我處下列貨物擬向你處投保國內貨物運輸保險： 編號：___ ------------------------------------------------------- |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                | ------------------------------------------------------- 頒布 單 位: 國家工商管理局經濟合同司 頒布 日 期: