EXCELMASKEDMASKED MASKED, Current A/C 601-003-0000-0
Credit Card
I hereby authorize CMB Wing Lung Insurance Co. Ltd to debit from my Credit Card account the premium of the cover type selected.
VISA
MasterCard:
-
-
-
Card Expiry Date:
(yyyy/mm)
Name of Credit Card holder:
Particulars of Insurance
Insured Address:
(if different from correspondence address)
One Year Insurance Period:
From (yyyy/mm/dd)
Insured Items & Sum Insured
1. Contents
HKD500,000
Gross Floor Area
sq.ft
2. Personal and Occupier Liability
HKD5,000,000
3. House
HKD
Mortgagee
4. Personal Accident (Age Limit 16 - 65)
a. Accidental Death &
Permanent Disablement
HKD
b. Temporary Disablement
HKD
(per week)
c.
Medical Expenses
HKD
(per event)
5.
Worldwide All Risk (Please provide receipt copy)
Item name
Sum Insured In HKD
a.
b.
c.
d.
6. Domestic Servants (Age Limit 65)
Cover A
Cover B
Name of Servant:
Sex:
M
F
Nationality:
Date of Birth:
(yyyy/mm/dd)
HKID / Passport No.:
Please complete the following if Section 4 above is selected :
a)
Name of Insured:
Sex:
M
F
Date of Birth:
(yyyy/mm/dd)
HKID No.:
Occupation:
Beneficiary:
b)
Name of Insured:
Sex:
M
F
Date of Birth:
(yyyy/mm/dd)
HKID No.:
Occupation:
Beneficiary:
c)
Name of Insured:
Sex:
M
F
Date of Birth:
(yyyy/mm/dd)
HKID No.:
Occupation:
Beneficiary:
Declaration
I/We hereby apply for insurance as set out in the Company's Family Package 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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