ZAVAROVALNICA TRIGLAV, d.d.

miklošièeva cesta 19, ljubljana

ID ŠT. ZA DDV SI80040306

OBMOÈNA ENOTA .........................................................................................................................

Vprašalnik za zavarovanje proizvajalèeve odgovornosti za izdelke

Product Liability Insurance Questionnaire

I. SPLOŠNI PODATKI O ZAVAROVANCU / GENERAL INFORMATION ABOUT INSURED

1. Zavarovanec in njegov naslov: ALISA , ALENKA STOPAR S.P.

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Name and address of insured:

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Davèna številka / Fiscal number: SI 56402791

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Telefonska številka, številka faksa in elektronska pošta: 04 2314400, 031 376937

tel: ............................................................................................................... , fax: ..................................................................................

Telephone number, fax number and e-mail: INFO@ALISA.SI

e-mail: .......................................................................................................................................................................................................

2. 46.160 (Posr.-teks.,oblač.,krzn.,obutve,usn.izd.)
Registrirana dejavnost / Registered activity: .............................................................................................................................................................................................................................................................

3. Opis podjetja/družbe in poslovne dejavnosti / Description of company and business activity:

Prosimo, podajte podrobne informacije, po potrebi na posebnem listu in priložite relevantne brošure, letake, navodila za proizvodnjo itd.
Please give detailed information, if necessary on an extra sheet, and supply relevant brochures, leaflets, manufacturing guidelines, etc.
Proizvodnja spodnjega perila: nedrčki za dojenje, nosečniško perilo, stoma perilo, pooperativno perilo,
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korzeti, izdelava po meri. Vsi izdelki so razviti v našem podjetju po kreacijah modne oblikovalke Alenke
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Stopar. Izdelke tržimo preko trgovin v Sloveniji in Hrvaški ter preko spleta po celem svetu.
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II. VPRAŠANJA ZA OCENO RIZIKA / QUESTIONS FOR RISK ASSESSMENT

Izdelki / Products

1. Izdelki, ki jih imate v proizvodnih programih / Products in your production program:

spodnje perilo
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2. Izdelki, za katere želite skleniti zavarovanje / Products, for which you want to get Insurance:

perilo za bolnike s stomo - stoma hlačke in pasovi

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3. Ali izdelkom prilagate potrebna navodila in opozorila / Do you attach the necessary instructions and warnings to your products?

x
¨ da / yes ¨ ne / no

4. Ali sami opravite / Do you perform: montažo / installation? ¨ da / yes ¨ ne / no

servis / service? ¨ da / yes ¨ ne / no

5. Kakšna je življenjska doba vaših izdelkov / What is the life cycle of your products?

cca 2 leti
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6. Navedite vse proizvode, ki so gorljivi, eksplozivni, strupeni, radioaktivni ali nevarni na kakršenkoli drug naèin:
State all the products that are flammable, explosive, toxic, radioactive or dangerous in any other way:

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VP-oiz-rpo/11-9
Promet / Turnover

1. Promet iz prodaje izdelkov / Volume of annual product sales: Zneski so izraženi v EUR / Amounts are expressed in EUR:

a) obmoèje R. Slovenije / area of the R. of Slovenia

21.000
v preteklem letu / in the past year: ..................................................................................................................................................

30.000
naèrtovane v tekoèem letu / planned in the current year: ........................................................................................

b) države EU / EU countries
3.300
v preteklem letu / in the past year: ..................................................................................................................................................
40.000
naèrtovane v tekoèem letu / planned in the current year: ........................................................................................

c) ostala Evropa / rest of Europe

v preteklem letu / in the past year: ..................................................................................................................................................

naèrtovane v tekoèem letu / planned in the current year: ........................................................................................

d) ostali svet (brez Severne Amerike) / rest of the world (excluding North America)

400
v preteklem letu / in the past year: ..................................................................................................................................................
1.000
naèrtovane v tekoèem letu / planned in the current year: ........................................................................................

e) Severna Amerika / North America

v preteklem letu / in the past year: ..................................................................................................................................................

naèrtovane v tekoèem letu / planned in the current year: ......................................................................................

Od tega / From this:

95%
lastni proizvodi /own products: ........................................................................................................................................................... %.

5%
blago za nadaljnjo prodajo / merchandise held for resale: ........................................................................................ %.

