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