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C M Y K MD031/05.2005
Blue Cross (Asia-Pacific) Insurance Limited
Blue Cross (Asia-Pacific) Insurance Limited (‘Blue Cross’) is a member of the Bank of East Asia Group. With more than 35 years of experience in the insurance industry, Blue Cross provides a comprehensive range of products including life, travel, medical and general insurance, which caters to the needs of both individual and corporate customers.
Blue Cross has a strong track record in the development of new products and tailor-made services. As a pioneer in the development of managed care, Blue Cross is the first insurer to develop a ‘Preferred Provider Organization’ in Hong Kong and introduce preventive health check-up programs for its customers.
Blue Cross has received major awards in recognition of its contribution to the fields of insurance and customer services, such as the Hong Kong Award for Services – Innovation Award of the Year, the Superbrands Award and the Asia Pacific Customer Relationship Excellence Award – Innovative Technology of the Year.
藍十字(亞太)保險有限公司
藍十字(亞太)保險有限公司(「藍十字」)是東亞銀行集團成員,
於香港營運超過35年,提供多元化的保險產品,服務個人及公司
團體客戶,當中包括人壽保險、旅遊保險、醫療保險及一般保險
等,務求滿足客戶的不同需要。
藍十字擅於設計嶄新的保險計劃和服務,成績卓著,率先在香港
成立「醫療護理網絡」,同時是首間為客戶提供預防性身體檢驗
服務的保險公司。
藍十字屢獲殊榮,曾獲頒保險業及服務業多個主要獎項,例如
「香港服務業獎 ─ 創意獎」、「超級品牌」及「亞太顧客服務協會
─ 最佳創意科技獎」等。
29/F, BEA Tower, Millennium City 5, 418 Kwun Tong Road, Kwun Tong, Kowloon, Hong Kong
香港九龍觀塘道418號創紀之城5期東亞銀行中心29樓Tel電話:3608 2888 Fax傳真:3608 2938
www.bluecross.com.hk
MD031/05.2005
CUSTOMER SERVICE HOTLINE客 戶 服 務 熱 線
3608 2988E-mail電郵:[email protected]
Student Personal AccidentProtection Plan學生意外保障計劃
1. I hereby apply for a policy to be based on the above statements. I declare that to the best of my knowledge and belief all answers to the foregoing questions are correctly recorded, and that they are full, complete and true. I further declare that I am/the applicant is now in good health to the best of my knowledge and belief.
2. I / We understand and agree that any personal information is collected or held by Blue Cross (Asia-Pacific) Insurance Limited (“the Company”) to enable the Company to carry on insurance business and may be used, stored, disclosed and transferred (within or outside of Hong Kong) to any individuals / organizations associated with the Company or any selected third party as the Company may consider necessary for the purposes of: (1) any insurance or financial related product or service or any addition, alteration, variations, cancellation or renewal or reinstatement of them; (2) any scope of insurance coverage, claim processing /investigation, any analysis of it and data matching; (3) promotion of financial products or services by the Company and its affiliated companies; and (4) communicating with me/us/ the insured or any relevant organization/person as the Company may consider necessary . I / We have the right to obtain the “Privacy Policy Statement”, access to and to request correction of any personal information concerning myself/ourselves held by the Company. Such request could be made to the Company's Corporate Data Protection Officer at 29th Floor, BEA Tower, Millennium City 5, 418 Kwun Tong Road, Kwun Tong, Kowloon, Hong Kong.
1.本人謹根據以上陳述申請投保人身意外保險。本人聲明,上述問題之所有答案均是根據本人全部所知所信正確填寫,並為完全和真確。此外,本人亦根據全部所知所信作出聲明,本人/受保人現時之健康狀況良好。
2.本人/我們明白並同意藍十字(亞太)保險有限公司("貴公司")可收集或持有本人/我們之個人資料用於保險業務之用途,並可將此等資料使用、儲存、透露及轉交(於本地或以外)予任何與貴公司有關之人士 / 機構或被選定之第三者,作以下用途:(1)有關保險或財務之產品或服務,或該等產品或服務之增加、更改、轉變、取消、更新或復效;(2)任何保障範圍,處理理賠/調查或其有關分析及資料核對;(3)任何貴公司及其附屬公司之財務計劃、商品及服務之推廣活動;及(4)與本人/我們/受保人或貴公司認為有關之機構/人仕聯絡。本人/我們有權致函香港九龍觀塘道418號創紀之城5期東亞銀行中心29樓向貴公司之個人資料保護主任索取「私隱政策聲明」,查詢及要求更正貴公司所持有有關之個人資料。
(Please complete this form in BLOCK LETTERS 請以英文正楷填寫)
Name of Applicant Relationship to Student
投保人姓名� � � 與受保人關係
Correspondence Address Telephone No.
