Cerere - chestionar/Questionnaire – proposal form

privind asigurarea de r`spundere civil` professional` a cadrelor didactice ]i pedagogice/regarding

professional liability insurance for teachers
(face parte integrant` din poli\a de asigurare privind r`spunderea civil` professional` a cadrelor
didactice ]i pedagogice)/(is integrand part and also complete the policy regarding professional liability
insurance for teachers) (cod RC111/code RC111)

1. Solicitant/Asigurat / Applicant/Insured
(individual/institu\ie educativ` –
nume
/denumire)/Individual/school/institution
- name):

2. Sediul social (adresa)/Registered office

(address)

3. Nr. tel./Phone no.

Fax:

4. Detalii privitoare la activitatea desf`]urat`:

I. Cadrul didactic care solicit` asigurare

individual`:/Theacher that asks for an individual policy:
- institu\ia educativ` unde î]i desf`]oar` activitatea:/the
institution where the teacher works:

- titulatura, func\ia:/title:

- num`r de ore de lucru pe lun`/no. of working hours in a

month:

- organiza\i/participa\i la activit`\i extra]colare (expozi\ii,

excursii, tabere etc)/Do you organize/participate at any
activity related to the teaching process (exhibitions, trips,
camping etc.)

- Limita agregat a r`spunderii:/Aggregate limit of

liability:
- Limita r`spunderii pe eveniment:/Limit of liability per
event:
II. Institu\ia ]colar` care solicit` asigurarea pentru toate
cadrele didactice:/The School/Institution that asks for a
policy for all teachers:
- num`r cadre didactice/number of teachers

- structura pe categorii/categories

Prezentul chestionar face parte integrant` din poli\a de asigurare

Formular D2.1-PL1-CH_RC111 / e/r 1/3
 - num`r elevi înscri]i într-un an ]colar/number of
scholars/scholar year

- organiza\i activit`\i extra]colare (expozi\ii, excursii,

tabere etc)?/Do you organize any activity related to the
teaching process (exhibitions, trips, camping etc)?
- limita agregat a r`spunderii/aggregate limit of liability:
- limita r`spunderii pe eveniment/limit of liability per
event:
- limita r`spunderii afferent` unui cadru didactic/limit of
liability per one teacher:

5. Informa\ii referitoare la asigur`ri ]i daune/information about insurance and damages

A\i avut anterior o asigurare de r`spundere civil`  Da/Yes  Nu/No

professional`?Have you previously been insured Dac` da, v` rug`m preciza\i:/If so, please
for Professional Liability Insurance? specify:
-Asigur`torul/The Insurer:

-perioada de asigurare/insurance period:

-limita r`spunderii/limit of liability:

-desp`gubiri pl`tite/paid indemnities:

A\i avut reclama\ii în activitatea dvs profesional`,  Da/Yes  Nu/No

în ultimii 3 ani?/Have you had any claims in your *
professional activity in the last three years?

A\i avut cereri de desp`gubire în ultimii trei  Da/Yes  Nu/No

ani?/Have you had any indemnity claims in the last *
three years?

A\i pl`tit desp`gubiri în ultimii trei ani?/Have you  Da/Yes  Nu/No

paid indemnity in the last three years? *

*Dac` da, men\iona\i anul, motivele, sumele pl`tite/If yes, specify the year, the reasons, the paid sums

6. Cunoa]te\i circumstan\e care pot determina

reclama\ii sau plângeri împotriva dvs.?/Are
you aware of any circumstances or incidents
which may result in a claim against your
firm?

Prezentul chestionar face parte integrant` din poli\a de asigurare

Formular D2.1-PL1-CH_RC111 / e/r 1/3
 7. Fran]iza solicitat`:/Requested deductible: -fran]iza ptr. r`spundere civil` legal`/deductible
for public liability
-fran]iza ptr. r`spundere civil` professional`

8. Perioada de asigurare/Insurance period

9. Modalitatea de plat` a primei de  integral/integral

asigurare/Payment of insurance premium  în rate/by installments
nr. rate/no. of installments

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 that 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 integrant` din poli\a de asigurare

Formular D2.1-PL1-CH_RC111 / e/r 1/3