我处下列货物拟向你处投保国内货物运输保险： 编号：___ ------------------------------------------------------- |被保险人                                                                                                  | |-----------------------------------------------------| |    标记或发票号码    |    保险货物名称    |件    数|    提单或通知单号次    |    保  险  金  额      | |-----------|----------|----|------------|------------| |                      |                    |        |                        |                        | |                      |                    |        |                        |                        | |                      |                    |        |                        |                        | |----------------------------------------|------------| |运  输  工  具|                  |    约                  启                  |赔款偿|                ||              |                  |          年    月    日                    |      |                | |(及转载工具)|                  |    于                  运                  |付地点|                | |-------|---------|-----------------------------------| |              |                  |  转载  |                                                            | |运  输  路  线|  自    经    到  |  地点  |                                                            | |-----------------------------------------------------| |要保险别：基本险    附加险别      基本险费率    ‰    附加险费率    ‰                                    | |----------------------------------------------------  | |                                                                    |  投保单位签章                      | |                                                                    |                                    ||                                                                    |      年    月    日                | ------------------------------------------------------- 颁布 单 位: 国家工商管理局经济合同司 颁布 日 期: