ringthepastfiveyears?若是,请告之具体情况:IfYes,pleaseprovidetotallosses□是Yes□否No年份Year索赔数额/数量NumberandamountofClaim已赔数额Settledamount索赔原因CauseofClaim贵公司是否已获悉某些可导致向贵所索赔的情况及事件?Areyouawareofanycircumstancesorincidentswhichmayresultinaclaimagainstyou?若是,请说明详情。Ifso,pleasegivedetails.————————————————————————————————□是Yes□否No兹声明以上问卷表中的回答和陈述是基于本人所了解的情况,陈述的内容完整且真实。投保人明白若陈述中有虚假和故意隐瞒,保险人有权解除保险合同或拒绝履行赔偿。Theanswersinthisquestionnaireare,pleteandtrue.pletestatementsintentionally,theInsurerhastherighttowithdrawfromtheContractortorefuseindemnification.日期Date:______________________签名盖章signature,seal____________________地点Place:中国上海Shanghai,China以上所填的信息将被本公司严格保密,本公司保证不向第三方透露,除非本保险的共同保险人或者再保险人。Allinformationisdealtwithinstrictconfidenceandisnotmadeavailabletothirdparties,exceptforco-insurersandreinsurers,ifanyinvolved.
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