PDF《团险被保险人健康风险告知书》

团险被保险人健康风险告知书 Group Life Assured Health Declaration 投保团体: Company Name: 保单编号: Policy Number: 姓名: Name: 性别:男女Sex: Male Female 出生日期: Date of Birth: 身高: 米Height: m 体重: 公斤 Weight: kg 证件类型: ?身份证 ?护照 ?其它_ Document Type: ID card Passport Others_ 证件号码: ID/Passport Number: 被保险人 Particulars of Life 婚姻状况:? 已婚 ? 未婚 ? 离婚 ? 丧偶 Marital status: Married Single DivorcedWidowed 行业类型: Type of industry: 具体工作: Occupation: 请提供 是 或 否 的答案,若被保险人为未成年人,则请被保险人的父母代为回答: Please tick '

Yes'

or '

No'

to the questions below.

If the Life Assured is below

18 years old, all the questions should be duly answered by his/her parents: 有Yes 无No

1、您是否曾在投保医疗、意外或人寿保险时被拒绝、延期或附加条件承保? Have you ever been refused insurance or been offered insurance with restricted benefits or other than standard rates? ? ?

2、目前尚在住院或病假中? Are you now hospitalised or on sick leave? ? ?

3、近两年内有无超过三周的病假或因患病而减轻劳动量? During the past two year, have you ever been absent from work due to sickness for more than

10 days, or reduced your workload because of sickness? ? ?

4、现在或过去有无患肿瘤、癫痫、脑震荡、精神病、心脏病、高血压、血管硬化、中风、糖尿病、尿毒症、慢性酒精 中毒、肝硬化;

肾切除三年以上(外伤性切除不在此列)、肾病等泌尿系统疾病;

性病等生殖系统疾病;

哮喘、肺 结核等呼吸系统疾病;

胃、肝、胆、肠等消化系统疾病;

血液病、爱滋病等病症? Have you ever had or been told that you have tumours, epilepsy, cerebral concussion, mental disorders, heart diseases, hypertension, arteriosclerosis, apoplexy, diabetes, uraemia, chronic alcoholism, hepatocirrhosis;

kidney removal more than

3 years (excluding traumatic removal), nephropathy or any other urinary diseases;

sexually transmitted diseases or any other disorders of genital organs;

asthma, tuberculosis or any other respiratory diseases;

any stomach or bowel disorders, liver disorders, gallbladder disorders, intestinal disorders;

any disorders of blood;

AIDS, any other illness, disorder, operation not mentioned above? ? ?

5、您是否曾使用任何成瘾药物或曾接受戒毒治疗? Have you ever been addicted to any drugs or excessive narcotics or have you ever been treated for addiction to drugs? ? ?

6、在最近

6 个月内,您是否有任何身体不适症状或体征,如持续发热、疼痛、眩晕、胸痛、咳嗽、咯血、腹痛、便血、 紫斑、体重短期内下降超过

5 公斤等? Have you ever suffered from any discomfort or do you have any symptoms such as prolonged fever, aches, dizziness, chest pain, persistent cough, coughing with blood, stomach ache, blood in stools, purpura, weight loss by more than 5kg during the past

6 months? ? ?

7、有无身体残障状况? Do you suffer from any physical disability? ? ? 被保险人健康及风险告知

8、有无从事危险运动或竞技的嗜好,如:潜水、跳伞、攀岩运动、探险活动、武术、摔跤、赛马、赛车、自驾机飞行 热气球飞行、滑雪、冲浪、登山、漂流、蹦极、特技表演等? Do you take part or have you any intention of taking part in any hazardous sports or activities such as scuba diving, parachuting, rock boarding, exploration, Kungfu, wrestling, horse racing, car racing, private flying, ballooning, skiing, surfing, mountaineering, wakeboarding, bungee jumping, stunt performance, etc. ? ? SH-GEB-HD-001B OCT05 请提供 是 或 否 的答案,若被保险人为未成年人,则请被保险人的父母代为回答: Please tick '