Professional Documents
Culture Documents
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:
10. Imprejurimi/surroundings
17. In activitatea asigurata aveti depozite sau sunt Pentru fiecare material folosit rugam precizari
folosite produse periculoase: gaze, explozibili, privind cantitatea, depozitarea, masuri de
substante periculoase, hidrocarburi, azbest, protectie / For each material, please specify the
substante toxice, materiale radioactive etc?/ quantity, nature, places and destination,
Do you have warehouses or use dangerous protection measures
products: chemicals, explosives, dangerous
materials, flammable, combustible, asbestos,
radiation and radioactive etc.?
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
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
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?
25. Ati avut anterior o astfel de polita de Daca da, rugam precizati:/If so, please specify:
asigurare?/Have you previously been - Asiguratorul/The Insurer
insured for a services supplier’s liability - perioada de asigurare/insurance period
insurance? - limita raspunderii/limit of liability
- despagubiri platite/paid indemnities
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?
30. Detalii privind conditiile de asigurare:/ - limita raspunderii pe perioada asigurata/ aggregate
Details about the insurance conditions: limit of liability:
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)