Chestionar – cerere de asigurare/Questionnaire-proposal form

privind asigurarea de raspundere civila profesionala a brokerilor de asigurare/

regarding professional liability insurance of insurance brokers
(constituie parte integranta si completeaza polita de raspundere civila profesionala a brokerilor de
asigurare)/(is integrand part and also complete the policy regarding professional liability insurance of
Insurance Brokers (cod RC107/code RC107)

1. Solicitant/Asigurat
Applicant/Insured

2. Sediul social / Registered office

(In cazul mai multor adrese, specificati
fiecare adresa precum si responsabilul
principal/(if more please specify each
address and the person is responsible for)

3. Tel. / fax. / Phone / Fax.

4. Numarul de inregistrare la
Registrul Comertului/
Fiscal Registration Number

5. Anul infintarii si numarul avizului de

infiintare/Establishing date and no. of the
establish note

6. Numarul autorizatiei Comisiei de

Supraveghere a Asigurarilor/Document
of establishing, license no.

7. Numarul angajatilor cu contract de munca cu norma întreaga/No. of employees with full time
work contract
Nume si prenume/ Experienta profesionala/ Specializarea, cursuri
Name and surname Professional experience absolvite/Experience,
graduated courses

8. Numarul angajatilor cu contract de munca cu program redus/No. of employees with part time
work contract
Nume si prenume/ Experienta profesionala/ Specializarea/cursuri
Name and surname Professional experience absolvite/Experience,
graduated courses

Prezentul chestionar face parte integranta din polita de asigurare

Formular D2.1-PL1-CH_RC107 / e/r 1/3 1
 9. Tipul activitatilor desfasurate pentru clienti, conform autorizatiei/ Type of activities developed
for the clients according to the authorization
- negocierea contractelor de
pe piata interna/on the local market 
asigurare/insurance contracts
pe piata internationala/on the international market 
negotiation
- negocierea contractelor de
pe piata interna/on the local market 
reasigurare/
pe piata internationala/on the international market 
reinsurance contracts negotiation
- inspectie de risc/
risk inspection
- regularizare in caz de dauna/
damage settlement
- comisariat de avarie/
damage committee
- alte activitati (precizari)/
other activities (details)

10. Tipul asigurarilor intermediate si ponderea acestora in activitatea desfasurata/type of

intermediated insurance contracts and share of this insurance types intermediated in the whole
activity
Asigurari de bunuri/good insurance da/yes  nu/no  %
Asigurari de mijloace de transport (terestru, aerian, feroviar, naval)/means of %
transportation insurance (land transport, air transport, railway transport, water
transport) da/yes  nu/no 
Asigurari de raspundere civila/liability insurance da/yes  nu/no  %
Asigurari de raspundere civila profesionala/professional libility insurance %
da/yes  nu/no 
Asigurari CAR/EAR/ CAR/EAR insurance da/yes  nu/no  %
Asigurari CMR / CMR insurance da/yes  nu/no  %
Asigurari CARGO/ CARGO insurance da/yes  nu/no  %
Asigurari echipamente electronice/Electronic equipment insurance da/yes  nu/no  %
Asigurari daune din intreruperea afacerii/Business interruption insurance %
da/yes  nu/no 
Asigurari financiare/Financial insurance da/yes  nu/no  %
Asigurari RCA/RCA insurance da/yes  nu/no  %
Asigurari CARTE VERDE/Green Card insurance da/yes  nu/no  %
Asigurari de credite si garantii/Bond and Credit insurance da/yes  nu/no  %
Asigurari de accidente sI boala/Insurance for accidents and disease da/yes  nu/no  %
Asigurari de viata/life insurance da/yes  nu/no  %

11. Clienti cu care aveti incheiate contracte de brokeraj, ponderea acestora/Share of clients with
whom you have concluded brokerage contracts:
- persoane fizice/individuals  %
- persoane juridice/legal bodies  %

Prezentul chestionar face parte integranta din polita de asigurare

Formular D2.1-PL1-CH_RC107 / e/r 1/3 2
 12. Ati mai incheiat o polita de
raspundere profesionala anterior?/ Daca da, precizati/ If so, please specify:
Have you previously been insured - societatea de asigurare/the Insurer
for professional liability
insurance? - perioada de asigurare/insurance period
- limita raspunderii/limit of liability
- despagubiri platite/paid indemnities

13. In activitatea desfasurata pana in

prezent ati primit vreo cerere de Daca da, detaliati/If so, please details:
despagubire? / Have you had any
claims related to your professional
activity?

14. In prezent, aveti cunostinta de

evenimente ce ar putea da nastere Daca da, detaliati/If so, please details:
unor cereri de despagubiri in
viitor? / Do you know any
circumstances that could cause
any claims against you?

15. Valoarea totala a primelor de

asigurare/reasigurare intermediate in anul
financiar anterior/The total amount of
insurance and reinsurance premiums
corresponding to the contracts intermediated
in the previous financial year

16. Valoarea totala a comisioanelor de

intermediere incasate in anul financiar
anterior/The total amount of fees cashed in
the previous financial year

17. Limita raspunderii solicitata pe perioada asigurata/

Aggregate limit of insurance
Limita raspunderii pe eveniment/limit of insurance per event
dar limitata la/but limited at:
daune materiale/eveniment
materiale damages/event
invaliditate permanenta/persoana/eveniment/
permanent disability/person/event
deces/persoana/eveniment/
death/person/event

18. Fransiza solicitata/Requested deductible

- fransiza pentru raspundere civila legala/

deductible for general third part liability

Prezentul chestionar face parte integranta din polita de asigurare

Formular D2.1-PL1-CH_RC107 / e/r 1/3 3
 - fransiza pentru raspundere civila profesionala/
deductible for professional liability

19. Perioada de asigurare/Insurance period

Solicitantul declara ca cele completate in prezenta cerere de asigurare sunt reale si in conformitate cu
documentele pe care le poseda./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 politei ce se va emite si constituie parte
integranta 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

(numele, semnatura si stampila)/(name, signature and stamp)

Prezentul chestionar face parte integranta din polita de asigurare

Formular D2.1-PL1-CH_RC107 / e/r 1/3 4