Personal Accident Insurance Application accepted! Application No.：EB123456
Name of Proposer:
Mr. yutyffgcd
(Surname, Given Name)
Correspondence Address:
18A, The World Finance Center
Luohu District, Shenzhen
Email Address:
tomren@cmbwinglungbank.com
Telephone No.:
12345678 (Home)
12345678 (Office)
12345678 (Mobile)
Person Insured:
Person Insured
HKID No.:
C387979(A)
Sex:
F
Occupation:
IT
Date of Birth:
1991/01/19
(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:
VISA:
3233-2323-3223-3232
Expiry Date:
2010/01
Card Holder Name:
Hua LI
Premium:
2,075.00
Occupation Classification
ii. Other non-manual occupations
Benefit
Sum Insured
Accidental Death & Permanent Disablement:
HKD7,878
Temporary Disablement:
HKD 8,787 (Per Week)
Medical Expenses:
HKD 8,778 (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.
This application is subject to final approval of CMB Wing Lung Insurance Co. Ltd. Our staff will contact you on the next working day.
Thank you for using Personal Accident Insurance Application Service.
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