

❑

________________________________________________________________________________________________

4. Please tick the business nature of Applicant and its subsidiaries and associated companies.

How long has the Insured been in business? 被保险人从事该行业多久 Other detailed background information of the Insured, is there any website ？被保人的详细背景资料，是否有网址可查阅？

__________________________________________________________________________________________________________

________________________________________________________________________________________________

Has any insurer ever cancelled or declined your products liability? 以往是否有保险公司取消或降低贵司的产品责任保险？

YES NO ❑

❑

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If ”YES”, please explain. 如果有，请详细解释

__________________________________________________________________________________________________________

________________________________________________________________________________________________

Does the Insured in the USA/Canada have a Subsidiary Affiliate Representative Others 被保险人在美国或加拿大是否有附属公司分公司联络处其他 If yes, please give name(s), address(es), telephone(s), fax(es) and operation: 若有，请列出名称、地址、电话、传真及经营性质

Areas to be covered: 承保区域

❑USA/Canada ❑ Europe ❑ Australia ❑ Asia ❑ ROW ☐ Please Specify______________

美国/加拿大欧洲澳大利亚亚洲世界其他地区（请详细说明）

9. Policy period desired: 希望保险期限

From 从________________________________to至_______________________________________

10. Limit of liability desired ________________________CSL(occurrence/aggregate)

保险责任限额合并单一责任额(每一事故 / 保险期间累积金额)

11. Deductible per occurrence USA/Cda 每次事故免赔额（美国/加拿大）_______________________

Deductible per occurrence excl. USA/Cda 每次事故免赔额（美国/加拿大除外）________________________

12. Policy Trigger desired？希望的保单承保方式？

□ Claims made basis 索赔发生制 □ Occurrence basis 事故发生制

13. Do you require ”Vendors Liability”? 是否需要投保“销售商责任”？

YES NO ❑

❑

→ If ”YES”, please provide the list of vendor(s) and address(es). ( If there is more than one vendor, please indicate sales

Please state ALL products which you at present produce/distribute. 请陈述贵司所有目前生产/销售的产品

List any product for which cover is required and tick its current status, where: 请列出所有被保险产品并在其目前的状态上打√

(A) All products discontinued or recalled within the last five years (please shortly explain for each).

近五年内已经停止销售或曾被召回过的产品（请逐一加以简要说明） (B) All products that have been introduced during the last three years.

过去三年内推出的产品

Note: any additional product will be covered only from the date on which it is reported to the Company.

来年将推出的新产品

备注：所有新增产品仅在向保险人报备之日后方可被承保

3. Please give territorial split of your turnover by product lines for 请分区域给出被保险产品年销售额 a. Next year (est.) 下一年（预计）____________

b. Current year 今年____________

c. Last year 上一年____________

4. Full description of all products to be insured (supported by brochures and illustrations):

*Use - finished consumer products? bulk products? ingredients? components for consumer product? or OEM products? or for industrial equipments? complete industrial equipments? etc.

用途 - 完整消费产品？散装货品？配料？消费产品的零部件？OEM 产品？工业设备的零部件？或成套工业设备？等。 *Distribution - products sold direct to consumers? to wholesalers/importers? to retailers via insured's own import/sales subsidiary? or to manufacturers who integrate the insured's product into their products?

分销方式 - 产品是否直接销售给消费者? 批发商/进口商? 通过被保险人自己的进口/销售分支机构售给零售商? 或售与其他制造商用做配件？

Suppliers and distributors of your products 贵司产品的供应商和销售商

a. Is any product sold as component parts for other products? 是否有产品是以零件方式销售？

YES NO

b. Could any of your products or services be used on or in connection with: 贵司产品或服务是否会用于

- -

❑

aircraft/missile/aerospace?飞机/导弹/航空 Watercraft or offshore? 船舶或海洋

❑ ❑ ❑

❑ ❑ ❑ ❑

c. Are any of your products explosive, flammable, or poisonous, either by itself

or in combination with other materials?

