PICC中国人民保险公司南京分公司

                              The People's Insurance Company of China，Nanjing Branch

货物运输保险投保单

APPLICATION FORM FOR CARGO TRANSPORTATION INSURANCE

被保险人

INSURED：                                                                 

发票号（INVOICE NO．）________________

合同号（CONTRACT NO．）_______________

信用证号（L/C NO．）__________________

发票金额（INVOICE AMOUNT)                投保加成(PLUS)                 ％

兹有下列货物向________投保。（INSURANCE IS REQUIRED ON THE FOLLOWING COMMODITIES：）

启运日期：                                装载运输工具：

DATE OF COMMENCEMENT：                    PER CONVEYANCE：                 

自                         经                  至                              

FROM                     VIA                 TO                             

提单号：                           赔款偿付地点                                

B/L NO．                          CLAIM PAYABLE AT                          

投保险别：（PLEASE INDICATE THE CONDITIONS ＆/OR SPECIAL COVERAGES：）  

请如实告知下列情况：（如“是”在［  ］中打“√”，“不是”打“×”）IF ANY，PLEASE MARK“√”OR“×”

1．货物种类：袋装［  ］散装［  ］冷藏［  ］液体［  ］活动物机器／汽车［  ］危险品等级［  ］

  GOODS：BAG/JUMBO BULK REEFER LIQUID LIVE ANIMAL MACHINE/AUTO DANGEROUS CLASS

2．集装箱种类：普通［  ］开顶［  ］框架［  ］平板［  ］冷藏［  ］

CONTAINER：ORDINARY OPEN FRAME FLAT REFRIGERATOR

3．转运工具：海轮［  ］飞机［  ］驳船［  ］火车［  ］汽车［  ］

    BY TRANSIT：SHIP PLANE BARGE TRAIN TRUCK

4．船舶资料：船籍［  ］船龄［  ］  

 PARTICULAR OF SHIP：REGISTRY  AGE

备注：被保险人确认本保险合同条款和内容已经完全了解。投保人（签名盖章）APPLICANT'S

SIGNATURE THE ASSURED CONFIRMS HEREWITH THE

TERMS AND CONDITIONS OF THESE INSURANCE                       

CONTRACT FULLY UNDERSTOOD                                                  电话：(TEL)__________________

投保日期：                                                                 DATE地址：（ADD)_____________