货物运输保险单

我处下列货物拟向你处投保国内货物运输保险:

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|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                |

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颁布 单 位: 国家工商管理局经济合同司

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