我處下列貨物擬向你處投保國內貨物運輸保險:
    編號:___
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    |被保險人                                                                                                  |
    |-----------------------------------------------------|
    |    標記或發票號碼    |    保險貨物名稱    |件    數|    提單或通知單號次    |    保  險  金  額      |
    |-----------|----------|----|------------|------------|
    |                      |                    |        |                        |                        |
    |                      |                    |        |                        |                        |
    |                      |                    |        |                        |                        |
    |----------------------------------------|------------|
    |運  輸  工  具|                  |    約                  啟                  |賠款償|                |
    |              |                  |          年    月    日                    |      |                |
    |(及轉載工具)|                  |    于                  運                  |付地點|                |
    |-------|---------|-----------------------------------|
    |              |                  |  轉載  |                                                            |
    |運  輸  路  線|  自    經    到  |  地點  |                                                            |
    |-----------------------------------------------------|
    |要保險別:基本險    附加險別      基本險費率    ‰    附加險費率    ‰                                    |
    |----------------------------------------------------  |
    |                                                                    |  投保單位簽章                      |
    |                                                                    |                                    |
    |                                                                    |      年    月    日                |
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    頒布 單 位: 國家工商管理局經濟合同司
    頒布 日 期: