雇主责任险风险问卷调查表

Is there any other welfare commercial insurance policy purchased for your employee besides this insurance□是Yes□否No
请简单评述本单位的福利和收入水平在同行业中的所处地位：
Please give comment in respect of your employee’s welfare and salary
若有，请说明污染物的性质及其可能对人体导致的危害后果If Yes, please advise the nature of
such hazardous pollutants：
____________________________________________________________________________
themanagementboard？
□是Yes
□是Yes
□否No
□否No
3．生产过程中是否有特殊危险的作业Is there any dangerous operation involved in the course of
production？
若有，请说明危险的来源If Yes, please advise the source of such danger：
□领先superior□高于平均水平above average□一般水平average□低于平均水平below average
3．请按下表填写雇员的情况:
Please fill in the following blank
雇员工种
Classification
Of Work
人数
Number of
Employee
50岁以上员工占比Percentage of Employee over 50：________%
2．是否为本单位雇员缴纳四金？Do you pay to legal welfare funds for all of your employees□是Yes□否No
除本保险外，是否还为雇员购买其他商业保险？
_____________
行业风险防范Loss Control
1．是否设有安全生产管理部门Do you have special department dealing with the management of
safety production？
是否有安全检查制度并得到能切实的落实Are all inspection systems for the purpose of safety
materials：
____________________________________________________________________________
上述危险品属于the above-said dangerous products are：
□易燃combustible□易爆explosive□有毒poisonous□辐射radioactive
若无防护措施，将对人体导致的后果please describe the potential negative effects brought to the
human body by such pollutants in case that no protection measures are implemented：
是否拥有特种工程车？Do you possess engineering vehicles for specialized operation□是Yes□否No
若有，请说明：If so, please specify车辆类型type数量quantity
______________________
______________________
4．企业性质Nature ofEnterprise
□国营state-owned□集体collective□私营private-owned□股份制shared□中外合资joint
□外商独资，请告知外方的国籍：foreigner-owned, pleaseadvise nationality of the owner
____________________________________________________________________________
有无防护措施、应急抢救预案和安全制度Do you have sufficient protection measures, safety
system, and first aid plan against the harm brought by such pollutants？
______________________
雇员情况condition of employee
1．员工人数No. of Employee:___________
其中，人事/人力资源部员工数Amidst above,No.ofEmployeesinthepersonnel/human resourcedepartment: _________________
_____________
_____________
______________
______________
_____________
_____________
______________
______________
_____________
_____________
______________
______________
有无防护措施、应急抢救措施和安全制度Do you have sufficient protection measures, safety
system, and first aid plan against the harm brought by such pollutants？
□是Yes
□是Yes
□否No
___________________________________________________________________________
上述操作属于the operation is：
□带电in electrification□高温in high temperature□爬高in high altitude
女性员工占比Percentage of Female Employee：________%
30岁以下员工占比Percentage of Employee below 30：________%
30~50岁员工占比Percentage of Employee between 30 and 50：________%
fully implemented and performed？
□是Yes
□是Yes
□否No
□否No
2．员工是否经过专业技术培训Have all of your staff been trained in professional technique
courses？
员工是否能遵守各项制度和纪律Could your staff oblige all the disciplines and system made by
2．总部地址Address of Head Officein P.R.China
____________________________________________________________________________________________________________
3．工作地点Work-place
请详述：Please describe
____________________________________________________________________________________________________________
6．普通汽车数量Number of regular automobiles：___________________________________________________________________________
personnel all the time？
危险品在厂区内运送是否有专门路线Do you prescribe special route for hazardous material
transportation in plant？
危险品集中放置处和仓库周围有无设立危险警示标志Do you set warning signs around the
雇主责任保险Employer’sLiability Insurance
风险调查问卷Risk Evaluation Questionnaire
概况GeneralInformation
1．投保人名称Name of Insured
____________________________________________________________________________________________________________
(若包含多个附地址清单Ifmore than one place areincluded, please attach list)
____________________________________________________________________________________________________________
□否No
4．生产过程中是否会产生影响雇员身体健康的污染物Are there any hazardous or poisonous