2. Kateri proizvodi so proizvedeni po naroèilu / Which products are made-to-order products?

perilo za posebne potrebe in izvenserijske velikosti

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5%
Delež teh proizvodov v skupnem prometu / Their share in total turnover: .................................................. %.

3. Kateri proizvodi so serijski / Which products are batch products?

nedrčki za dojenje, nosečnisko perilo, stoma perilo, pooperativno perilo
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Število proizvodov v seriji / Number of items in each batch: ..................................................................................... .

95%
Delež teh proizvodov v skupnem prometu / Their share in total turnover: .............................................. %.

Uvoz/izvoz / Import/exports

1. Ali sami izdelujete vse dele, ki jih vgrajujete v izdelek / Do you produce all the parts built-in the product?

¨ da / yes x¨ ne / no

Èe ne, prosimo navedite katere dele vam dobavljajo drugi proizvajalci / If not, please state which parts are supplied by other manufacturers:

pletivo - blago, elastika, plastični deli za nedrčke, sponke

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2. Ali uvažate blago neposredno od tujih proizvajalcev / Do you import goods directly from foreign manufacturers?

x¨ da / yes ¨ ne / no

Èe da, prosimo navedite proizvajalce / If so, please state the manufacturers:

Gregorx Poljska
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2
 Nosečniška oblačila
Vrste proizvodov / Type of products: ...............................................................................................................................................................................................................................................................................

Navedite države, iz katerih uvažate proizvode / Name the countries from which the products are imported:
Poljska
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Promet s temi proizvodi v EUR / Turnover from these products in EUR: ...........................................................................................................................................................................................

3. Ali uvažate sestavne dele ali konène proizvode iz držav izven obmoèja EU?
Do you import components or finished products from outside the EU?

x¨ da / yes ¨ ne / no

Èe da, naštejte tipe proizvodov / If so, please state the types of products:
sestavni deli : plastični deli za nedrčke, blago
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Navedite države iz katerih uvažate proizvode / Name the countries from which the products are imported:
Kitajska, Turčija
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Promet s temi proizvodi v EUR / Turnover from these products in EUR: ..........................................................................................................................................................................................

4. Ali izvažate proizvode sami oz. preko vaših predstavništev v tujini?

Do you export your products yourself or respectively through your branches abroad?

x da / yes
¨ ¨ ne / no

Èe da, ali imate predstavništva tudi v Severni Ameriki / If so, do you also operate in North America?
ne
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5. Ali lahko vaše proizvode izvažajo tretje osebe (izvozna podjetja, turisti itd.) brez vaše vednosti?
Can your products be exported by third parties (eg. export companies, tourists etc.) without your knowledge?

¨ da / yes x
¨ ne / no

Èe da, prosimo naštejte proizvode, ki jih lahko tretje osebe izvozijo v Severno Ameriko:
If so, state which products can be exported to North America by third parties:

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Promet s temi proizvodi v EUR / Turnover from these products in EUR: ..........................................................................................................................................................................................

6. Ali prodajate tuje proizvode pod / Do you sell foreign products under:

a) svojim imenom - znamko / your own name - trademark?

¨ da / yes x
¨ ne / no

Èe da, prosimo navedite proizvajalce / If so, please state the manufacturers:

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Vrste proizvodov / Type of products: ...................................................................................................................................................................................................................................................................

Navedite države, iz katerih uvažate proizvode / Name the countries from which the products are imported: ..............................................................................

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Promet s temi proizvodi v EUR / Turnover from these products in EUR: .............................................................................................................................................................................

b) imenom ali znamko drugih proizvajalcev / the names or brands of other manufacturers?

x¨ da / yes ¨ ne / no

Èe da, prosimo navedite proizvajalce / If so, please state the manufacturers:

Gregorx
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Vrste proizvodov / Type of products: nosečniška oblačila

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Navedite države, iz katerih uvažate proizvode / Name the countries from which the products are imported: ................................................................................
Poljska
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500
Promet s temi proizvodi v EUR / Turnover from these products in EUR: ...............................................................................................................................................................................

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7. Ali prodajate proizvode brez blagovne znamke, proizvajalci pa vam niso znani?
Do you sell no-name products, the manufacturers of which are not known to you?

¨ da / yes x
¨ ne / no

Vrste proizvodov / Type of products: ...............................................................................................................................................................................................................................................................................

