Chestionar - cerere de asigurare privind/Questionnaire - proposal form regarding

raspunderea civila legala a societatilor service auto/legal liability insurance for motor-vehicles services
(face parte integranta si completeaza polita de asigurare)(is integrant part and also complete the policy)
(cod RC17/code RC17)

1. Solicitant/Asigurat / Applicant/Insured
(nume/denumire) / (name):
(Cod Fiscal)/(Fiscal Code)

2. Adresa/Sediul legal/
Address/Registered office:

3. Telefon, fax/
Phone, fax:

4. Data infiintarii firmei/

Establishing Date:

5. Nr. Registrul Comertului/

The Commerce Register no.:

6. Autorizatia de functionare (nr. si data

eliberarii/Authorization for working (no.
and date):

7. Descrierea serviciilor prestate/

Description of performed services:

8. Cifra de afaceri/turnover - pe anul anterior/on the past financial year

- estimat pe perioada de asigurare/estimate on the insurance period

9. Locatiile la care Solicitantul isi adresa,descriere/address, description

desfasoara activitatea/
Locations where the Applicant performs
specialized services:

10. Imprejurimi/surroundings

11. Mijloace de productie/

Means of production

Prezentul chestionar face parte integranta din polita de asigurare

Formular D2.1-PL1-CH_RC17 / e/r 1/3
12. Alte dotari/Other technical equipment

13. Sediile, locatiile la care Solicitantul isi desfasoara activitatea

sunt imprejmuite/prevazute cu sistem de alarma sau paza ?/
Are the buildings, locations where the Applicant performs
specialized services fenced/endowed with alarm/guard
protection system ?

14. Exista masuri speciale incendiului/fire  exploziilor accidentale/explosions 

privind prevenirea / Are
premises adequate with
protection against:
Rugam detalii privind: tipul de detectare sau sistem de alarma,
interventia formatiunilor specializate in caz de eveniment, surse de
energie sau apa in caz de eveniment / Please, details about: the alarm
equipment, intervention of specialized authorities, energy or/and water
sources, in case of any occurrence

15. Asiguratul are experienta in domeniul

pentru care solicita asigurarea? / How
long have you been in the business to be
covered?

16. Accesul persoanelor straine este permis liber

sau cu insotitor? / Is the access free or only
with authorized company?

17. In activitatea asigurata aveti depozite sau sunt
folosite produse periculoase: gaze, explozibili,
substante periculoase, hidrocarburi, azbest,
substante toxice, materiale radioactive etc?/
Do you have warehouses or use dangerous
products: chemicals, explosives, dangerous
materials, flammable, combustible, asbestos,
radiation and radioactive etc.?
Pentru fiecare material folosit rugam precizari
privind cantitatea, depozitarea, masuri de
protectie / For each material, please specify the
quantity, nature, places and destination,
protection measures

18. Detalii privitoare la personalul angajat - efectiv pe anul financiar anterior/ effective on
(categorii de personal, numarul de angajati, the past financial year
etc.) / Details about employees (categories of
employees, number of employees, etc.) - estimat pe perioada de asigurare/ estimated on
insurance period

- executanti/operatives
- TESA/administrative

19. Se lucreaza in schimburi?/Do you

work on shifts?

Prezentul chestionar face parte integranta din polita de asigurare

Formular D2.1-PL1-CH_RC17 / e/r 1/3
20. Numarul maxim de masini care se pot gasi in
service la un moment dat/Maximum cars
indoors service at a given moment

21. Precizati numarul mediu de masini reparate

intr-o luna/Repaired cars average in one month

22. Prestati serviciile specializate: - numai pentru autovehicule romanesti/for domestic vehicles
only 
- numai pentru autovehicule straine/for foreign vehicles only 
- pentru autovehicule romanesti si straine/for domestic and
foreign vehicles 

23. Prestati serviciile specializate la sediul dvs.

sau si la domiciliul clientilor?/Do you perform
specialized services only at your locations or
al client’s home?

24. Se executa probe dupa executarea Daca da, precizati:/If so, please specify:
lucrarilor de service?/Have you test cars - aveti angajati soferi profesionisti?/do you have
after service? professional drivers?
Doriti acoperire si pentru raspunderea
civila pe perioada executarii acestor - testele se fac in locuri special amenajate?/are the
probe? / Do you request cover for legal tests made on special trucks?
liability during testing period?

Va rugam, specificati traseul pe care se efectueaza

probele / Please, specify trucks

Vor fi acoperite numai traseele declarate/Only

indicated trucks will be covered

25. Ati avut anterior o astfel de polita de
asigurare?/Have you previously been
insured for a services supplier’s liability
insurance?
Daca da, rugam precizati:/If so, please specify:
- Asiguratorul/The Insurer
- perioada de asigurare/insurance period
- limita raspunderii/limit of liability
- despagubiri platite/paid indemnities

26. A existat vreun Asigurator care a anulat

sau refuzat reinnoirea politei?/Was is any
Insurer that cancelled your insurance
policy or that refused conclusion of the
policy?

27. In activitatea desfasurata pana in prezent Daca da, detaliati:/If so, please give details:
ati primit vreo cerere de despagubire? /
Have you had any claims about your
activity until now?
Prezentul chestionar face parte integranta din polita de asigurare
Formular D2.1-PL1-CH_RC17 / e/r 1/3
28. Ati platit despagubiri in ultimii cinci
ani?/Have you paid any indemnities in
the last five years?

29. In prezent, aveti cunostinta de

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

30. Detalii privind conditiile de asigurare:/ - limita raspunderii pe perioada asigurata/ aggregate
Details about the insurance conditions: limit of liability:

- limita raspunderii pe eveniment/ limit of liability per

event:

31. Fransiza solicitata:/ Requested deductible:

32. Perioada de asigurare/Insurance period

Declaram ca informatiile furnizate in acest chestionar sunt adevarate si ca nici un element sau
circumstanta de fapt care ar putea influenta evaluarea riscului nu a fost ascunsa./The Applicant declares
that all the information provided in this questionnaire corresponds to the reality and no circumstance
that could influence the risk appreciation was hidden.
Suntem de acord ca acest chestionar precum si alte eventuale acte declarative sa constituie baza
contractului de asigurare, facand parte integranta din acesta./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, stampila)/(name, signature and stamp)

Prezentul chestionar face parte integranta din polita de asigurare

Formular D2.1-PL1-CH_RC17 / e/r 1/3