公司印章： 填表日期
联系人： 联系电话（座机）： 联系电话（手机）：
注：此表统计范围是各保险公司在自查过程中发现和整改的问题，不包括保保险监管部门已处罚和已采取其他监管措施的内容。
附件3：
××保险公司费用支出数据真实性自查情况统计表
| 所辖分支机构（简称） | 虚列办公费 | 虚列营业费 | 小金库 | 假发票 | 支付正式员工手续费 | 通过虚列费用方式在帐内支付手续费金额 | 账外暗中支付手续费金额 | 通过虚列费用方式支付的薪金、福利（金额） | 采取虚增业绩的手段发放的奖金、分红（金额） | 公司代缴个人罚款 | 其他 |
| 笔数 | 金额 | 笔数 | 金额 | 个数 | 金额 | 张数 | 金额 | 人次 | 金额 | 人次 | 金额 | 个数 | 金额 |
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