Specified Professional Liability Proposal Form
专业人员职业责任保险投保申请书
Note: This Policy does not cover any insured event occurred in the following countries: Syria, Iran, Cuba, Burma
and Sudan.
注意： 本保险不承保于以下国家发生的保险事故：叙利亚伊朗、古巴、缅甸和苏丹。
I. APPLICANT DETAILS 投保人的基本资料
Name of Applicant/Insured: 投保人/被保 险人名称：
Applicant’s Organization Code投保人的机构代码:
Address(es):地址： Web Site Address: 网址
Establishment Date: 成立日期：
II. BUSINESS ACTIVITIES业务活动
2. Please state the following details: 请提供以下详细资料：
Number of Partners/Directors/Principals: 合伙人/董事/负责人的人数： Number of Professional Employees: 专业人员的人数： Number of Other Technical Staff: 其他技术人员的人数： Number of Trainee Staff: 受训员工的人数：
Number of Non-Technical Staff (i.e. administration, clerical, typists etc.): 非技术人员的人数（如行政、文员、打字员等）
3. Please give the following details of all Partners/Directors/Principals: 请提供所有合伙人/董事/负责人的以下详细资料：
Years as Partner Name姓名 Qualifications职位 Years in Industry从业
/Director/Principal担任合伙人/时间
董事/负责人的时间
If a Partner/Director/Principal has been working in the relevant industry for less than 3 years, we will require a brief resume outlining career details. 若贵公司上述合伙人/董事/负责人中有从事该行业不足三年者，请提供其个人工作简历。
4. Please provide a full description of the activities of Insured: 请详细描述贵公司的业务活动：
5. Please state, during the past 5 years: 过去5年中，
(a) has the name of the Insured(s) been changed? 贵公司是否变更过公司名称？ Yes是 No否
(b) has any other business(es) been purchased, merged or consolidated with the Insured? 贵公司是否发生过并购或整合？ Yes是 No否
If “yes”, please provide details on a separate sheet. 如果“是”，请单列一页详细说明。
6. Please provide details of any major new operations undertaken during the last 12 months or planned for the next 12 months. 如果贵公司在过去12个月或拟在将来12个月增设任何重大新业务，请提供详细说明。
7. Please approximate the business activities by percentage of fee income derived.请提供贵公司营业收入的具体业务分类及百分比
8. Please give names of any professional organisations or associations of which the Insured or principals are members: 请列明贵公司或贵公司负责人加入的任何专业组织或行业协会的名称：
9. Please give the following fee income details: 请说明贵公司以下收入情况：
10. Please provide details of the 5 largest contracts you have carried out in the past five years: 请说明最近5年中所履行的合同金额最大的5个合同的详细情况：
11. Does the Insured have written contracts or agreements with each client? 贵公司是否与每位客户签订书面协议？
Yes是 No否
If “yes”, please attach copy of standard contract terms如果“是”，请提供标准合同条款。
12. Subcontracting Work 分包业务
(a) Please state the amount of Insured’s involvement in subcontracting work to others. ______% 请说明贵公司分包业务的比例。
(b) If subcontracting work exists, please describe the services undertaken and provide a specimen of the contract terms applicable to this work. 如果存在业务分包，请描述分包的具体业务内容，并提供分包业务的标准合同样本。
(c) Are subcontractors required to carry their own Professional Liability insurance? 是否要求分包商自行投保职业责任保险？
Yes 是 No 否
III. FRAUD & DISHONESTY COVERAGE不诚实、欺诈保障
13. If the Insured wishes to have coverage for Fraud/ Dishonesty, please complete the following: 如果贵公司有意获得不诚实或欺诈的保障，请回答以下问题：
(a) Has the Insured(s) sustained any loss or claim through the fraud or dishonesty of any person?
贵公司是否曾因任何人的欺诈或不诚实行为而遭受损失或索赔？ Yes是 No否 If “yes”, please specify如果“是”，请详细说明：
(b) Is the Insured(s) aware of any allegation or occurrence of fraud or dishonesty at any time committed by any past or present partner, director or employee? 贵公司是否知悉其任何过去或现在的合伙人、董事或雇员存在被指称或实际的欺诈或不诚实行为？ Yes是 No否 If “yes”, please give details and state precautions taken to prevent a reoccurrence.如果“是”，请详细说明并明确贵公司为防止再次发生所采取的防范措施？
(c) Does the Insured(s) always require satisfactory references or only when engaging senior employees? 贵公司何时要求提供可信的雇员推荐证明？ Always 任何时候 Senior Appointments Only只有委任高层职位时 Nature of Reference
推荐证明的形式
Written 书面 Verbal口头
(d) Is any employee allowed to sign cheques on his/her signature alone for values exceeding US$50,000? 贵公司是否有雇员可单独签发价值超过RMB400,000的支票？ Yes 是 No否 If “yes”, please give details on a separate sheet. 如果“是”，请另附纸张详细说明。
(e) How frequently are cheques carried out on all entries in the cash book with paying-books, receipts, counterfoils and vouchers and reconciled with bank statements including the balance of cash and unpresented cheques,
independently of employees receiving or banking monies, in respect of monies belonging to the Insured as well as in trust on behalf of others? 对于贵公司的资金或代管的信托资金，多长时间由收取资金或经办银行业务的雇员以外的人员，对现金账册中的所有科目与支出账册、收据、支票存根以及凭证进行一次独立性核查并调整其与银行对账单（包括现金余额和未兑现的支票）相一致？