通信地址� � � 電話
Policy Effective Date (dd/mm/yy) - For 1 year
保單生效日期(日/月/年)� � � � � - 為期1 年�
(Policy effective date subject to Company's underwriting acceptance 承保日期以本公司審核為準)
Name of Student to be insured Sex
受保學生姓名� � � 性別
H.K.I.D. Card No. Date of Birth (dd/mm/yy)
香港身分證號碼� � � 出生日期(日/月/年)
Height Weight
身高� � � 體重
Full Name and Address of School Enrolled
就讀學校名稱及地址
Plan selected for one year 所選投保計劃
Applicantion For Student Personal Accident Protection Plan 學生意外保障計劃申請書
Please Tick the Payment Mode 請選擇付款方法
Cash
現金
Cheque - payable to "Blue Cross (Asia-Pacific) Insurance Limited"
支票-收款人為「藍十字(亞太)保險有限公司」
Credit Card(s) VISA Master Card信用卡� � � � VISA 萬事達�
I hereby authorize Blue Cross (Asia-Pacific) Insurance Limited to debit the annual premium
from my credit card account for the insurance policy.
本人茲授權藍十字(亞太)保險有限公司每年從本人的信用卡賬戶扣取應繳的保險費。
Credit Card Account No. Expiry Date
信用卡賬戶號碼� � � 信用卡到期日
Cardholder's Name Cardholder's Signature
持卡人姓名� � � 持卡人簽署
Plan 2
計劃二
$400
$480
Plan 3
計劃三
$600
$680
Plan 1
計劃一
$300
$380
Signature of Insured / Parent / Guardian Date (dd/mm/yy)受保人/家長/監護人簽署� 日期(日/月年)
Notes: 1) All questions must be answered fully.�2) Beneficiary of Personal Accident benefits should be insured's legal estate.
注意:�1) 每條問題必須詳細回答。�2) 保單受益人將會是受保人的合法遺產繼承人。
Benefits and exclusions are only briefly outlined here. For details please refer to the policy.�以上簡介僅供參考之用,實際承保條款以正式保單為準。
The liability of Blue Cross (Asia-Pacific) Insurance Limited does not commence until this�application has been accepted by the Company and the premium has been paid in full.�本申請書須經藍十字(亞太)保險有限公司接受,並在保費繳付後,藍十字(亞太)保險有限公司所承保之責任始行生效。
For Intermediary Use Only - 保險營業員專用
Name of Intermediary Intermediary's Code
中介人姓名� � � 中介人編號
For Office Use Only - 本公司專用
Policy No. Underwriting Approval
保單號碼� 批核人簽署
Premium Payment Ref. No.
付款編號
Declaration 聲明
C M Y K MD031/05.2005
STUDENT PERSONAL ACCIDENT PROTECTION PLAN 學生意外保障計劃
Accidental Death/Permanent Total Disablement Benefits Schedule�意外死亡/永久完全殘廢賠償表
Insured Events�事故�
1. Accidental Death 意外身故
2. Permanent Total Disablement 永久完全殘廢
3. Permanent and Incurable Paralysis of all Limbs�四肢永久癱瘓及無法痊癒
4. Permanent Total Loss of Sight of both Eyes�永久完全喪失雙眼視力
5. Permanent Total Loss of Sight of one Eye�永久完全喪失一眼視力
6. Loss of or Permanent Total Loss of use of two Limbs�喪失雙肢或雙肢完全失去功能
7. Loss of Permanent Total Loss of use of one Limb�喪失任何一肢或任何一肢完全失去功能
8.�Permanent Total Loss of Speech and Hearing�永久完全不能言語及失聰
Percentage of�Sum Insured�投保額賠償率
100%�
100%
100%
100%
50%
100%
50%
100%
�
Protection Highlights
1.Covers Accidental Injury, Medical Expenses & Hospital Income
2.24-hour worldwide protection
3.Any hospital & doctor you may choose
保障特點
1.�保障意外身故、傷殘、意外醫療或受傷住院之費用
2.�二十四小時全球保障
3.�可自由選擇醫院及醫生
Definitions
Accidental Injury -�
means bodily injury arising from an event occurring entirely beyond the
Insured Person's control and caused by violent external and visible
means.