贵司任何一种产品其自身或与其它材料结合后是否具有爆炸性、易燃或有毒 d. Could any of your products be classified as: 贵司是否有产品被归类为：

- -

pharmaceuticals? 药品 cosmetics? 化妆品

❑ ❑ ❑ ❑

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e. Are any of your products sold under another name or label ? 贵司产品是否有以其他品牌或商标进行销售 f. Do you purchase materials or components from others? 贵司是否从他处购买原材料或商品零配件

Please explain all of the above ”YES” answers below. 以上回答如果“是”，请解释原因

__________________________________________________________________________________________________________

________________________________________________________________________________________________

Please provide claims history for the last 3 years (both paid and reserved claims and valuation date)请您提供近三年来索

B ） Describe all losses over $5,000.00(paid or reserved) 叙述所有超过五千美元之损失（已决或未决）

________________________________________________________________________________________________

__________________________________________________________________________________________________________ Please give a brief description of all claims in the past exceeding 10% of the desired limit of indemnity and/or involving bodily injury in USA/Canada. 请简单描述一下过去超过预期赔偿限额10%的赔案情况（包括美加地区人身伤害的赔案）

Is there a current carrier? 目前有保险公司承保吗 YES NO

If yes, please indicate the carrier, the form of the policy and other details 若有，请列出保险公司名称，并说明保单形式及其他详细情况 1. →

Do others assemble your product? 贵司产品是否由他人装配

If ”YES”, please indicate dealer, consumer or importer.如果有，请简要的说明经销商、消费者或进口商

If assembly is to be done by consumers? 产品是否由消费者完成装配

文字是英文还是其他语言，请详细说明。 3.

__________________________________________________________________________________________________________ Do you pack for others? 您是否为他人包装

Do you pack under trade names other than your own? 您是否用他人的商标包装而非用自己的

请您简要说明由于在运输过程中损害而导致顾客拒收的商品占整个销售商品的百分比

YES NO ❑ ❑

❑ ❑

YES NO

YES NO ❑

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YES NO ❑

❑

__________________________________________________________________________________________________________ ❑ ❑

2. →

If ”YES”, are instructions written in English, or are instructions written in any other language(s)? Please Specify.如果是，说明书的

→ Please indicate percentage of total sales rejected by customers due to damage in transit.

________________________________________________________________________________________________ →Please describe any written or printed warnings contained on thin film or plastic packaging

(or attach them to this questionnaire). 请把任何手写或打印在薄膜或塑胶封带上的警告写下来（或把它们贴在该调查表上）

________________________________________________________________________________________________

__________________________________________________________________________________________________________

1. 2. 3.

Do you do your own design work? 您是否自行设计

Do you maintain records of design changes and reasons justifying these changes? 是否保留有关设计变更及设计变更理由记录贵司的产品设计是否符合或超过政府和行业标准

YES NO ❑ ❑ ❑

❑ ❑ ❑

YES NO

Are your products designed to meet or exceed government and industry standards? YES NO

4. 1. 2. 3.

Is there a written quality control procedure? 是否有书面质量控制程序

贵司是否会按客户的指定要求生产

Do you manufacture your product(s) to the specifications of your customer?

YES NO ❑

❑

YES NO ❑ ❑ ❑ ❑ ❑

❑ ❑ ❑ ❑ ❑

YES NO YES NO

Do you have a quality control manager responsible only to top management: 贵司是否有仅对最高管理层负责的品质控制经理 Supplies and components 产品材料和零配件 ∙ ∙ ∙

Are they ordered to your specifications? 是否按公司所需的规格而订购 Have you determined which ones are critical to the safety of your final product? 是否能判断哪一部分的材料或零部件将影响到贵公司最终产品的安全 Are the warranties obtained from all suppliers? 是否所有供应商皆提供品质保证

FINAL PRODUCTS 成品 ∙ ∙

Is each product subject to and do they confirm with applicable safety standards? YES NO

❑

What kind of quality certificates has the Insured obtained? (Attached copy of such certificates) 被保险人已取得何种质量认证 (请附上证书的复印件)

ISO9000 ISO9001 ISO14000 UL CE FDA CCC TUV CSA Other certificates 其他认证 _______________________________ ∙ ∙

What percentage are tested? 检测的百分比

_____________________________________________________________________________________________________ Are records of results of quality control tests kept so that you can identify at a later date what tests you applied to a given product at a given time? ∙

How far back do your records go? (Give date) 贵司的记录可以追溯到什么时候（写明日期）

_____________________________________________________________________________________________________ ∙

If your products are manufactured to the specifications of your customers, do they test the product upon receipt?

