CERERE CHESTIONAR / PROPOSAL FORM

privind / regarding
ASIGURAREA DE RASPUNDERE CIVILA A ADMINISTRATORILOR SI DIRECTORILOR
EXECUTIVI / DIRECTORS` AND OFFICERS` LIABILITY

1. Denumirea Companiei / Title of the Company

C.I.F. / Fiscal registration number

2. Compania este o subsidiara a unei alte companii sau o

subsidiara in proprietatea statului? / Is the Company a
subsidiary of another company or a state owned subsidiary?

3. Sediul Social / Principal Address:

4. Obiectul de activitate / Activity:

5. Compania si-a desfasurat in mod continuu activitatea

in ultimii trei ani? / Has the company been trading for
three years or more?

6. Precizari referitoare la actionarii Pondere actiuni

Companiei / Details of any Denumirea Actionarului / detinute /
Tara / Country
shareholding in the Company Name of Shareholder Percentages of
shares held

7. Limita de raspundere solicitata /

Required limit of indemnity

8. Au existat cereri de despagubire formulate impotriva NU [NO] / DA [YES] - daca DA, va

companiei sau fostilor asociati sau actualilor asociati care ar rugam precizati motivele / If YES please give full
putea sa dea nastere la pretentii de despagubire actuale sau details
potentiale in baza prezentei polite? / Has any claim for
damages that would have been actually or potentially covered
by the insurance applied for ever been entered against the
company or against present or past members of the bodies to
be covered by the insurance?

9. In prezent, aveti cunostinta de evenimente care ar putea da NU [NO] / DA [YES] - daca DA, va
nastere unor cereri de despagubiri impotriva companiei sau a rugam precizati motivele / If YES please give full
uneia dintre persoanele asigurate? / Are any circumstances details
known to exist which could lead to a claim for damages
against the company or any of the insured persons?

10. Cifra de afaceri estimata pe perioada de asigurare / Estimated turnover:

Prezentul chestionar face parte integranta din polita de asigurare

Formular D2.1-PL1-CH_RC110 / e/r 1/3 1
 11. Compania a inregistrat profit net in ultimii doi ani? / NU [NO] / DA [YES]
Did the company have a net profit for the last two years?

12. Compania a inregistrat un rezultat net pozitiv in urma NU [NO] / DA [YES]

ultimului audit? / Did the company record a positive net
worth at the last reported audited accounts?

Semnatarul, autorizat de catre Companie si in numele Companiei, declara cu toata responsabilitatea si buna
credinta ca declaratiile facute in prezenta sunt adevarate si corespund realitatii. De asemenea, se agreaza ca aceasta
Cerere-Chestionar si declaratiile facute sa stea la baza contractului de asigurare in cazul in care Polita va fi emisa
si sa faca parte integranta din Polita.
The Undersigned authorised Officer of the Company, and on behalf of the Company declares that to the best of
his/her knowledge and belief the statements set forth herein is true. Although it is agree that this Form and the said
statements shall be the basis of the contract should a Policy be issued and this Form attaches and become part of
the Policy.

Semnatura / Signed:

Data / Date:

Prezentul chestionar face parte integranta din polita de asigurare

Formular D2.1-PL1-CH_RC110 / e/r 1/3 2