Weekly 每周 Monthly 每月 Quarterly 每季度 Others (please specify) 其他，请详细说明
(f) Are client funds kept in a properly designated client account which is separate from the bank account of the Insured? 客户资金是否正确地单独存入指定的客户账户？ Yes是 No否 IV. INSURANCE & LOSS HISTORY保险及索赔情况
their predecessors in business or any of the present or former partners, directors or principals? 贵公司的合伙人/董事/负责人进行调查后，是否注意到针对贵公司、前身公司、现任或前任合伙人/董事/负责人曾提起过任何赔偿请求？
Yes是 No否
to a claim against the Insured or their predecessors in business or any of the present or former partners, directors or principals? 贵公司的合伙人/董事/负责人进行调查后，是否注意到任何可能导致针对贵公司、前身公司、现任或前任的合伙人/董事/负责人提出赔偿请求的情况或事件？ Yes 是 No否
If you have answered “YES” to questions 14 or 15, then full details of each matter must be advised before quotation can be considered. We must remind you that it is imperative to answer these questions correctly. FAILURE TO DO SO COULD WELL PREJUDICE YOUR RIGHTS, if a subsequently a claim should arise. 如果投保人对第14或15项的回答为“是”，本公司须在报价前获得关于上述问题的详细资料。本公司特此提醒投保人，请务必如实回答上述问题，否则发生赔偿请求时，被保险人的权利可能受到严重影响。
16. (a) Please list out details of previous Professional Liability Insurance carried during the past 3 years. 请详细说明最近3年中所投保的职业责任保险
Period 保险期间 Insurer 保险人 Limit责任限额 Excess自负额 Premium保险费
If none, then please check here 如果没有投保，请在此注明
(b) Has any proposal for Professional Liability Insurance made on behalf of the Insured(s) or any predecessors in the business, or present partners/directors or principals ever been declined or has such insurance ever been cancelled or renewal refused or special terms imposed? 以贵公司名义投保，或贵公司或其前身公司、或现任合伙人
/董事/负责人投保职业责任保险时是否遭到拒绝，或承保后，是否被解除保险合同、或被拒绝续保、或被附加特别条款承保？ Yes是 No否 If “yes”, please advise reason(s). 如果选择“是”，请详细说明原因。
17. (a) Please specify Limit of Liability desired: 请说明贵公司希望获得的责任限额：
￥____________ ￥___________ ￥____________ ￥ ____________ ￥____________ (b) Deductible desired: 贵公司有意承担的自负额：
￥____________ ￥___________ ￥____________ ￥ ____________ ￥____________
Dispute Resolution 争议解决 (a) □ Litigation 诉讼
(b) □ Submitted to Shanghai Arbitration Commission提交上海仲裁委员会仲裁
SIGNING THIS PROPOSAL DOES NOT BIND THE PROPOSER TO COMPLETE THIS INSURANCE
本投保申请书的签署不约束投保人或本公司签订保险合同
V. DECLARATION投保人/被保险人声明
I/We declare that the statements and particulars in this application/ proposal are true and that no material facts have misstated, misrepresented or suppressed after enquiry. I/ We agree that this application/ proposal, together with any other information supplied by me/ us shall form the basis of any contract of insurance effected between the Insurer and me/ us. I/ We undertake to inform the Insurer of any material alteration to those facts occurring before the renewal / completion of the contract of insurance.
本人特此声明：以上各项陈述及细节均真实完整，没有误述或隐瞒任何重要事实。兹同意本投保申请书以及所提供的其它信息均构成本双方所签订的保险合同的基础。本人承诺，若与投保申请有关的信息于签订或续展保险合同前发生任何重大变更，本人将及时通知保险公司。
重要提示：
为了保障您自身的权益，请在确认投保本保险前，仔细阅读理解保险合同的各项规定，尤其是免除保险人责任的规定。请在投保之前向保险公司业务人员或致电：4008208858询问保险合同各项规定，并听取保险公司业务人员的说明。请确保您对保险公司业务人员的说明完全理解，没有异议。如未询问，则视同已经对合同内容完全理解并无异议。
投保单、报价单、保险条款、保险单、批单或批注及其它约定书均为保险合同的构成部分。
IMPORTANT NOTICE:
In order to protect your own interests, before applying for this Policy, please read carefully the terms and conditions of this Policy, especially the exclusions. Please contact our salespersons or call 4008208858 to enquire the terms and conditions of this Policy. Please make sure that you fully understand the explanations of our salespersons. With no enquiry, you are deemed to have fully understood the terms and conditions of this insurance contract.
The Application Form, Quotation, policy wording, Schedule, any endorsement attached hereto or marked thereon and any other written agreement shall form integrated parts of this Policy.
本人确认：
本人已经认真阅读保险合同规定，尤其是免除保险人责任的规定，并对贵公司就保险合同的内容说明和提示完全理解，没有异议，申请投保。本人(我们)知晓所有保险责任均以本保险合同所载为准。
I acknowledge:
that before applying for the insurance, I have read carefully the terms and conditions of this Policy, especially the exclusions, and fully understand your explanations and reminder. I (we) understand that all insurance coverage is subject to the terms and conditions of this Policy.
Signed 签名
Title 职务
Insured(s) 投保人
Date 日期
VI.
(to be signed by Partner/ Director or Principal or equivalent) 合伙人/董事/负责人或同等职位者签署
PLEASE ENCLOSE WITH THIS PROPOSAL FORM 请附上以下资料 A Brochure (if available) 公司简介（如果有）
Copy of Standard Contract Terms (if available) 标准合同条款复印件（如果有）