如果贵司产品是按照客户要求的规格制造的，他们是否在收货时进行检测 ∙

Do you receive an acceptance sign-off from your customer? 贵司客户是否签字验收

YES NO ❑

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YES NO ❑

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YES NO ❑

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是否每一项产品均遵循且符合国家标准

贵司是否记录了质量控制试验的结果，以便于在随后时间里鉴别哪些测试是在既定时间用于既定产品

Are hazards inherent in the final product, and warnings against foreseeable misuse and abuse made known to the ultimate user by: 制成品固有的危险和可以预见的由误用及滥用造成的危险通过下列哪些措施使最后的使用者得知： ∙ ∙ 2.

∙ ∙ ∙

Other means (attach details) 其他措施（附上细节）

in English? 用英语

in any other language(s)? Please specify. 用其他语言？请指出。 Are warnings/instructions 警告/说明书用哪种语言书写

warning labels at the point of hazard? 提示有风险的警告标签 Written instructions 书面说明

YES NO ❑ ❑ ❑ ❑ ❑

❑ ❑ ❑ ❑ ❑

YES NO YES NO

__________________________________________________________________________________________________________

YES NO ❑

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3a. Are instructions, warnings, labels and advertising texts viewed by an attorney to

assure that they are complete and understandable to the ultimate user, and avoid overstatement relative to safety or omissions relative to hazards?

使用说明、警示、标签及广告内容是否经由律师确认以便可以完整被最终用户理解，避免对产品的安全性做夸大或遗漏说明 → If ”NO”, please state who reviews such instructions, warnings, etc.如果“否”，请指出由谁来审查使用名、警示等

__________________________________________________________________________________________________________

________________________________________________________________________________________________

3b. If you export to the USA/Cda are instructions written 如果贵司产品出口到美加，说明书 YES NO

∙ ∙ 4. 5. 6.

in English? 用英语书写

in any other language(s)? Please specify. 用其他语言书写？请说明。

❑ ❑

__________________________________________________________________________________________________________ Do you expressly disclaim or limit warranties for your products? 贵司是否明确限制或拒绝保证贵公司的产品

Are all warranties and/or disclaimers reviewed by a legal counsel? 是否所有产品保证/拒赔声明均由法律顾问审核

Do you provide any specific training or instructions for the ultimate user to use your product properly?

贵司是否为最终用户提供专门培训或课程来使他们正确使用贵司产品

YES NO ❑ ❑ ❑

❑ ❑ ❑

YES NO YES NO

7. Are salesmen and distributors made aware of your desire to be informed of cases where your product is used for a purpose for which it was not designed? 销售商和分销商是否意识到贵司希望了解您的产品在哪里被用作什么用途

YES NO ❑

❑

Have your products ever been subject to inquiry or investigation relative to product safety by any governmental agency?

贵司产品是否被政府机构作过有关产品安全性的质询或调查 → 2. → 3. → 4.

Do you have a written products recall plan? 您是否有关于产品召回的书面计划？ If ”YES”, please attach. 如果有，请附上。

Have you ever recalled products because of a potential product safety hazard? 贵司是否因为潜在的安全隐患而召回过产品

If ”YES”, please attach details and indicate percent of recovery. 如果有，请附上详细资料和说明召回比例

Do you have a written products safety program for which specific individuals have responsibility for implementation?

贵司是否为那些有执行责任的特殊个体准备了书面产品安全计划 →

If ”YES”, please attach. 如果有，请附上。

YES NO ❑

❑

YES NO ❑

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YES NO ❑

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If ”YES” attach details. 如果有，请附上详细资料。

YES NO ❑

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________________________________________________________________________________________________

__________________________________________________________________________________________________________

6. 7.

请解释如何区分您和相似竞争者的产品和零件

Explain how you can identify your products and parts from similar competitors’ products and parts.

__________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Can you determine based on available records for all products you have sold: 贵司是否能基于已出售产品的有效记录做出决策 ∙ ∙ ∙

when any given product item was manufactured? 既定产品的生产时间 to whom it was sold, and the date of sale? 销售给谁及销售时间 who supplied parts and supplies going into the final products? 谁提供零配件及哪些零配件将最终进入成品

YES NO ❑ ❑ ❑

❑ ❑ ❑

8. 9.

Do you maintain copies of old manuals and advertising material? YES NO 贵司是否保存了旧说明书和广告材料的副本

Person in –charge the insurance matter in your company? 贵司谁负责保险事宜

Name （姓名）: __________________ Tel（电话）: __________________________ Title（职务）: ____________________ a.

Do you have a written procedure for obtaining information about product complaints, accidents and injuries involving your products?

