Chestionar Brokeri
Chestionar Brokeri
1. Solicitant/Asigurat
Applicant/Insured
4. Numarul de inregistrare la
Registrul Comertului/
Fiscal Registration Number
7. Numarul angajatilor cu contract de munca cu norma întreaga/No. of employees with full time
work contract
Nume si prenume/ Experienta profesionala/ Specializarea, cursuri
Name and surname Professional experience absolvite/Experience,
graduated courses
8. Numarul angajatilor cu contract de munca cu program redus/No. of employees with part time
work contract
Nume si prenume/ Experienta profesionala/ Specializarea/cursuri
Name and surname Professional experience absolvite/Experience,
graduated courses
11. Clienti cu care aveti incheiate contracte de brokeraj, ponderea acestora/Share of clients with
whom you have concluded brokerage contracts:
- persoane fizice/individuals %
- persoane juridice/legal bodies %
Solicitantul declara ca cele completate in prezenta cerere de asigurare sunt reale si in conformitate cu
documentele pe care le poseda./The Applicant declares that all the information provided in this
questionnaire corresponds to the reality and no circumstance, which could influence the risk
appreciation, was hidden.
Datele incluse în prezenta cerere de asigurare stau la baza politei ce se va emite si constituie parte
integranta a acesteia./ The Applicant agrees that this questionnaire-proposal form and all the other
declarative documents are the basis of the insurance contract and are integrant part and also complete
the policy.
Data:/Date:
SOLICITANT/ASIGURAT
APPLICANT/INSURED