Promet s temi proizvodi v EUR / Turnover from these products in EUR: ...........................................................................................................................................................................................

8. Kdo so kupci vaših proizvodov / Who are the buyers of your products?

x
¨ veleprodaja / wholesale ¨ letalska, železniška industrija / aviation/railway industry

x¨ maloprodaja / retail ¨ ladjedelništvo, avtomobilska industrija / watercraft/auto industry

¨ drugi industrijski sektorji / other industrial sectors:

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9. Prosimo navedite kupce oz. družbe, s katerimi je vaše podjetje povezano kapitalsko ali kako drugaèe:
Please state the customers or companies with which your company is capital or otherwise-related:

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10. Trgovsko blago, namenjeno nadaljnji prodaji / Merchandise intended for resale:

Ali ste odgovorni za / Are you responsible for:

¨ pakiranje / packaging? .........................................................................................................................................................................................................................................................................................................

¨ polnjenje / filling? .....................................................................................................................................................................................................................................................................................................................

¨ oznaèevanje / labeling? ....................................................................................................................................................................................................................................................................................................

¨ drugo obdelavo tega blaga / other treatment: of these merchandise? ..................................................................................................................................................................................

11. Ali želite pridobiti kritje iz naslova razširjene proizvajalèeve odgovornosti za izdelke?
Do you wish to obtain extended product liability coverage?

¨ da / yes ¨ ne / no

V kolikor želite pridobiti tako kritje, vas prosimo, da odgovorite na sledeèa vprašanja pod rubriko Razširjeno kritje. Èe takega kritja ne želite,
prosimo nadaljujte z izpolnjevanjem vprašalnika pri rubriki Garancija/svetovanje.
If you wish to obtain such coverage, please fill out the following questions under the section Extended coverage. If you don’t wish to obtain such
coverage, please continue with completing the questionnaire in the section Warranty/advice.

Razširjeno kritje / Extended coverage

1. Ali so vaši proizvodi spojeni, zliti ali obdelani skupaj z drugimi proizvodi s strani tretjih oseb?
Are your products connected, blended or processed with other products by third parties?

¨ ne / no ¨ da, naslednji proizvodi / yes, the following products: ................................................................................................................................................................

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Najveèje število proizvodov v seriji / Maximum number of products per batch:

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S katerimi drugimi proizvodi so vaši proizvodi spojeni, zliti ali zmešani?

With which other products are your products connected, blended or mixed?

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2. Ali so vaši proizvodi nadalje obdelovani s strani tretjih oseb, ne da bi bili spojeni, zliti ali zmešani z drugimi proizvodi?
Are your products further processed by third parties without being connected, blended or mixed with other products?

¨ ne / no ¨ da, naslednji proizvodi / yes, the following products: .............................................................................................................................................................................

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Najveèje število proizvodov v seriji / Maximum number of products per batch:

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Za katero obliko nadaljnje obdelave gre / Type of further processing?

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3. Kateri od vaših proizvodov (lastni proizvodi, trgovsko blago za nadaljnjo prodajo, dobave s strani tretjih oseb) morajo biti sestavljeni, vgrajeni,
vzdrževani itd.? / Which of your products (own products, merchandise held for resale, supplies made by third parties) need to be assembled,

integrated, maintained etc.?

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Najveèje število posameznih proizvodnih serij / Maximum number of batches produced: ...........................................................................................................................................

Najveèje število proizvodov v seriji / Maximum number of products per batch: .....................................................................................................................................................................

4. Ali so ti proizvodi sestavljeni, vgrajeni, vzdrževani itd. s strani vašega osebja?

Are these products assembled, integrated, maintained etc. by your own staff?

¨ ne / no ¨ da / yes

Letna masa plaè v EUR / Annual payroll amount in EUR: ..............................................................................................................................................................................................................................

5. Ali so ti proizvodi sestavljeni, vgrajeni, vzdrževani itd. s strani vaših podizvajalcev?

Are these products assembled, integrated, maintained etc. by sub-contractors?

¨ ne / no ¨ da / yes

Letna vrednost naroèil v EUR / Annual value of orders in EUR: ..............................................................................................................................................................................................................

V kateri tovarni sestavljajo, vgrajujejo, vzdržujejo itd. vaše proizvode?

In which factory are your products assembled, integrated, maintained etc.?

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6. Ali so vaši proizvodi vgrajevani v zraèna, cestna, železniška vozila in plovila?