贵司是否有获得由于产品所带来的抱怨、意外事故和人身伤害信息的书面程序

YES NO ❑

❑

10. Complaints 陈述

b. Have you made distributors aware of your desire for prompt notice of all complaints, accidents and injuries involving your product;

贵司是否让分销商意识到您渴望及时了解所有由于产品所带来的抱怨、意外事故和人身伤害信息

❑

c. Does your procedure provide for examining and preserving any allegedly defective product with the results of such examination record?

由于这些调查记录，贵司是否有程序去调查并保留声称的缺陷产品

❑

d. Do reports on complaints, accidents, injuries, and the examination of products involved go to the person responsible for product safety?

❑

关于贵司由产品所带来的抱怨、意外事故、人身伤害和产品检验的报告，是否提供给了负责产品安全的人

e. Are results used for improving the product/process procedures? 结果是否用于提高产品/生产过程

❑

1. 2. 3.

Can we take an on-site survey in your premises? YES NO 是否可以到被保险人工厂做现场查勘

Telephone No. of Contact （联系电话） ___________________________________________

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Person to contact （联络人） _____________________ Title （职务） ______________________________

I/We declare the above statements and particulars to be true and correct, and agree that they shall be the basis of the contract between the Company and myself /ourselves.我等兹声明上述一切报表及细则均属正确，并同意本项声明作为我等与保险公司订立契约之基础。 The Proposer hereby guarantees that this insurance does not relieve the third parties from legal responsibility. 投保人保证该保险的安排不免除第三方依法应负之责任。

Applicant: （申请人）

Duty （职务）: _______________________________________

Telephone （电话）: __________________________________

_________________________________

Date （日期）: _______________________________________

1. 2. 3.

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NAME OF COMPANY: 公司名称

PRINCIPAL ADRESS: 总公司地址 Does applicant have subsidiaries or divisions? 申请人是否还有其他附属机构?

If ”YES”, please specify. 如果有，请详细说明

__________________________________________________________________________________________________________

YES NO ❑

❑

________________________________________________________________________________________________

4. Please tick the business nature of Applicant and its subsidiaries and associated companies.

__________________________________________________________________________________________________________

________________________________________________________________________________________________

Has any insurer ever cancelled or declined your products liability? 以往是否有保险公司取消或降低贵司的产品责任保险？

YES NO ❑

❑

→

If ”YES”, please explain. 如果有，请详细解释

__________________________________________________________________________________________________________

________________________________________________________________________________________________

Areas to be covered: 承保区域

❑USA/Canada ❑ Europe ❑ Australia ❑ Asia ❑ ROW ☐ Please Specify______________

美国/加拿大欧洲澳大利亚亚洲世界其他地区（请详细说明）

9. Policy period desired: 希望保险期限

From 从________________________________to至_______________________________________

10. Limit of liability desired ________________________CSL(occurrence/aggregate)

保险责任限额合并单一责任额(每一事故 / 保险期间累积金额)

11. Deductible per occurrence USA/Cda 每次事故免赔额（美国/加拿大）_______________________

Deductible per occurrence excl. USA/Cda 每次事故免赔额（美国/加拿大除外）________________________

12. Policy Trigger desired？希望的保单承保方式？

□ Claims made basis 索赔发生制 □ Occurrence basis 事故发生制

13. Do you require ”Vendors Liability”? 是否需要投保“销售商责任”？

YES NO ❑

❑

→ If ”YES”, please provide the list of vendor(s) and address(es). ( If there is more than one vendor, please indicate sales

Please state ALL products which you at present produce/distribute. 请陈述贵司所有目前生产/销售的产品

List any product for which cover is required and tick its current status, where: 请列出所有被保险产品并在其目前的状态上打√

(A) All products discontinued or recalled within the last five years (please shortly explain for each).

近五年内已经停止销售或曾被召回过的产品（请逐一加以简要说明） (B) All products that have been introduced during the last three years.

过去三年内推出的产品

Note: any additional product will be covered only from the date on which it is reported to the Company.

来年将推出的新产品

备注：所有新增产品仅在向保险人报备之日后方可被承保

3. Please give territorial split of your turnover by product lines for 请分区域给出被保险产品年销售额 a. Next year (est.) 下一年（预计）____________

b. Current year 今年____________

c. Last year 上一年____________

4. Full description of all products to be insured (supported by brochures and illustrations):

*Use - finished consumer products? bulk products? ingredients? components for consumer product? or OEM products? or for industrial equipments? complete industrial equipments? etc.

