This document is a questionnaire for a commercial and industrial liability insurance application. It requests information about the applicant's operations, locations, revenues, employees, assets, past insurance and claims history, and desired coverage amounts. The applicant is asked to provide details on their business activities, establishments, transit of people and property on site, financials, existing risks like equipment or hazardous materials, and any plans for expansion.

1. LIABILITY INSURANCE FOR COMMERCIAL AND/OR INDUSTRIAL
ESTABLISHMENTS, EMPLOYERS AND CONTINGENT RISKS–
MOTOR-DRIVEN LAND VEHICLES
QUESTIONNAIRE ATTACHED TO INSURANCE APPLICATION
1 – Name of applicant:
2 – Date of operations inception:
3 – In the last years, has the name of the company been changed or has there been any merger with
or acquisition of another company? In case yes, please provide details:
4 – Applicant’s line of business:
a) main line of business:
b) others, including those conducted outside the locations specified under Item 5 below:
5 – Nature and address of the applicant’s establishments (headquarters, branch offices, offices,
plants, stores and warehouses): (street, city, and state).
5.1 – In the event of industrial establishments, or establishments designed for the storage of toxic,
corrosive, flammable or explosive substances, a sketch must show the location of the establishment
in regards to neighboring property, including information on how distant neighboring buildings are
located and their use (residential, commercial or industrial – in the last two, information must also
include the type of business conducted at those locations).
6 – The transit or permanence of any third parties (whether people or property) in the applicant’s
establishments. Please state frequency of transit or permanence:
( ) High ( ) Medium ( ) Low
Allianz Seguros S.A
Rua Luís Coelho, 26 CEP 01309-900 São Paulo - SP CP 1506 CEP 01059-970 Tel (011) 281-5533 Fax (011) 288-3849 End Tel “Segurasil” Telex (11) 32191 BCSG BR

2. 7 – Gross revenues of the company, in constant currency:
IN THE LAST 12
MONTHS
ESTIMATE FOR THE
PERIOD OF INSURANCE
a) Operational revenue from
main activity
b) Other revenues
TOTAL
Note: The Applicant must specify if the amounts are stated in thousands, what currency is
used, etc.
8 – Number of employees:
9 – Inform the existence of any of the following:
( ) railroad branch and/or own railroad
( ) boilers
( ) moving equipment: cranes, forklifts, etc.
( ) toxic, corrosive, flammable or explosive substances
( ) restaurants or similar installations
( ) signs or billboards of the applicant by public roads or on third-party locations.
10 – Please check if interested in hiring any of the following coverages:
( ) competitions and sports events;
( ) use of mechanical equipment on public roads near the establishment
( ) Personal Property of employees in the custody of the applicant
( ) Damages caused by medical malpractice
11 – Does the applicant know of any fact that may give rise to a claim against the company? In case
yes, please provide details.
12 – In regards to the present risk, is the applicant aware of any claim against the applicant in the
last years? In case yes, please state the date, the amount and the cause of each claim, even if
insurance was available during that period.
13 – Has any insurer ever refused any request by the applicant for similar insurance, established
aggravated conditions for the acceptance of such insurance, or refused the renewal of any insurance
Allianz Seguros S.A
Rua Luís Coelho, 26 CEP 01309-900 São Paulo - SP CP 1506 CEP 01059-970 Tel (011) 281-5533 Fax (011) 288-3849 End Tel “Segurasil” Telex (11) 32191 BCSG BR

3. for the applicant? In case yes, please indicate the reasons stated by the insurer.
14 – In the event the applicant has, or has had in the past, any insurance that covers the same perils
applied for insurance herein, please name such insurer.
15 – Are there any plans for the expansion of the applicant’s activities during the applied-for policy
period?
16 – Desired Sums Insured:
Commercial and/or Industrial Establishments: R$
Contingent Risks – Motor-driven land vehicles R$
Employer: R$
Personal Property of employees R$
17 – I hereby state that the above information is true and that I am aware that in the event of claim it
is found that the amounts which based the premium calculation were below the actual amounts, the
indemnity shall be reduced proportionately to the difference between the premium paid and the
premium payable.
_________________________________ ___________________________________
Place and date Signature of the Applicant or
Legal Representative
Allianz Seguros S.A
Rua Luís Coelho, 26 CEP 01309-900 São Paulo - SP CP 1506 CEP 01059-970 Tel (011) 281-5533 Fax (011) 288-3849 End Tel “Segurasil” Telex (11) 32191 BCSG BR

