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CERERE CHESTIONAR

DATA: _________

A. DATE DESPRE ASIGURAT:

Denumire societate:____________.Cod fiscal:___________________


Persoana de
Contact:_________________________________________________________________
Sediu social: _______________________________
Activitate principala: ______________________________
Cifra de afaceri pe anul trecut_____________Estimare pe anul urmator:_______
Nr. de angajati:_______________________________________________________________________
Volumul brut al salariilor pe anul trecut:___________ Estimare pe anul urmator:__

B. VALORI DE ASIGURAT - INCENDIU - Valoarea total _______________________________


Cldire/R.L. ____________ Mijloace fixe ________________________
Mrfuri ___________________ Daune vecini ____________________________________

C. CLDIRI
Suprafaa - total ___ din care acoperit _____________________________________
nlime i subsoluri
Structura portant vertical i planee ______________________________________________________
Structura portant a acoperiului _____________________________
Perei exteriori _____________________________________________________________________
Acoperi ______________________________________________________________________________________
Izolaii, mansarde i acoperiri n general ___________________________-_________________
______________________________________________________________________________________________
Luminatoare ________________________________
Deschideri pentru ventilaie aerian __________________________________________________________________

SC. ASIG MANAGEMENT - BROKER DE ASIGURARE S.R.L.


Str. Alexandru Ioan Cuza, nr. 10 Et. 2, Ap. 11, Sector 1, Bucuresti, Romania Numar de inregistrare : J40/15696/2006;
Cod unic de inregistrare : 19073410; Cont : RO39BRDE441SV74609324410 Banca : BRD - Ag. Theodor Pallady
Capital subscris si varsat: 40.000 RON
D. ACTIVITATE
Descriere - _____________
Cantiti de substane periculoase n lucru ____
Lucrri speciale _____________________________________________________________
Amplasarea lucrrilor speciale __________________________________
Utilaje _________________________________________________________________________________________
_______________________________________________________________________________________________

E. MAGAZII
Descrierea mrfurilor din depozite
- materii prime
- semifabricate ___________________________________________________________________
produse finite ___________________________________________________________________
produse refrigerate_______________________________________________________________
Amplasarea magaziilor ______________________________________________________________________
Modalitatea de depozitare __________________________________________________________________________
Cantiti de substane periculoase n depozite __________________________________________________________

F. INSTALAII
Centrale termice __________________________________________________________________
Rezervor de apa propriu _____________________________________________________
Substaii electrice ___________________________________________________________________________
Rezervoare de gaz i lichide inflamabile __________________________________________________________
Sursa de apa(publica sau proprie)____________________________________________________
Generator propriu______________________________________________________________________________
G. VECINTI
_______________________________________________________________________________________________
_______________________________________________________________________________________________

H. MSURI DE PROTECIE N CAZ DE INCENDIU/FURT

Instalaii de prevenire _____________________________________________________________________________


Instalaii de alarm ____________________________________________________________
Paza permanenta__________________________________________________________

SC. ASIG MANAGEMENT - BROKER DE ASIGURARE S.R.L.


Str. Alexandru Ioan Cuza, nr. 10 Et. 2, Ap. 11, Sector 1, Bucuresti, Romania Numar de inregistrare : J40/15696/2006;
Cod unic de inregistrare : 19073410; Cont : RO39BRDE441SV74609324410 Banca : BRD - Ag. Theodor Pallady
Capital subscris si varsat: 40.000 RON
Contract cu firma de monitorizare si paza_______________________________________________________________
Mijloace de stingere ____________________________________________________________________
- Pichet pompieri - amplasare ___________________________________________________________
- personal pe schimb ____________________________________________________
- dotri _______________________________________________________________
- Hidrani - nr. total n funciune ________________
- amplasare _____________________________________________
- Sting_toare - nr. total n funciune _______________________________________________
- amplasare ________________________________________________
- Alte mijloace _____________________________________________________________________________
_________________________________________________________________________________________
Distana pn la pompierii militari ___________________________________________________________
Diverse ___

SC. ASIG MANAGEMENT - BROKER DE ASIGURARE S.R.L.


Str. Alexandru Ioan Cuza, nr. 10 Et. 2, Ap. 11, Sector 1, Bucuresti, Romania Numar de inregistrare : J40/15696/2006;
Cod unic de inregistrare : 19073410; Cont : RO39BRDE441SV74609324410 Banca : BRD - Ag. Theodor Pallady
Capital subscris si varsat: 40.000 RON