Are these products integrated into air/road/rail/water crafts?

¨ ne / no ¨ da / yes

Kateri od vgrajevanih proizvodov se lahko pozneje odstranijo, èe se izkaže, da imajo napako?

Which of these integrated products can later be removed if proved to be defective?

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Najveèje število posameznih proizvodnih serij / Maximum number of batches produced: ...........................................................................................................................................

Najveèje število proizvodov v seriji / Maximum number of products per batch: .....................................................................................................................................................................

7. Kateri od strojev, ki jih dobavljate, sestavljate, vzdržujete itd. so uporabljeni za proizvodnjo ali obdelavo drugih proizvodov?
Which of the machines supplied, assembled, maintained etc. by you are used in the manufacturing or processing of other products?

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8. Katere polizdelke oz. surovine nabavljate od dobaviteljev, da lahko proizvajate konène izdelke?
Which intermediate products or raw materials do you procure from suppliers in order to manufacture end products?

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Vrednost materialov v EUR / Value of materials in EUR: ...............................................................................................................................................................................................................................

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9. Ali je mogoèe odstraniti posamezne sestavne dele proizvoda, da bi se odpravilo morebitno škodo, ali je potrebno odstraniti celotni proizvod?
Is it possible to remove individual components of a product in order to eliminate a potential damage, or does the entire product have to be removed?

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10. Ali uporabljate orodja za proizvodnjo ali obdelavo strojev, kalupov in proizvodov s podroèja merjenja proizvodnih postopkov ter tehnologije kontrole kvalitete?
Do you use tools for producing or handling machines, moulds and products from the field of process-measurement and quality control technology?

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11. Ali želite v kritje vkljuèiti tudi stroške preizkušanja in iskanja napak v skladu s 7. èlenom predmetnih pogojev?
Do you want coverage to include the costs of testing and defect location costs in the accordance with Article 7 of relevant conditions?

¨ ne / no ¨ da / yes

Garancija/svetovanje / Express warranty/consulting

1. Ali ponujate garancijo za vaše proizvode ali njihove lastnosti (npr. rok trajanja, vzdržljivost, moè, obstojnost barv, nevtralnost okusa, temperaturna
odpornost, moè lepljenja itd.)?
Do you offer express warranty on your products or their features (eg. in terms of shelf life, strength, degree of colour fastness, neutral taste,
resistance to temperature, adhesive strength etc.)?

x¨ ne / no ¨ da / yes

Za katere proizvode / For which products? ...............................................................................................................................................................................................................................................................

Za katere lastnosti - karakteristike / For which features - characteristics? .................................................................................................................................................................................

V kakšni obliki / What form does this take? ................................................................................................................................................................................................................................................................

2. Ali vašim strankam ponujate svetovalne storitve / Are you offering consulting services to your customers?

x osebno svetovanje / personal consulting

¨ ¨ drugo (prosimo navedite) / other (please give details)

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3. Ali dajete garancije / Do you give warranty?

x
¨ ne / no ¨ da / yes

4. Ali morate nuditi daljše garancijske roke, kot so predpisani z zakonodajo / Are you required to offer longer warranty periods than those prescribed by law?

x
¨ ne / no ¨ da / yes

5. Za kakšne garancijske roke se obièajno dogovorite s kupci / What warranty periods are usually agreed with customers?

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Pogoji dostave, prodaje / Terms and conditions of delivery/sale

1. Ali je prodaja - dostava ponavadi opravljena na podlagi vaših pogojev?

(Èe da, prosimo posredujte dokumentacijo in pogoje dostave za domaèe in tuje kupce.)
Are sales - deliveries normally conducted on the basis of your own terms?
(If so, please supply documents and delivery terms for domestic and foreign buyers.)

¨ ne / no x
¨ da / yes ¨ v nekaterih primerih / in some cases

2. Ali prodajate svoje proizvode / Do you sell your products:

x
¨ neposredno konènim uporabnikom / directly to the end users?

x
¨ konènim uporabnikom preko posrednikov / indirectly via intermediaries?

¨ nadaljnim proizvajalcem polizdelkov / to further producers of semi finished products?

3. Ali je odgovornost vaših dobaviteljev/podizvajalcev velikokrat razlièna od vaše (npr. preko njihovih splošnih pogojev poslovanja)?
Is the liability of your suppliers/subcontractors frequently restricted to your disadvantage (eg. through their own general business terms and conditions)?

¨ ne / no ¨ da / yes

Približni delež prometa (%) / Approximate value of turnover (%): .........................................................................................................................................................................................................

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Raziskave/razvoj/nadzor / Research/development/controls

1. Ali ima vaše podjetje lastni raziskovalni oz. razvojni oddelek / Does your company have its own research or development department?

¨ ne / no x
¨ da / yes

2. Katere proizvode razvijate in od kdaj so na tržišèu / What products do you develop and since when are they on the market?
perilo od leta 2009
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3. Ali ste izdelek, ki ga želite zavarovati razvili sami / Have you developed the product that you want to insure?

¨ ne / no x
¨ da / yes

Èe ne, po kateri tehnologiji ga proizvajate / If not, based on which technology is it produced?

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Koliko èasa je že v proizvodnji / How long has it been in production? ...................................... let / years.

4. Kako vaše podjetje nadzira proizvode, dobavljene s strani tretjih oseb (vhodna kontrola)?
How does your company monitor products supplied by third parties (incoming inspection)?

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5. Ali nadzorujete kvaliteto lastnih izdelkov med proizvodnjo / Do you provide quality control of your products during production?

¨ ne / no x
¨ da / yes

6. Ali so rezultati vhodne, vmesne in konène kontrole dokumentirani?

Are the results of incoming/production control and final inspections documented?

¨ ne / no ¨ da / yes

Kontrola osnovnih mer izdelka in vizualni pregled pred pakiranjem.

Po katerih vidikih / According to what aspects? .......................................................................................................................................................................................................................................................

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7. Kako dolgo hranite to dokumentacijo / How long are records kept? .....................................................................................................................................................................................................

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8. Ali so med kontrolo proizvodov odvzeti vzorci / Are samples of the inspected products taken?

x
¨ ne / no ¨ da / yes

Èe da, kako dolgo se hranijo / If so, how long are they kept? ....................................................................................................................................................................................................................

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9. Ali ima izdelek vaše ime in oznako / Does the product have your name and code?

¨ ne / no x
¨ da / yes

10. Kateri proizvodi so narejeni po tujih licencah / Which products are manufactured according to foreign licenses?

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11. Kdo so nosilci teh licenc / Who are the licensors of these products? ..............................................................................................................................................................................................

12. Prosimo navedite licence za vaše razliène proizvode / Please state the licensees for your various products?

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III. VPRAŠANJA O ŠKODNEM DOGAJANJU / QUESTIONS ABOUT CLAIMS EVENTS

1. Koliko ste morali v zadnjih treh letih plaèati svojim strankam ali tretjim osebam iz naslova škod, ki so nastale z vašimi proizvodi, vkljuèno z nerešenimi
škodnimi zahtevki (izkljuèujoè zneske zaradi lastnih škod)?
Over the last three years, how much have you had to pay customers or other third parties in damages arising from losses caused by your
products, including outstanding claims (not including amounts paid in respect of the defective product itself)?

Leto / Year Število / Number Znesek v EUR / Amount in EUR Iz razširjenega kritja / From extended coverage

0
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2. Kateri proizvodi so bili vkljuèeni / Which products were involved? .......................................................................................................................................................................................................

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3. Najvišji škodni zahtevek v EUR / Highest single claim in EUR? ..............................................................................................................................................................................................................

4. Ali obstaja veè škodnih zahtevkov zaradi enega samega proizvoda / Has there been a series of claims in respect of a product?

x
¨ ne / no ¨ da / yes

5. Kakšne tipe škodnih zahtevkov prièakujete v povezavi z zavarovanjem vaše produktne odgovornosti (npr. izguba pri zlitju, stroški namešèanja -
odstranjevanja itd.)?
What type of claim profiles do you imagine occurring in respect of your product liability cover (eg. blending loss, installation - removal costs,
processing costs)?

Z našim izdelkom ni možno povzrčiti škode , zavarovanje potrebujemo zaradi ISO standarda bodočega
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distributerja za Italijo.
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6. Prosimo ocenite višino tipiène škode, ki bi izhajala iz potencialnega škodnega zahtevka (v EUR)?
Please estimate the amount of typical loss arising from potential civil claim (in EUR)?

