机器损坏险保险合同

时间：2017/8/7 14:34:00 来源：网友

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 the 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 Insurance:Months, from 0:00 ofto 24:00of

5.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 ItemsSum InsuredDeductible 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

Professional Expenses

其他费用

Other Expenses

6.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 Item	型号 Model	数量 Qty.	主要技术参数 Major Tech. Parameter	制造商Manufacturer	制造年份 Year of Manu.	保险金额 Sum Insured	维护及保用期情况 Maintenance & 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 etc. 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)YesNo

项目Item

损坏时间Breakdown Timed

损失金额Loss Amount

10.有无制定操作规程？是否

Any Operating System? If Yes, Please State.YesNo

11.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?YesNo

11.2操作人员是否持证上岗？是否

Are the Operator Working With Qualitication Certificate?YesNo