Chestionar - cerere de asigurare / Questionnaire – proposal form

privind r`spunderea civil` legal` a societ`\ilor de alimenta\ie public` / regarding legal liability insurance
for catering (cod RC11/code RC11)

1. Solicitant/Asigurat (denumire, cod

fiscal) / Applicant/Insured (name, fiscal
code):

2. Sediul social / Registered office:

Tel./Fax / Phone/Fax:

3. Data [nfiin\`rii firmei / Establishing date:

Nr. certificate [nmatriculare la Registrul
Comer\ului / Certificate of registration
issued by The Commerce Register No.:

4. Autoriza\ia de desf`]urare a activit`\ii

(nr. ]i data eliber`rii) / Authorization for
working (number and date)

5. Descrierea activit`\ii prestate (restaurant, snack,

cofet`rie, patiserie, pizerie, rotiserie, fast food, etc.) /
Description of activity (restaurant, snack,
confectionery, pastry shop, pizzeria, fast food, etc.)

6. Cifra de afaceri / Turnover: pe anul anterior / on the past financial year:

- estimat pe perioada de asigurare / estimated on the period of

insurance:

7. Informa\ii referitoare la loca\ii/[mprejurimi / Information about branches/premises:

a) Construc\ii/loca\ii principale (tipul construc\iei, adresa) ]i [mprejurimile / Buildings (type,
location) and surroundings:

b) Mijloace de produc\ie / Means of production:

c) Alte dot`ri / Other endowments:

8. De\ine\i surse proprii de aprovizionare (ferme Da/Yes □ Nu/No □

pentru cre]terea animalelor pentru carne, vin
din produc\ia proprie etc.) / Do you have own
supplies sources (cattle farms, wine from own
production ect.)?

Prezentul chestionar face parte din poli\a de asigurare

Formular D2.1-PL1-CH_RC11 / e/r 1/3 1
 9. Livra\i produse la domiciliul clien\ilor? / Do Da/Yes □ Nu/No □
you deliver products at client’s home?

10. Num`rul mediu de clien\i dintr-o zi/

Daily average of clients:

11. Num`rul total de salaria\i … din care / Number of employees …….. from which:
- personal specializat (buc`tari, cofetari etc.)/
specialized staff (cooks, confectioners etc.)
- personal TESA / administrative staff:

12. Programul de lucru (num`r schimburi/zi, num`r zile

lucrate pe s`pt`m@n` / Schedule of working:
(shift/day, working days/week):

13. Spa\iile special amenajate de p`strare a obiectelor clien\ Da/Yes □ Nu/No □

ilor (garderobe, separeuri, vestiare) sunt p`zite? / Are the
special places where the clients left the luggage
(wardrobe, snug, locker romms) safety keeping?

14. A\i avut anterior o poli\` de Da/Yes □ Nu/No □

asigurare de r`spundere civil`
legal`? / Have you previously
been insured for legal liability?
Dac` da, v` rug`m preciza\i: / If so, please specify:
- Asigur`torul / The Insurer:
- Perioada de asigurare / Period of insurance:
- Limita r`spunderii / Limit of liability:
- Desp`gubiri pl`tite / Paid claims:

15. A existat vreun Asigur`tor care a anulat sau refuzat Da/Yes □ Nu/No □
re[nnoirea poli\elor? / Was it any Insurer that cancelled
an insurance policy concluded with you or that refused
conclusion of a policy?

16. A\i avut cereri de desp`gubire [n leg`tur` cu Da/Yes □ Nu/No □

pagube produse de vreun serviciu [n ultimii
trei ani? / Have you had any indemnity
claims in the last three years?

17. A\i pl`tit desp`gubiri [n ultimii trei Da/Yes □ Nu/No □

ani? / Have you paid indemnity in the Dac` da, men\iona\i anul, motivele, sumele pl`tite / If
last three years? yes, specify the year, the reasons, the paid sums:

18. Cunoa]te\i circumstan\e care pot

determina reclama\ii/pl@ngeri
[mpotriva dvs.? / Is your firm aware of
any circumstances or incidents which
mai result in a claim against your firm?

Prezentul chestionar face parte din poli\a de asigurare

Formular D2.1-PL1-CH_RC11 / e/r 1/3 2
 19. Detalii privind condi\ - limita r`spunderii pe perioada asigurat`/ aggregate limit of
iile de asigurare:/ responsibility:
Details about the
insurance conditions: - limita r`spunderii pe eveniment/ limit of responsibility per event:

- limita ptr. deces/persoan`/eveniment:/

limit for death/person/event:
- limita ptr. invaliditate permanent`/persoan`/ eveniment:/
limit for permanent disability/person/event:

20. Fran]iza / Deductible:

21. Aria geographic` pentru care se solicit`

acoperirea / Territorial cover:

22. Perioada de asigurare / Period of insurance:

Solicitantul declar` c` cele completate în prezenta cerere de asigurare sunt reale ]i în conformitate cu
documentele pe care le posed`./The Applicant declares that all the information provided in this
questionnaire corresponds to the reality and no circumstance which could influence the risk
appreciation was hidden.
Datele incluse în prezenta cerere de asigurare stau la baza poli\ei ce se va emite ]i constituie parte
integrant` a acesteia./ The Applicant agrees that this questionnaire-proposal form and all the other
declarative documents are the basis of the insurance contract and are integrant part and also
complete the policy.
Data:/Date:

SOLICITANT/ASIGURAT APPLICANT/INSURED

Prezentul chestionar face parte din poli\a de asigurare

Formular D2.1-PL1-CH_RC11 / e/r 1/3 3