PDF《意外急救医疗保险投保书》

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 职业 Occupation 公司名称 Company Name 公司地址 Company Address 住宅地址 Residential Address 联络电话 住宅 手提 办公室 Contact No.

Home Mobile Office 电邮地址 E-mail Address 乙部 被保险人资料 Part B Details of Insured 被保险人姓名 性别 出生日期 回乡卡 / 护照号码 与个人卡持有人关系 Insured Name Sex Date of Birth Chinese Re-entry Permit / Passport No. Relationship 个人卡持有人 Individual Card Owner 家庭卡持有人 Family Card Owner 注明 配偶 ?指有效婚姻中的丈夫或妻子 Remarks Spouce It means a husband or wife in a valid marriage 子女 ?指有效婚姻双方或其中一方所生的儿子或女儿 v包括单方或双方的非婚生子女或领养子女) Child It means a son or daughter of one or both parties to a valid marriage ( It includes an illegitimate or adopted child of one or both parties) 丙部 受益人资料 Part C Details of Beneficiary 受益人姓名 中文 英文 Name of Beneficiary Chinese English 香港身份证号码 / 护照号码 与持卡人关系 HKID Card No. / Passport No. Relationship 丁部 保障选择 Part D Type of Covers 保险期限 全国卡 广东卡 Period of Insurance Whole China Card Guangdong Card 一年 个人卡 Personal Card HK$个人卡 Personal Card HK$ One Year 家庭卡 Family Card HK$X 人person 家庭卡 Family Card HK$X 人person 二年 个人卡 Personal Card HK$个人卡 Personal Card HK$ Two Year 家庭卡 Family Card HK$X 人person 家庭卡 Family Card HK$X 人person 三年 个人卡 Personal Card HK$个人卡 Personal Card HK$ Three Year 家庭卡 Family Card HK$X 人person 家庭卡 Family Card HK$X 人person 合共保费 Total Premium HK$HK$ 意外急救医疗保险投保书Emergency Accidental Medical & Hospitalization Insurance Proposal Form 1. 3. 2. 4. N/A 戊部 付款方式 Part E 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. 信用卡付款 Credit Card 信用卡到期日 Credit Card Expiry Date MM/YY) 信用卡持有人姓名 信用卡帐户号码 Name of the Card Holder Credit Card Account No. 本人现授权中国太平洋保险v香港w有限公司从本人上述之信用卡帐户支取有关保险之保费. I hereby authorize the CHINA PACIFIC INSURANCE CO., (H.K.) LTD. to debit my credit card account above for the insurance premiums of this insurance policy. 信用卡持有人签署 Signature of Card Holder 日期 Date 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 / 我们清楚明白 ?中国太平洋保险(香港)有限公司(以下简称"中太保")保留一切接纳申请与否之权利. ?此「意外急救医疗保险卡」 / 「家庭卡」适用於中国卫生部认可之紧急救援网络医院. ?任何非因意外事故受伤所致之医疗费用,本保险概不负责. ?所有超出赔偿限额以外之急救医疗费用,概由投保人自行支付. ?若投保人选择广东省地域围,则本保险概不负责所有超出广东省地域围之意外及其有关的急救医疗费用. ?本投保书被中太保批核七天后保障才正式生效及同意该投保书和声明将被用作双方合约之根,而一切之保险条款均以中太保签发之保险单为准. Declaration By Proposer I / We understand ?CHINA PACIFIC INSURANCE CO., (H.K.) LTD. (hereinafter called "CPIC" reserves the right to accept / reject my / our application. ?This Accidental Emergency Medical Card / Family Card will be accepted by MOH International Assistance Net-work Hospitals. ?The emergency medical expenses that are not directly and solely caused by accidental bodily injury are not covered under this policy. ?The part of emergency medical expenses exceeding the maximum sum insured will be borne by the insured. 注: 请附上回乡证v回乡卡w/ 护照副本 Remarks: Please attach a photocopy of the Insured's Chinese Re-entry Permit / Passport 投保人签署 Signature of Proposer 日期 Date Agent Code Client Code Account Handler Remark 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. 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)