4. COMPLEMENTARY INFORMATION
If interested in the additional coverages below, please inform the following:
1) Custody of Third-party Vehicles
Please state separately the address of the risk location and the area assigned exclusively to the
parking of vehicles, in m2
, excluding free area for maneuvering and circulation:
ITEM ADDRESS AREA
2) Subsidiary Liability – for goods owned by the applicant when such goods are transported by third
parties, arising from explosion, fire and leakage (Hazardous Loads)
a) what conveyances are used;
b) number of road vehicles owned by third parties and used for the transport of the applicant’s
goods;
c) average number of monthly air, water or road travels;
d) list of products transported, indicating the respective nomenclature, UN code, physical
condition, type of packaging and container;
e) purpose of transport (delivery of goods, incineration of industrial refuse, etc.); and
f) territorial scope (domestic and international);
Note: The risk for the transport of goods owned by the insured and transported on road vehicles
owned by the insured shall be exclusively allocated to Optional Vehicle Liability.
3) Machinery and/or Equipment Assembly and Installation Services
a) payroll of workers involved in this work
Allianz Seguros S.A
Rua Luís Coelho, 26 CEP 01309-900 São Paulo - SP CP 1506 CEP 01059-970 Tel (011) 281-5533 Fax (011) 288-3849 End Tel “Segurasil” Telex (11) 32191 BCSG BR

5. a.1) in the last twelve months:
a.2) estimate for the period of insurance
b) in the event of hiring third parties to perform these services, please state the amount of labor costs
involved in such hiring;
b.1) in the last twelve months:
b.2) estimate for the period of insurance
c) forecast for the maximum number of contractors hired by the insured and working at the same
time at the same site during the policy period;
d) considering the total of services, please state the percentage of those in which there are
foundation works, even if such work is occasional;
e) Desired Sum Insured.
4) Rendering of Services at Third-party Locations
a) type of service rendered;
b) number of workers that exclusively render the above services;
c) Desired Sum Insured.
5) Liability – Contingent Risks resulting from the habitual transport of employees or agents in
road vehicles of third parties
a) number and type of vehicles
b) Itinerary of these vehicles;
qoper
Allianz Seguros S.A
Rua Luís Coelho, 26 CEP 01309-900 São Paulo - SP CP 1506 CEP 01059-970 Tel (011) 281-5533 Fax (011) 288-3849 End Tel “Segurasil” Telex (11) 32191 BCSG BR

6. a.1) in the last twelve months:
a.2) estimate for the period of insurance
b) in the event of hiring third parties to perform these services, please state the amount of labor costs
involved in such hiring;
b.1) in the last twelve months:
b.2) estimate for the period of insurance
c) forecast for the maximum number of contractors hired by the insured and working at the same
time at the same site during the policy period;
d) considering the total of services, please state the percentage of those in which there are
foundation works, even if such work is occasional;
e) Desired Sum Insured.
4) Rendering of Services at Third-party Locations
a) type of service rendered;
b) number of workers that exclusively render the above services;
c) Desired Sum Insured.
5) Liability – Contingent Risks resulting from the habitual transport of employees or agents in
road vehicles of third parties
a) number and type of vehicles
b) Itinerary of these vehicles;
qoper
Allianz Seguros S.A
Rua Luís Coelho, 26 CEP 01309-900 São Paulo - SP CP 1506 CEP 01059-970 Tel (011) 281-5533 Fax (011) 288-3849 End Tel “Segurasil” Telex (11) 32191 BCSG BR