PDF《旅游保险投保书》

甲部 投保人资料 Part A Personal Details of the Proposer 投保人姓名 中文 英文 Name of Proposer Chinese English 联络电话 住宅 手提 办公室 Contact No.

Home Mobile Office 通讯地址 Mailing Address 电邮地址 E-mail Address 乙部 被保险人资料 Part B Details of the Insured 出生日期 (日/月/年) 联络电话 Date of Birth (dd/mm/yy) Contact No. 丙部 受益人资料 Part C Details of Beneficiary 丁部 旅程资料 Part D Details of Itinerary 保险期限 由至(起讫两日均包括在内) Period of Insurance From To (Both dates inclusive) 行程总日数 目的地 No. of days of Travel Destination 地区1: 地区2: 全世界 地区 Area Area 1: Area 2: Around the World 被保险人 被保险人及其配偶 被保险人类别 Insured Person Insured Person and Spouse Insured Person 被保险人及其一名子女 被保险人及其家人 总人数: Insured Person and one child Insured Person and his family Total No. of Travellers: 单段旅程 是否总共保费 One Way Travel Yes No Total Premium 戊部 附加人身意外保障 Part E Additional Personal Accident Insurance Protection 被保险人姓名 Name of Insured Person 投保金额 Insured Amount * 附加人身意外保障只适用於16至65岁之被保险人 * Additional Personal Accident Insurance Protection only applies to the Insured aged between

16 and 65. 受益人姓名 联络电话 旅游保险投保书Travel Insurance Proposal Form HKD250,000.00 Relationship with Beneficiary 与受益人关系 Name of Insured 被保险人姓名 Name of Beneficiary 与投保人关系 Relationship with Proposer 中国、缅甸、泰国、马来西亚、新加波、印尼、菲律宾、汶莱、越南、柬埔寨、台湾省、韩国、日本及关岛 Contact No. HKD500,000.00 Passport No. 护照号码 Passport No. 护照号码 China, Myanmar, Thailand, Malaysia, Singapore, Indonesia, The Philippines, Brunei, Vietnam, Cambodia, Taiwan, Korea, Japan and Guam 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/吾等谨此声明,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呈报. 本人/吾等保证各被保险人绝不会违反医生之劝告或仅为获得医疗而外出旅行.各被保险人对已安排而又需取消或提早结束之行程事先均绝对不知情. Declaration Agent Code Client Code Account Handler Remark Total Premium Official Use Only 投保人签署 Signature of the Proposer 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)