Asigurm tot ce conteaz pentru tine.

Anexa la ctr. RC*/..

Chestionar - Cerere de asigurare / Questionnaire proposal form

privind rspunderea profesional a experilor contabili i a contabililor autorizai / regarding professional liability of authorized
accountants (Cod RC102 / Code RC102)

1 Solicitant/Asigurat (individual/cabinet/ societate de

expertiza)
Applicant / Insured (individual/ Partnership /Firm):

2 Adresa (domiciliul, sediul social, sucursale,

filiale) / Adress/Headquarters/Branches/
Agencies:

3 Tel./Fax / Phone/Fax:

4 Document de nfiinare (nr. Autorizaie

CECCAR, nr.carnet) / Document of
establishing (no. license CECCAR etc):

5 Pentru persoane fizice / For individuals

Calitatea / Qualification:
Expert contabil / Qualified accountant
Contabil autorizat cu studii superioare / Authorized Accountant - graduated studies
Contabil autorizat cu studii medii / Authorized Accountant high school studies
Modul de desfurare a activitii / Type of developing activity:
Cu titlu individual / Independent
Salariat la o societate de expertiz / Employed at a Consulting Firm
Cenzor extern independent / External independent censor
Enumerai toate lucrrile pe care le realizai / Please, specify all the activities you do (taxation, consultancies, examination of annual reports,
audits):

Numr de contracte de prestri servicii ncheiate / Number of contracts of performance and services:

Numii clienii cei mai importani / Please, specify your most important clients:

Avei clienti de alt naionalitate (firme strine, reprezentante externe, societi mixte) / Do you performed accountable services for international
clients?

Societile pentru care desfurai activitatea de cenzorat/audit / Censor/Audit activity developed for:

Suntei membru al unor organisme profesionale de profil? Mentionai / Are you member of a relevant professional association? Please, specify:

6 Pentru persoane juridice / For legal bodies:

Modul de desfurare a activitii / Type of developing activity :
Cabinet propriu / Own office
Societate de expertiz contabil / Accountant expertise Company
Groupama Asigurri
Pag 1/3
Sediul central: Str. Mihai Eminescu nr. 45, sector 1, 010513, Bucureti, Romnia
Capital social subscris i vrsat: 345.757.050 lei; CUI 6291812; RC: J40/2857/2010;
Autorizat de Autoritatea de Supraveghere Financiar (C.S.A.) sub nr. RA 009; Operator de date cu caracter personal 10152; Ediia a 2 a_Martie 2013
Alo Groupama 0374 110 110; Fax: 0040 21 310 99 67; www.groupama.ro; office@groupama.ro
 Asigurm tot ce conteaz pentru tine.

Date legale despre acionari/asociai/personalul angajat / Details about shareholders/partners/other staff:

-dac spatiul este insuficient se anexeaz o list/use separate sheef if insufficient space above:
Poziia deinut n cadrul
Numele i prenumele / Calificarea / Experiena profesional / Vechimea n profesie / Length of
societii / Position held in the
Name and surname Qualification Professional experience service
company

Venitul realizat (fr TVA) / Total Income (without VAT):

- n anul anterior / on the past financial year:
- Estimat n anul n curs / Income estimate in current financial year:
Enumerai lucrrile pe care le executai / Describe your principal activities:

Numrul clienilor / Number of clients . din care firme strine / from which foreign companies: ..
Enumerai cei mai importani clieni / Please, specify the most important clients of yours:

Suntei membri ai unor organisme profesionale de profil? Nominalizai. / Are you member of a relevant professional association? Please, specify:

7 Ai avut anterior o asigurare de rspundere da/yes nu/no

civil profesional / Have you previously been
insured for Professional Liability Insurance?
Dac da, v rugm precizai:/If so, please specify:
- Asigurtorul/Insurer:
- perioada de asigurare/insurance period:
- limita rspunderii/limit of liability:
- despgubiri pltite/paid indemnities:

8 A existat vreun Asigurtor care a anulat sau refuzat rennoirea polielor? / Was it any da/yes nu/no
Insurer that cancelled an insurance policy concluded with you or that refused
conclusion of a policy?

9 Ai avut reclamaii, n activitatea dvs. profesional, n ultimii 3 Da/yes Nu/no

ani? / Have you had any claims related your professional
activity

10 Ai avut cereri de despgubire n ultimii 3 ani / Have Da/yes Nu/no

you had any indemnity claims in the last three years?

11 Ai pltit despgubiri n ultimii trei ani? / Have Da/Yes Nu/No

you paid indemnity in the last three years? Dac da, menionai anul, motivele, sumele pltite / If yes, specify the year, the reasons, the
paid sums:

Groupama Asigurri
Ediia a 2 a_Martie 2013 Pag 2/3
 Asigurm tot ce conteaz pentru tine.

12 La momentul completrii cererii-chestionar este n desfurare un control sau ai fost

anunai c urmeaz un control sau exist circumstane care pot determina
reclamaii/plngeri mpotriva dvs. / Are there any current control/checking operations
concerning your previous activity, developed by competent authorities, at the moment
of fulfillment of present proposal form? Have you been informed that exist any
circumstances or incidents which may result in a claim against your firm?

13 Detalii privind condiiile de asigurare:/ Details - limita rspunderii pe perioada asigurat/ aggregate limit of responsibility:
about the insurance conditions:
- limita rspunderii pe eveniment/ limit of responsibility per event:

- limita ptr. deces/persoan/eveniment:/

limit for death/person/event:
- limita ptr. invaliditate permanent/persoan/ eveniment:/
limit for permanent disability/person/event:

14 Franiza / Deductible:

15 Aria geographic pentru care se solicit acoperirea /

Territorial cover:

16 Perioada de asigurare / Period of insurance:

Declar pe proprie rspundere c datele comunicate n aceast CERERE DE ASIGURARE sunt reale i sunt de acord ca acest document s fac parte integrant din
contractul de asigurare i s stea la baza evalurii riscului de ctre Asigurtor. Sunt de acord ca Groupama Asigurari SA s nu m despgubeasc n cazul n care
constat c datele furnizate n aceast declaraie nu corespund adevrului, ori pe parcursul derulrii asigurrii nu am adus la cunotin orice informaie de natur s
modifice condiiile de asigurare iniiale, nelegnd c declaraiile false pot implica, dup caz, rspunderea penal (conform legislaiei n vigoare). Sunt de acord ca
societatea Groupama Asigurari SA s prelucreze datele cu caracter personal, pe care le-am furnizat n scopul administrrii contractului de asigurare, n conformitate cu
dispoziiile Legii 677/ 2001 pentru protecia persoanelor cu privire la prelucrarea datelor cu caracter personal i libera circulaie a acestor date.

I take it upon myself to declare that all the data communicated by means of the hereby INSURANCE APPLICATION are real and I agree that this document should
form an integral part of the insurance agreement and underlie the risk assessment by the Insurer. I duly agree that Groupama Asigurari SA should not grant any
compensations to me if they should find that the data provided by means of the hereby statement are false or during the development period of the agreement I did not
notify any information that should change the initial insurance conditions, understanding that the false statements may involve, as the case may be, criminal liability
(according to the enforced legislation). I grant my permission to Groupama Asigurri SA concerning the processing of my personal data, provided for the purpose of
insurance agreement administration, in accordance with the provisions of the Law no. 677/ 2001 for the personal protection concerning the processing of personal data
and the free circulation of these data.

Data:/Date:

SOLICITANT/ASIGURAT APPLICANT/INSURED

Groupama Asigurri
Ediia a 2 a_Martie 2013 Pag 3/3