PDF《汽车保险投保书》

U/MP/092001 先生 女士 公司 Mr.

Ms Company 汽车保险投保书 MOTOR VEHICLE INSURANCE PROPOSAL FORM 投保人姓名 Proposer full name 电话 Telephone Number 职业 Occupation 地址 Address 保险生效日期 Period of Insurance 由From 至To 保月For Months 投保类别 Type of Cover 综合保险 Comprehensive 第三者保险 Third Party Only 投保汽车资料 PARTICULARS OF VEHICLE TO BE INSURED 汽车登记号码 Registration number 汽车牌子 Make 型号 Model 座位数目(司机除外) Seating Capacity (excluding Driver) 汽车容量(c.c.) Cylinder Capacity 车辆总重量 Gross Vehicle Weight 引擎号码 Engine Number 底盘号码 Chassis Number 车身类型 Type of Body 制造年份 Year of Manufacture 车门数量 No. of Door 购买日期 Date when purchased 投保汽车通常停泊处 Usual parking places of the Motor Vehicle 汽车市值估计,包括附件及备件 Estimated Vehicle Value incl. accessories and spare parts whilst thereon HK$ 除固定零件外如有加装附件,请列明价值 Please list all additional accessories and provide breakdown of the cost 加装附件 Additional Accessories 价值 Value (HK$) 阁下的汽车有否装置任何防盗设备? 如 有 请注明牌子及型号 Has a theft alarm system been installed in the vehicle? If Yes please state make and model 投保汽车有否曾作任何形式的改装或修饰? 如 有 请详述之 Has the vehicle been modified in any way? If Yes please specify 阁下是否此汽车的车主? 如 否 请详述之 Are you the owner of the vehicle? If No please give full details 阁下的汽车是否用分期付款方法购入? (本公司会多提供一份保单以便阁下转交按揭公司) 若 是 请注明按揭公司名称及按揭档案编号 Is the Vehicle under a hire purchase agreement? (an extra copy of the policy will be sent to you for forwarding to your hire purchase company). If Yes please state the name of the hire purchase company and your hire purchase reference number 汽车用途 USE OF VEHICLE 车辆类别 Class of Motor 其他,请列明 Others, please specify : 上述投保汽车是否需要於中国境内行驶? 如 是 请注明车辆於国内行走之地区围 Is the above vehicle required to be driven within P.R.C.? If Yes please state the geographical area 投保汽车有否接载乘客或货物而作租用或牟利用途? 如 有 请详述之 Will passengers or goods be carried for hire or reward? If Yes please give full details 驾驶者资料 PARTICULARS OF NAMED DRIVERS 请列明所有将会驾驶此车人仕之个人资料 Please state below all persons who will drive the vehicle 驾驶人姓名 Names of Drivers 出生日期 (日/月/年) Date of Birth (D/M/Y) 驾驶执照编号 Driving License Number 驾驶年资 Driving Experience 职业 Occupation 注意:私家车综合保险之基本保费只包括两名记名驾驶人.在缴付额外保费情况下保单可增加至四名记名驾驶人. Note :The basic premium for a private car comprehensive policy accounts for

2 named drivers. The policy may be extended to include upto

2 additional named drivers on payment of an additional premium. U/MP/092001 以上列名的驾驶者有否在过去三(3)年内触犯任何交通条例?违例泊车除外. 如有此记录者,请详述之 Have any of the above drivers been convicted of any driving offence in the last three (3) years? Other than parking. If Yes please give full details 以上列名的驾驶者,有否在过去三(3)年内发生汽车意外或向保险公司作出索偿? 如有此记录者,请详述之 Have any of the above drivers involved an accident or made a motor claim in the last three (3) years? If Yes please give full details 以上列名的驾驶者,曾否被保险公司拒绝续保、取消未到期之保险、或附加特别之强制条款於保单内?如有,请详述之 Have any of the above drivers to your knowledge may drive the Motor Vehicle been declined such application, or been refused renewal, or been terminated such insurance, or been imposed special terms on your/his/her policy by any insurance company ? If Yes please give full details 无索偿折扣记录 NO CLAIM DISCOUNT 请注明在前次承保的保险公司所享有的「无索偿折扣」优惠 Please state entitlement of No Claim Discount from previous Insurer 汽车登记号码 Registration number % 请附上「无索偿折扣」优惠证明文件,即续保通知书或提供有关资料 Please attach a copy of your renewal notice or provide the name of your previous insurer and the policy number 承保之保险公司名称 Name of Previous insurer 保单号码 Policy number 声明 DECLARATION 1. 本人/我们谨声明上列各节均属无讹,更绝未隐瞒任何事实,而投保车辆亦属完整及宜於道路上行驶及本投保车辆并未作出任何改装或改变以 增加车辆之性能. I/We declare that to the best of my/our knowledge and belief that the foregoing answers are true;