PDF《火灾保险投保书》

甲部 投保人资料 Part A Personal Details of The Proposer 保户名称 Name of Insured 通讯地址 Mailing Address 电邮地址 联络电话 E-mail Address Contact No.

乙部 投保财产资料 Part B Details of Property Insured 保险地址 Insured Situation 受抵押人 Mortgagee(s)/Lien Holder(s) 银行档案编号 Bank Reference Number 楼宇年龄 建筑物层数 Age of Building No. of Storey 建筑物结构 一等建筑 (全钢筋混凝土结构) 其他, 请注明: Structure of Construction Class I (Reinforced concrete throughout) Others, please specify: 占用性质 住宅 办公室 仓库 其他, 请注明: Occupation Dwelling Office Storage Others, please specify: 经营业务 Business 保单生效日期 由至(起讫两日均包括在内) Period of Insurance (dd/mm/yy) From To (Both dates inclusive) 丙部 保障选择 Part C Insurance Covers 请选择其中一栏 火灾基本险 保障A 保障B Please tick one of the boxes FIRE ONLY AP1* AP2* *按照条文 *Subject to Endorsement 火灾基本险 : 火灾、闪电及家用锅炉或家用气体燃料爆炸. Fire Only : Fire, Lightning or Explosion of boilers or gas used for domestic purpose. 保障A : 火灾、闪电、家用锅炉或家用气体燃料爆炸、喉管爆裂、消防洒水装置渗漏及爆炸. AP1 : Fire, Lightning, Explosion of boilers or gas used for domestic purpose, Bursting Pipes, Sprinkler Leakage and Explosion only. 保障B : AP2 : 丁部 保险标的及投保金额 Part D Insured Items and Sum Insured 项目 Item(s) 房屋楼宇结构(沟渠及地基除外) HK$ Building/Flat - Including Landlord'

s Fixtures and Fittings (Excluding Drains and Foundations) 家俱、固定装置及可拆除装置 HK$ Furniture, Fixtures and Fittings 机器及零件(模具除外) HK$ Machinery/Plant and Equipment (Excluding Moulds of any kind) 经营之存货及物料(包括制成品及半制成品) HK$ Stock and Materials in Trade - Including Finished and Semi-Finished Goods 其他 HK$ Others, please specify 总投保金额 HK$ TOTAL SUM INSURED 投保金额 Sum Insured 火灾保险投保书Fire Insurance Proposal Form 火灾、闪电、家用锅炉或家用气体燃料爆炸、喉管爆裂、消防洒水装置渗漏、爆炸、台风及暴风(包括洪水)、地震、飞行物体坠落、车辆撞击、罢工与暴动及恶意破坏. Fire, Lightning, Explosion of boilers or gas used for domestic purpose, Bursting Pipes, Sprinkler Leakage, Explosion, Typhoon &

Windstorm (including Flood), Earthquake, Aircraft Damage, Vehicle Impact, Riot &

Strike and Malicious Damage. 戊部 风险评估 Part E Risk Assessment 项目 Item(s) 1. 是否有任何特殊情况会提高本保险保障的风险? Are there any circumstances connected with the risks which would render the Insurance more than normally hazardous? 2. 阁下是否曾申请财产火险或全险? Have you ever insured for Fire or Property All Risks Insurance? 3. 阁下是否在申请上述保险或续保时被拒绝p撤回p取消或附加特别条款? Have you ever been declined, cancelled, refused or imposed special terms when you apply or renew the above mentioned Insurance? 4. 在过去五年内o阁下是否有因本保险保障之风险而蒙受损失? Have you sustained any loss during the past five years from any of the perils now proposed to cover? 阁下如在上述任何一项回答 是 , 请详述. If your answer is Yes in any of the above question, please give details: 己部 付款方式 Part F Payment Method 支票付款 Cheque 划线支票抬头人请填写 中国太平洋保险(香港)有限公司 Please cross your cheque and make it payable to CHINA PACIFIC INSURANCE CO., (H.K.) LTD. 现金付款 Cash 请亲临中国太平洋保险(香港)有限公司 地址 :香港湾仔港湾道18号中环广场4301室Please pay at the office of China Pacific Insurance Co., (H.K.) Ltd. Address:Suite 4301, 43/F., Central Plaza,

18 Harbour Road, Wanchai, Hong Kong. 收集个人资料声明 阁下提供的资料,为本公司提供保险业务所需,并可能使用於下列目的: ?任何与保险或财务有关的产品或服务或该等产品或服务的任何更改、变更、取消或续期 Personal Data Collection Statement The information you provide to us is collected to enable us to carry on insurance business and may be used for the purpose of ?any insurance or financial related product or service or any alternations, variations, cancellation or renewal of them. ?any claim or analysis of it. 声明 本人谨此声明,根救怂八,上述所有资料均属实无讹且为事实之全部,而所有能影响该项申请评估的事实因素均已呈报. Declaration Rate and Excess 是Yes 否No I declare that the information given above is true and complete to the best of my knowledge and believe that all the material facts affecting the assessment of this application has been disclosed. 是Yes 否No 否No 是Yes 否No I understand that proposal will not become effective until it has been accepted by China Pacific Insurance Co., (H.K.) Limited and agree that this proposal and declaration should be the basis of the contract between me and China Pacific Insurance Co., (H.K.) Limited. ?任何索偿或索偿分析及可能转移予现存或不时成立的任何有关的公司或任何其他从事与保险或再保险业务有关的公司或与保险业务有关的中介人或索偿或调查或 其他服务提供者或任何保险公司的协会或联会. 阁下有权查阅及要求更正由中国太平洋保险(香港)有限公司持有有关阁下的个人资料,如有此项要求,可向本公司的个人资料(私隐)条例监察主任提出. 联络电话s(852)

2541 4338 本人明白本投保书在中国太平洋保险(香港)有限公司接纳后,保单始正式生效.本人亦同意此投保书及声明将会作为本人与中国太平洋保险(香港)有限公司之 间的合约基础. You have the right to obtain access to and to request correction of any personal information concerning yourself held by China Pacific Insurance Co., (H.K.) Ltd. Requests for such access can be made to our Personal Data (Privacy) Ordinance Compliance Officer. The contact number is (852)

2541 4338. And may be transferred to any related business partners, companies carrying on insurance or reinsurance related business or an intermediary or a claims or investigation or other service provider providing services relevant to insurance business or any association or federation of insurance companies that exists or is formed from time to time. 是Yes Total Premium Official Use Only 投保人签署 Signature of Proposer 日期 Date Agent Code Client Code Account Handler Remark ........