机器损坏险保险合同,范文

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.
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1.被保险人名称和地址Name and Address of the Insured: |
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2.营业性质Nature of Business: |
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3.被保险机器所在地Location of Machinery to be Insured: |
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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 |
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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* |
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 ------------- ----------|
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6.总保险金额Total Sum Insured: |
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7.保险费率Premium Rate: |
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8.保险费Premium: |
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*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
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| ________________________________________________ |
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| ________________________________________________ |
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| ________________________________________________ |
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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
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| |
| ________________________________________________ |
| |
| ________________________________________________ |
| |
| ________________________________________________ |
| |
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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).
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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 _____________________________________ |
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10. 有无制定操作规程? ---是 ---否 |
Any Operating System? If Yes, Please State. | |Yes | |No |
--- --- |
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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? | |Yes | |No |
--- --- |
11.2 操作人员是否持证上岗? ---是 ---否 |
Are the Operator Working With Qualitication Certificate? | |Yes | |No |
--- --- |
11.3 平均上岗时间The Average Time of Employment in this Post |
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12. 维修情况Condition of Maintenance? |
12.1 有无配置专业维修人员? ---是 人数 ---否 |
Any Trained Maintenance Worker? | |Yes Numbers______ | |No |
--- --- |
12.2 是否进行日常的维修和保养? ---是 ---否 |
Any Daily Maintenance? | |Yes | |No |
--- --- |
12.3 大修每隔____个月进行一次Ovrhaul Every______Months |
12.4 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 |
--- --- |
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13. 特别条款Specila Provisions: |
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14. 备注Remarks: |
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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。 |
I/We(the Applicant & the Insured) to hereby declare that the above contents are truly filled in, and that I/We |
have understood the Company"s explanation on the clauses of Erection All Risks Insurance and its additional |
contents (including exclusions), and that I/We agree to apply for Erection All Risks Insurance subject to the |
above-mentioned clauses and its additional contents. |
投保人及被保险人(签章) 电话 |
Signatures of the Applicant & the Insured ____________ Telephone ____________ |
地址 日期 |
Address _____________________________ Date_______________ |

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