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 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 24:00of5.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 itemssum insureddeductible for any one accident*保险财产property insured(look overleaf)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 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item型号model数量qty.主要技术参数major tech. parameter制造商manufacturer机器损坏险保险合同机器损坏险保险合同1.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 of to 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 items sum insured deductible for any one accident* |保险财产(详见背面) |property insured(look overleaf) ------------- ----------|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项目型号数量主要技术参数制造商制造年份保险金额维护及保用期情况item model qty. major tech. manufacturer year of manu. sum insured maintenance & un-expiredparameter guarantee period----------------------------------------------------| ||________________________________________________ | | || ________________________________________________ | | || ________________________________________________ | | |----------------------------------------------------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制造年份保险金额维护及保用期情况item model qty. major tech. manufacturer year of manu. sum insured maintenance & un-expiredparameter guarantee period----------------------------------------------------| || ________________________________________________ | | || ________________________________________________ | | || ________________________________________________ | | |----------------------------------------------------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 andtemperature.(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 amount _____________________________________ |--------------------------------------------------------|10. 有无制定操作规程? ---是 ---否 |any operating system? if yes, please state. | |yes | |no |--- --- |--------------------------------------------------------|11. 操作人员operator: |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? | |yes | |no |--- --- |操作人员是否持证上岗? ---是 ---否 |are the operator working with qualitication certificate? | |yes | |no |--- --- |平均上岗时间the average time of employment in this post |--------------------------------------------------------|12. 维修情况condition of maintenance? |有无配置专业维修人员? ---是人数 ---否 |any trained maintenance worker? | |yesnumbers______ | |no |--- --- |是否进行日常的维修和保养? ---是 ---否 |any daily maintenance? | |yes | |no |--- --- |大修每隔____个月进行一次ovrhaul every______months |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? | |yes | |no |--- --- |--------------------------------------------------------|13. 特别条款specila 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。