PDF《团险被保险人健康风险告知书》

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

9、您是否因工作原因需要经常前往某些地区或国家? Do you frequently travel abroad for business reasons? ? ?

10、妇女栏:(被保险人为女性时,请说明)FEMALES only. A、 过去五年内曾否患子宫、乳房、卵巢等生殖系统的疾病? Have you suffered from or are you aware of any disorders of uterus, breast, ovary or any other disorders of reproductive system? ? ? B、 目前是否怀孕? Are you now pregnant? ? ? C、 是否被诊断为高危妊娠? Have you been diagnosed of any complications? ? ?

11、少儿栏:(被保险人为 0~15 周岁的儿童时,请说明) Life Assured age below

16 only. A、 有无先天性、遗传性疾病或畸形? Do you have or been told that you have any congenital or hereditary disorders or deformation? ? ? B、 过去曾否患过肺炎、抽搐、腹泻、小儿麻痹、儿童多动症、脊髓灰质炎、麻疹、流行性脑脊髓膜炎、流行性乙 型脑炎、白喉、破伤风、百日咳等疾病? Have you ever suffered from pneumonia, fits, diarrhoea, infantile paralysis, hyper kinetic disorder, poliomyelitis, measles, meningitis, encephalitis B, diphtheria, tetanus, kink cough or any other illness or disorder not mentioned above? ? ? H E A L T H D E C L A R A T I O N 上述健康告知若回答有,请详述,并提供相关病历资料: If yes to any of the above questions, please give details at space provided. If available, please attach any medical reports that you may have which may help to speed up underwriting: 被保险人声明:

1、本告知书必须由被保险人(若被保险人为未成年人,则为其父母)亲自签名,被保险人不应授权任何人(包括中德安联的员工 或代理人)代为签名;

被保险人在发现任何保险文件上的签名非其本人签名时,需及时通知中德安联.

2、本告知书是保险公司同意承保及续保的重要证明文件,因此本告知书所填写的各项内容均属真实,并成为本保险合同及续保合同的 一个组成部分;

若日后发现告知不实,中德安联可依照相关保险法律法规的规定,不承担相关给付责任. Declaration: 1. This declaration shall be completed and signed by the Life Assured personally (If the Life Assured is a minor, his/her guardian shall sign). The Life Assured shall not ask other person (including the staff or insurance agent of Allianz China Life) to sign on behalf of them and shall inform Allianz China Life as soon as they find a fake signature. 2. This health &

risk declaration is an important proof for ........