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| Name of Proposer: |
Mr. HING LCUSTOMER NAME
(Surname, Given Name) |
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| Correspondence Address: |
18A, The World Finance Center |
| Luohu District, Shenzhen |
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| Email Address: |
tomren@cmbwinglungbank.com |
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| Telephone No.: |
88888888 (Home) (Home) |
|
66666666 (Office) (Office) |
|
18988888888 (Mobile) (Mobile) |
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| Person Insured: |
Person Insured |
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| HKID No.: |
C387979(A) |
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| Sex: |
M |
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| Occupation: |
IT |
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| Date of Birth: |
1972/01/19
(yyyy/mm/dd) |
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| One year Insurance Period: |
From 2009/01/20 (yyyy/mm/dd)
To 2010/01/20 (yyyy/mm/dd) |
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| Collection of Policy: |
to be mailed to correspondence address |
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| Premium Payment Account: |
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Primary Account: |
CHAN TAI MAN, Current A/C 601-000-0000-0 |
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| Premium: |
400.00 |
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| Occupation Classification |
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i. Professional, administrative and office duties without manual work |
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| Benefit |
Sum Insured |
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| Accidental Death & Permanent Disablement: |
HKD 10,000 |
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| Temporary Disablement: |
HKD 1,000 (Per Week) |
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| Medical Expenses: |
HKD 1,000 (Per Event) |
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| Note : Accidental Death and Permanent Disablement are compulsory. Temporary Disablement's sum insured should not exceed the average weekly income of proposer. |
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| Beneficiary |
Name of Beneficiary : |
Relationship with proposer : |
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| a. |
Hua Li |
Sister |
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| b. |
Roy Li |
Brother |
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| Please answer the following questions |
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| 1.Do you have any existing accident insurance ? |
Yes |
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| 2.Has any of your application for life or accident insurance been declined ? |
Yes |
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| 3.Is your hearing or sight in anyway impaired, or do you have any physical defect or infirmity ? |
Yes |
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| 4.Have you ever made a claim against any insurer in respect of any accident bodily injury ? |
Yes |
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| Please give details if the answer to any of the above is "Yes": |
Detail info for above questions. |
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| Declaration |
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| I/We hereby apply for insurance as set out in the Company's Personal Accident Policy, and I/we hereby warrant that the above particulars are true and agree that this proposal shall be the basis of the contract between myself/ourselves and the Company. |
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Customer Service Hotline: 2952 6666
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