某保险公司公众责任险投保书(3页).doc
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1.Name of Applicant投保人姓名
2.Correspondent Address/Tel. No. 通讯地址及电话
3.The Applicant is:投保人是:
IndividualPartnershipCorporationJoint Venture
独资合伙 股份公司 合资
4.The Premises to be insured is:被保险场所是:
a Hotela factorya Commercial Building
宾馆工厂 商业大楼
5.Business Address:营业地址:
Telephone:电话:
6.Period of Insurance保险期限 From由 To到
7.Limit of Insurance Liability:需保险金额:
Per Accident每次意外事故
Per Period of Insurance保险期限
8.Amount of excess your firm prepared to
carry for each property damage accident:每次财物损毁事故的自负额:
Per Accident 每次意外事故
9.How long has Insured been in business
at this premises被保险人在该保险场所从事业务有多久?
10.1)Enter check next to construction components
in the following spaces. If mixed construction,
indicate percentage in each category to add up to
100% or describe in space provided:
请在下列建筑结构处打勾。如是混合结构,请在每个类别上写上比例数,或在空格处详细描述。
StructureExteriorFloor Walls
A. Protected steel frame or reinforced concrete
被保护的钢架或钢盘混凝土
B.Unprotected steel or hollow concrete block
未保护钢架或空心混凝土板
C.Brick or masonry
砖瓦结构
D.Wood木结构
E.Other(Describe)其他(请详述)
Is the Applicant’s Maintenance of the Premises投保人对保险场所的维修