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:

------------ I

2. 营业性质Nature of

Business:

3. 被保险机器所在地Location of Machinery to be In sured: I

--------- I

4. 保险期限：个月，年月日零时起至年月十四时止I Period of Insurance: Months, from 0:00 of to

24:00of I

5. 被保险项目及保险金额Insured Items and Sum

Insured 日二

项目保险金额

额I

每次事故＊免赔

Insured Items Sum Insured

Accide nt* I

5.1 保险财产(详见背面)

Property Insured(Look Overleaf)

-------------- I

5.2 附加费用Additional Expenses

清除残骸费

用

I

Debris Removal Expenses －－－

－－－－

Deductible for Any One

灭火费

用

I

Fire Extinguishment Expinses I 专业费用

I

Professional Expenses I

其他费用

I

Other Expenses I

------------ I

6. 总保险金额Total Sum Insured:

－－－－－－－

7. 保险费率Premium

Rate:

－－－－－－－

8. 保险费

Premium:

I

＊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-expired

Parameter

Guarantee Period

I

I

I

I

I

I

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-expired

Parameter

Guarantee Period

I

I

I

I I

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(E)、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)

| | Yes

No |

项目Item _____

__________________________ I

损坏时间Breakdown Timed _____

__________________________ I

损失金额Loss Amount