PDF《雇员赔偿保险投保书》

U/EP/092001 雇员赔偿保险投保书 EMPLOYEES' COMPENSATION INSURANCE PROPOSAL FORM 公司名称 Full Company Name 通讯地址 Corresponding address 营业性质 Business Nature 工作详情 Particulars of work 保险生效日期 由至Period of Insurance From To 区域 香港 香港及 Area covered H.

K. only H.K. and 固定工作地址 Location of Employment 电话号码 Tel no. 投保雇员资料 Employees to be Insured 所有属於雇员赔偿条例下之员工均须包括在内 All employees within the scope of the employees' compensation ordinance must be included 雇员工作类别 雇员人数估计 年薪 / 工资及其它收入估计 保险公司专用 For Office Use Only Description of Employees' Occupation Estimated no. of Employees Estimated Annual Salaries / Wages & other Earnings 费率 Rate Percent 保费 Premium 编号 Class No. 条款 Clause 总计 Total 请回答下列各题,如答 "是" 请在下面提供详情 Please answer the following questions and give details below if your answer is "Yes" 您是否需要依驮辈钩ヌ趵侗３邪讨鹑? Do you wish to insure your liability under Employees' Compensation Laws to employees of sub-contractors? 您是否有雇用行业外之临时工人,外工或与您同住之家眷,并需要为该等雇员投保? Do you employ and wish to insure casual workers, out workers or family members residing with you? 您和您的雇员是否需要操作重型或危险的机器? Do you and your employees need to operate large and/or dangerous machinery? 您是否会使用液酸、有霉气体燃料、化学原料或炸药? Do you use any acids, toxic gases, chemicals or explosives? U/EP/092001 过去三年内您是否曾因员工意外伤亡而向保险公司索偿? Have you lodged any insurance claim, due to accident occurred to your employees at work during the past three years? 详情 Details : 您现在是否有在其他保险公司购买雇员补偿保险? In respect of Employees' Compensation Insurance are you currently insured by another insurance company? a) 您的投保申请或续保是否曾被拒绝、撤回或被提高保率? Has your proposal or renewal been declined, withdrawn or has an increased rate been required? 详情 Details : 投保人声明 Declaration 1. 本人/本公司欲以上述之条款向中国太平洋保险(香港)有限公司投保雇员赔偿保险 I/My company the undersigned, Desire to effect an insurance as abovestated in terms of the Policy to be issued by China Pacific Insurance Co., (HK) Ltd. 2. 本人/本公司同意保存完整之薪金及工资记录,於投保期限届满前按照中国太平洋保险(香港)有限公司之要求填报实际支付之薪金及工资有关资料并缴付超过以上所估计 之薪金及工资数额之保险费用. I/My company agree to keep a proper salaries and wages record and to render at the end of each period of insurance a statement in the form required by the company of all salaries and wages actually paid and to pay premium on any salaries and wages paid in excess of the amount estimated above. 3. 本人/本公司兹声明本人/本公司己阅读及审核上列之一切表报及细则均属正确,并无隐藏,虚报或歪曲任何事实. I/My company hereby declare that all the above statements and particulars which I/We have read over and checked are true, and that I/We have not suppressed, mis-represented or mis-stated any material fact. 4. 本人/本公司以合理估计本公司之年薪、工资及支出、并同意本项声明作为与中国太平洋保险(香港)有限公司订立契约之基础. I/My company have fairly estimated my/our total salaries wages and expenditure and i/my company agree that this declaration shall be the basis of the contract between me/us and the China Pacific Insurance Co.,(HK) Ltd. 5. 本人/本公司授权中国太平洋保险(香港)有限公司及其代理收取本人的个人资料代作缮发保单之用. I/My authorize China Pacific Insurance Co.,(HK) Ltd. and its agent to collect and use my/our personal data provided that China Pacific Insurance Co.,(HK) Ltd. shall always in compliance to all regulations set out by the Personal Data (Privacy) Ordinance (PCO) 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 ? 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仲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)