安装工程一切险投保单-2009
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安装工程一切险情况调查表及投保单Questionnaire and Proposal for Erection All Risks InsuranceNo.投保人/被保险人应向本公司提供工程承包合同、承包工程金额明细表、工程设计书、工程进度表和工程量清单、地质勘查报告和工地略图(平面图)等文件,并据实填写如下项目:1.投保人名称及地址:Name and address of the applicant:电子邮箱:邮编:电话:传真:E-mail: Postcode: Telephone: Fax:2.被保险人名称及地址:Name(s) and address (es) of the insured(s) :电子邮箱:邮编:电话:传真:E-mail: Postcode: Telephone: Fax:3.被保险工程名称及地址:Title and Location of contract:4.工程所有人名称及地址:Name and Address of principal:电子邮箱:邮编:电话:传真:E-mail: Postcode: Telephone: Fax:5.工程承包人名称及地址:Name(s) and Address (es) of Contractor(s)电子邮箱:邮编:电话:传真:E-mail: Postcode: Telephone: Fax:6.其他关系方名称及地址:Name(s) and Address (es) of other party (ies) Concerned电子邮箱:邮编:电话:传真:E-mail: Postcode: Telephone: Fax:7.安装机器设备主要制造人或出口商名称及地址:Name(s) and Address (es) of the main manufacturer or exporter of the machinery and equipment to be erected:8.安装机器设备情况(必要时另附清单):Description of the machinery and equipment to be erected (If necessary on a separate sheet):(1)如系单项设备,请逐一列明名称、型号、技术指标、制造厂方及价格:For single-item equipment,specify description、type、technical standard、manufacturer and value of the principal equipment:(2)如系成套设备,请列明主要设备的名称、技术指标、制造厂方及价格:For complete sets of equipment,specify names、type、technical standard、manufacturer and value of the principal equipment:(3)如有旧机器、设备,请逐一列明名称、价格及已提折旧:For second hand items,if any,specify descriptions、value and depreciation separately:9.安装前的机器设备:Machinery and Equipment , if any , specify descriptions、value and depreciation separately:(1)储存地点:Location of storage:(2)储存条件:Condition of storage:(3)保管方法:Manner of storage:10.承包商对这类安装是否有经验?是()否()Is the contractor experienced in this Y es Notype of work or erection method?11.由分包人安装的项目:What work will be erected by sub-contractors:12.分包人对安装的项目是否有经验?是()否()Is the sub-contractor experienced Y es Noin this type of work or erection method?13.本安装项目是否为原有工厂的扩展?如是,原有工厂是否继续生产?是()否()Y es NoIs the erection work extension of the old factory? If so, does the production of the old factory continue?(必要时,请附工厂平面图纸)(If necessary, please submit the plain drawing of the factory)14.地质情况:Geological conditions:______________________________________________________________________________ 地形特点:Terrain and its Features:地质及底土条件:Geological and subsoil conditions:地下水水位:Level of underground water:最近的江河、湖、海的名称、距离:Nearest river, lake, sea (name, distance) :以往最低、一般和最高水位:Past record of the lowest, mean and highest levels of water:__________________________________________________________________________其他地质情况:Others15.特殊风险情况的说明:Description of Special Risks:该地区曾是否有地震?如是,请列出震级是()否()Have earthquakes been observed in this area? Y es NoIf so, please state intensity (Metcalli) and magnitude (Richter)建筑物是否按有关防震规定设计?是()否()Is the design of the structure to be insured based Y es Noon regulations for earthquake-resistant structures?设计要求是否高于该防震规定?是()否()Is the design standard higher Y es Nothan the stipulation in the relevant aseismatic design regulation?是否有其他的火山、海啸风险?是()否()Are there any special risks such as volcanic eruption , seaquake etc.? Y es No雨季:从至Rainy season: from to最大降水量:每小时毫米,每天毫米,每月毫米Maximum Rainfall(mm): Per hour millimetre,Per day millimeter,Per month millimetre 暴风雨危险:小()中()大()Storm: minor medium high16.是否容易发生火灾、爆炸?如是,请说明情况:是()否()Whether fire or explosion easily occur? Y es NoIf so , please give description:17.安装现场周围环境状况:Description of surrounding of erection site:__________________________________________________________________________(1)现场及周围建筑的状况:Details about existing buildings and surrounding properties:(2)工程所有人或承包人所有的现场建筑物情况:Details about existing buildings owned by or held in care, custody or control of the principal or the contractor (s)18.被保险人就同一安装项目是否有其他保险?Does any other insurance cover the above construction work for the insured?如有,请列出保险公司名称及保险内容是()否()If so, please give details about names of insurance company and covers Y es No______________________________________________________________________________ 19.物质损失部分20.第三者责任Period of insurance(1) 建筑期限:Construction period:(2) 安装期限:Erection period:(3) 试车、考核期限:Period of testing and commissioning:_______________________________________________________________________________ 23.保证期限Maintenance period24.是否需要附加其它保障?如是,请列出具体内容是()否()Other extensions? If so, please state Y es No25.保险费支付日期:Date of premium payment:26.保险合同争议解决方式选择The way of solution to disputes of contract of insurance(1)提交仲裁委员会仲裁;Refer to the arbitration commission to arbitrate;(2)诉讼。
Lawsuit.27.特别条款Especially Clauses28.特别约定Especially Agreement本人(本公司)特此声明,以上陈述就我们所了解并相信是真实和全面的。