分销方式 - 产品是否直接销售给消费者? 批发商/进口商? 通过被保险人自己的进口/销售分支机构售给零售商? 或售与其他制造商用做配件？

Suppliers and distributors of your products 贵司产品的供应商和销售商

a. Is any product sold as component parts for other products? 是否有产品是以零件方式销售？

YES NO

b. Could any of your products or services be used on or in connection with: 贵司产品或服务是否会用于

- -

❑

aircraft/missile/aerospace?飞机/导弹/航空 Watercraft or offshore? 船舶或海洋

❑ ❑ ❑

❑ ❑ ❑ ❑

c. Are any of your products explosive, flammable, or poisonous, either by itself

or in combination with other materials?

贵司任何一种产品其自身或与其它材料结合后是否具有爆炸性、易燃或有毒 d. Could any of your products be classified as: 贵司是否有产品被归类为：

- -

pharmaceuticals? 药品 cosmetics? 化妆品

❑ ❑ ❑ ❑

→

Please explain all of the above ”YES” answers below. 以上回答如果“是”，请解释原因

__________________________________________________________________________________________________________

________________________________________________________________________________________________

Please provide claims history for the last 3 years (both paid and reserved claims and valuation date)请您提供近三年来索

B ） Describe all losses over $5,000.00(paid or reserved) 叙述所有超过五千美元之损失（已决或未决）

________________________________________________________________________________________________

Is there a current carrier? 目前有保险公司承保吗 YES NO

If yes, please indicate the carrier, the form of the policy and other details 若有，请列出保险公司名称，并说明保单形式及其他详细情况 1. →

Do others assemble your product? 贵司产品是否由他人装配

If ”YES”, please indicate dealer, consumer or importer.如果有，请简要的说明经销商、消费者或进口商

If assembly is to be done by consumers? 产品是否由消费者完成装配

文字是英文还是其他语言，请详细说明。 3.

__________________________________________________________________________________________________________ Do you pack for others? 您是否为他人包装

Do you pack under trade names other than your own? 您是否用他人的商标包装而非用自己的

请您简要说明由于在运输过程中损害而导致顾客拒收的商品占整个销售商品的百分比

YES NO ❑ ❑

❑ ❑

YES NO

YES NO ❑

❑

YES NO ❑

❑

__________________________________________________________________________________________________________ ❑ ❑

2. →

If ”YES”, are instructions written in English, or are instructions written in any other language(s)? Please Specify.如果是，说明书的

→ Please indicate percentage of total sales rejected by customers due to damage in transit.

________________________________________________________________________________________________ →Please describe any written or printed warnings contained on thin film or plastic packaging

(or attach them to this questionnaire). 请把任何手写或打印在薄膜或塑胶封带上的警告写下来（或把它们贴在该调查表上）

________________________________________________________________________________________________

__________________________________________________________________________________________________________

1. 2. 3.

Do you do your own design work? 您是否自行设计

Do you maintain records of design changes and reasons justifying these changes? 是否保留有关设计变更及设计变更理由记录贵司的产品设计是否符合或超过政府和行业标准

YES NO ❑ ❑ ❑

❑ ❑ ❑

YES NO

Are your products designed to meet or exceed government and industry standards? YES NO

4. 1. 2. 3.

Is there a written quality control procedure? 是否有书面质量控制程序

贵司是否会按客户的指定要求生产

Do you manufacture your product(s) to the specifications of your customer?

YES NO ❑

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YES NO ❑ ❑ ❑ ❑ ❑

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YES NO YES NO

Do you have a quality control manager responsible only to top management: 贵司是否有仅对最高管理层负责的品质控制经理 Supplies and components 产品材料和零配件 ∙ ∙ ∙

FINAL PRODUCTS 成品 ∙ ∙

Is each product subject to and do they confirm with applicable safety standards? YES NO

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What kind of quality certificates has the Insured obtained? (Attached copy of such certificates) 被保险人已取得何种质量认证 (请附上证书的复印件)

ISO9000 ISO9001 ISO14000 UL CE FDA CCC TUV CSA Other certificates 其他认证 _______________________________ ∙ ∙

What percentage are tested? 检测的百分比

How far back do your records go? (Give date) 贵司的记录可以追溯到什么时候（写明日期）

_____________________________________________________________________________________________________ ∙

If your products are manufactured to the specifications of your customers, do they test the product upon receipt?

