1 CERERE – CHESTIONAR/ PROPOSAL FORM privind asigurarea de răspundere civilă legală a producătorului/ regarding product liability insurance DATE GENERALE / GENERAL INFORMATION 1.Solicitant: denumire, cod fiscal /Applicant :Name, Fiscal Code: .................................................................................................................................................................................. 2. Sediul social al societăţii (adresa) / Registered office:.......................................................................... ....... Tel./phone no.........................................Fax.......................................................................................................... 3.Data înfiinţării firmei /Establishing Date........................... Nr. certificat de înmatriculare la Registrul Comerţului /Certificate of registration issued by The Commerce Register No./..... ......................................... 4.Adresa afacerii /Business headquarter: II. NATURA SI VOLUMUL ACTIVITATII / TYPE AND VOLUME OF ACTIVITY: 1. Felul activităţii /Type of activity: a) producţie b)distribuţie b1) engross b2) cu amănuntul c) import/export d) altele a) production b)distribution b1) wholesaling b2)retailing c) import/export d) others 2. Volumul vînzărilor /cifra de afaceri /Turnover: pe anul anterior /on the past financial year........................................; estimat pe perioada de asigurare /estimate on the period of insurance ...............................; 3. Informaţii referitoare la sedii/angajaţi: /Information about branches/ employees: a) Construcţii principale şi împrejurimi /Buildings and surroundings:.................................................... ............................................................................................................................................................................ ............................................................................................................................................................................ ............................................................................................................................................................................ ............................................................................................................................................................................ b) Aveţi depozite sau folosiţi produse periculoase (explozivi, gaze, benzină, acizi, uleiuri, chimicale, mase plastice etc.) / Do you have warehouses or use dangerous products (explosives and chemicals, combustible, flammable, radiation or radioactive, poisonous, toxic materials, etc.)? Nu (No) Da (Yes) Dacă da, precizaţi natura, locurile, destinaţia, stocurile curente:/ If yes, please give below details of types, nature, places and destination of current merchandises: Nu (No) Da (Yes) ............................................................................................................................................................................ ............................................................................................................................................................................ ............................................................................................................................................................................ c) Desfăşuraţi activităţi în afara localurilor proprii ? / Do you develop any activities at any other places outside own premises? Nu (No) Da (Yes) Dacă da, precizaţi şi ponderea % în cifra de afaceri: / If yes, please specify with what percent of annual turnover: ............................................................................................................................................................................ ............................................................................................................................................................................ ............................................................................................................................................................................ d) Numărul mediu de angajaţi (Average number of employees) :
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CERERE – CHESTIONAR/
PROPOSAL FORM
privind asigurarea de răspundere civilă legală a producătorului/