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IV. VPRAŠANJA O ZAVAROVALNEM KRITJU / QUESTIONS ABOUTE INSURANCE COVER

Obmoèje kritja / Geographical coverage

1. Prosimo navedite želeno geografsko obmoèje kritja / Please state the desired geographical scope of coverage:

x
¨ Evropa / Europe

¨ svet brez Severne Amerike / world excluding North America

¨ celotni svet / the whole world

¨ drugo / other: .........................................................................................................................

2. Za zavarovalno kritje na obmoèju Severne Amerike prosimo navedite / For insurance coverage in North America please state:

¨ uporabljene prodajne poti (direktna prodaja, podružnice, poslovalnice, itd.) / used sales channels (direct sales, branch offices, sales offices etc.):

.................................................................................................................................................................................................................................................................................................................................................................

¨ ali imate izkušnje z izvozom v Severno Ameriko ter kako dolgo / did you gain experience with exporting to North America and for how long?

.................................................................................................................................................................................................................................................................................................................................................................

¨ ali ima uvoznik oz. prodajalec v Severni Ameriki kritje za proizvajalèevo odgovornost tudi za uvožene izdelke?
does importer or seller in North America have products liability coverage also for imported products?

.................................................................................................................................................................................................................................................................................................................................................................

8
Trajanje zavarovanja / Duration of Insurance

1. Ali potrebujete zavarovalno kritje za že prodane proizvode / Do you need insurance coverage for products allready sold?

x¨ ne / no ¨ da / yes ¨ od katerega datuma dobave / from which date of delivery?

.........................................................................................................................................................................................................................................

2. Želeno obdobje kritja / Desired insurance period:

x
¨ letno kritje / annual policy

¨ doloèena doba .................... let / defined period of .................. years

¨ za nedoloèeno dobo / for an indefinite period

Franšiza / Deductible

1. Višina odbitne franšize / Amount of deductible:

¨ najveè 5.000 EUR za vsak škodni zahtevek / maximum EUR 5.000 of every claim

¨ drugaèna franšiza v EUR / other deductible in EUR: .............................................................................................................................................................................................................................

Zavarovalna vsota / Sum insured

1. Želena zavarovalna vsota / Required sum insured:

¨ zavarovalna vsota za proizvajalèevo odgovornost v EUR:

sum insured for Product Liability coverage in EUR: ..............................................................................................................................................................................................................................

¨ podlimit za razširjeno proizvajalèevo odgovornost v EUR:

sublimit for Extended Product Liability coverage in EUR: ...............................................................................................................................................................................................................

V. DODATNA POJASNILA ZAVAROVANCA / ADDITIONAL EXPLANATORY NOTES INSURED

Izjava / Statement
Vsi navedeni podatki, ki jih navajamo, so resnièni in toèni ter služijo zavarovalnici kot osnova za izdelavo ponudbe. Zavezujemo se, da bomo
zavarovalnici sporoèili vsakršne morebitne spremembe navedenih podatkov, ki bi nastopile pred sklenitvijo zavarovalne pogodbe. Zavarovalnica si
pridrži pravico do spremembe oziroma odstopa od morebitne ponudbe posredovane zavarovancu, pripravljene v okviru informacij, pridobljenih iz
predmetnega vprašalnika, v kolikor se izkaže, da so naknadno javljene bistvenega pomena za oceno tveganja predmetnega rizika.
Ta vprašalnik ne predstavlja ponudbe za sklenitev zavarovanja v smislu Obligacijskega zakonika in še ne obvezuje zavarovalnice za kritje. Vsi zgornji
podatki bodo upoštevani kot strogo zaupni.

We declare that all above statements are true and that we have withheld no information material to the insurer. We will inform the Insurance company
about all changes that may occur before conclusion of the insurance contract. The Insurance company has the right to change or withdraw any offer
prepared on the basses of information derived from this questionnaire if it turns out that additional reported information is essential for risk
assessment.
This questionnaire is not quotation according to the Code of obligations and does not oblige insurer for insurance cover. All information reported
herein will be kept strictly confidental.

Žabnica, 2.1.2018
.................................................................................................................................................................................... .
Kraj in datum / Place and date

Alisa, Alenka Stopar s.p.

.......................................................................................................................................................................................... ........................................................................................................................................................
Zavarovanec / Insured Posrednik / Agent

Vsi zgornji podatki bodo upoštevani kot strogo zaupni / All information reported herein will be kept strictly confidential.