如果贵司产品是按照客户要求的规格制造的，他们是否在收货时进行检测 ∙

Do you receive an acceptance sign-off from your customer? 贵司客户是否签字验收

YES NO ❑

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YES NO ❑

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YES NO ❑

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是否每一项产品均遵循且符合国家标准

贵司是否记录了质量控制试验的结果，以便于在随后时间里鉴别哪些测试是在既定时间用于既定产品

∙ ∙ ∙

Other means (attach details) 其他措施（附上细节）

in English? 用英语

in any other language(s)? Please specify. 用其他语言？请指出。 Are warnings/instructions 警告/说明书用哪种语言书写

warning labels at the point of hazard? 提示有风险的警告标签 Written instructions 书面说明

YES NO ❑ ❑ ❑ ❑ ❑

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YES NO YES NO

__________________________________________________________________________________________________________

YES NO ❑

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3a. Are instructions, warnings, labels and advertising texts viewed by an attorney to

assure that they are complete and understandable to the ultimate user, and avoid overstatement relative to safety or omissions relative to hazards?

__________________________________________________________________________________________________________

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3b. If you export to the USA/Cda are instructions written 如果贵司产品出口到美加，说明书 YES NO

∙ ∙ 4. 5. 6.

in English? 用英语书写

in any other language(s)? Please specify. 用其他语言书写？请说明。

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Are all warranties and/or disclaimers reviewed by a legal counsel? 是否所有产品保证/拒赔声明均由法律顾问审核

Do you provide any specific training or instructions for the ultimate user to use your product properly?

贵司是否为最终用户提供专门培训或课程来使他们正确使用贵司产品

YES NO ❑ ❑ ❑

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YES NO YES NO

YES NO ❑

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Have your products ever been subject to inquiry or investigation relative to product safety by any governmental agency?

贵司产品是否被政府机构作过有关产品安全性的质询或调查 → 2. → 3. → 4.

Do you have a written products recall plan? 您是否有关于产品召回的书面计划？ If ”YES”, please attach. 如果有，请附上。

Have you ever recalled products because of a potential product safety hazard? 贵司是否因为潜在的安全隐患而召回过产品

If ”YES”, please attach details and indicate percent of recovery. 如果有，请附上详细资料和说明召回比例

Do you have a written products safety program for which specific individuals have responsibility for implementation?

贵司是否为那些有执行责任的特殊个体准备了书面产品安全计划 →

If ”YES”, please attach. 如果有，请附上。

YES NO ❑

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YES NO ❑

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YES NO ❑

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If ”YES” attach details. 如果有，请附上详细资料。

YES NO ❑

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6. 7.

请解释如何区分您和相似竞争者的产品和零件

Explain how you can identify your products and parts from similar competitors’ products and parts.

YES NO ❑ ❑ ❑

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8. 9.

Do you maintain copies of old manuals and advertising material? YES NO 贵司是否保存了旧说明书和广告材料的副本

Person in –charge the insurance matter in your company? 贵司谁负责保险事宜

Name （姓名）: __________________ Tel（电话）: __________________________ Title（职务）: ____________________ a.

Do you have a written procedure for obtaining information about product complaints, accidents and injuries involving your products?

贵司是否有获得由于产品所带来的抱怨、意外事故和人身伤害信息的书面程序

YES NO ❑

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10. Complaints 陈述

b. Have you made distributors aware of your desire for prompt notice of all complaints, accidents and injuries involving your product;

贵司是否让分销商意识到您渴望及时了解所有由于产品所带来的抱怨、意外事故和人身伤害信息

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c. Does your procedure provide for examining and preserving any allegedly defective product with the results of such examination record?

由于这些调查记录，贵司是否有程序去调查并保留声称的缺陷产品

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d. Do reports on complaints, accidents, injuries, and the examination of products involved go to the person responsible for product safety?

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关于贵司由产品所带来的抱怨、意外事故、人身伤害和产品检验的报告，是否提供给了负责产品安全的人

e. Are results used for improving the product/process procedures? 结果是否用于提高产品/生产过程

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1. 2. 3.

Can we take an on-site survey in your premises? YES NO 是否可以到被保险人工厂做现场查勘

Telephone No. of Contact （联系电话） ___________________________________________

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Person to contact （联络人） _____________________ Title （职务） ______________________________

Applicant: （申请人）

Duty （职务）: _______________________________________

Telephone （电话）: __________________________________

_________________________________

Date （日期）: _______________________________________

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