Permanent Total Disablement -�
means an injury which within 12 months of the date of the accident
prevents the Insured Person from engaging in any occupation and
without hope of any improvement subject to the disability lasting for a
minimum of 52 consecutive weeks.
Accidental Medical Expenses -�
means the actual medical expenses necessarily incurred by the Insured
Person for medical treatment performed by a registered medical
practitioner/nurse from the date of the accident resulting in the injury
concerned.
Daily Hospital Income -�
means in the event the Insured Person is confined to hospital for
treatment of bodily injury for which compensation is payable for a period
not exceeding 365 days.
Accidental Death/Permanent Total Disablement Benefits Schedule�意外死亡/永久完全殘廢賠償表
Insured Events事故�
9. Permanent Total Loss of Hearing in 永久完全失聽 a) both ears 雙耳 b) one ear 單耳
10.Permanent Total Loss of Speech 永久完全喪失言語能力
11.Permanent Total Loss of the Lens of one Eye��永久完全喪失一眼角膜
12.Removal of the Lower Jaw by surgical operation��因外科手術切除下顎
13.Loss of or Permanent Total Loss of use of Thumb and four Fingers of ��喪失或永久完全失去四隻手指及姆指功能 a) Right Hand 右手 b) Left hand 左手
14.Loss of or Permanent Total Loss of use of four Fingers of��喪失或永久完全喪失四隻手指功能 a) Right Hand 右手 b) Left hand 左手
15.Loss of or Permanent Total Loss of use of one thumb ��喪失或永久完全喪失一隻姆指功能 a) Both Right Joints 兩個右手關節 b) One Right Joint 一個右手關節 c) Both Left Joints 兩個左手關節 d) One Left Joint 一個左手關節
16.Loss of or Permanent Total Loss of use of Fingers ��喪失或永久完全喪失手指功能 a) Three Right Joints 三個右手關節 b) Two Right Joint 兩個右手關節 c) One Right Joint 一個右手關節 d) Three Left Joint 三個左手關節 e) Two Left Joint 兩個左手關節 f) One Left Joint 一個左手關節* Left hand users can have the coverage percentage left and right hand reversed.*(以左手為慣用手者,賠償額將會左右互調)
17.Loss of Permanent Total Loss of use of Toes��喪失或永久完全喪失腳趾功能 a) All - one foot 一隻腳所有腳趾 b) Great - both Joints 大腳趾一兩個關節 c) Great - Joint 大腳趾一一個關節 d) Other toe 其他腳趾
18.Fractured Leg or Patella with established non-union ��折斷腿部或膝蓋而無法縫合
19.Shortening of Leg by at least 5cm 腳部縮短5厘米
Percentage of�Sum Insured�投保額賠償率
75%15%
50%�
30%
30%
70%
50%
�
40%
30%
30%
15%
20%
10%
10%
7.5%
5%
7.5%5%
2%
15%
5%3%
2%
10%
7.5%
Exclusions
Injury or death resulting from natural death,sicknees, suicide, self-inflicted injury,
pregnancy or childbirth, war, service in the armed forces, flying as a pilot or crew
member in any aircraft and if you are engaged in any professional sports.
不保事項
因自然死亡、疾病、自殺、自傷、懷孕或生育、戰爭、從事紀律部隊工作、
在任何飛機上擔任值勤工作,或參與任何專業體育活動而引致之死亡或受傷。
Schedule of Benefits and Premium Table
投保項目及保費表
Benefits投保項目
1. Accidental Death &�Permanent Total Disablement�意外死亡及永久完全殘廢
2.Accidental Medical Expenses�(maximum per accident/year)�意外醫療費用�(每次意外/每年最高賠償額)
3. Daily Hospital Income (maximum 365 days)�每天住院現金津貼 (最高可達365天)
4. Optional Benefits Chinese Bonesetter &�Acupuncturist treatment�(maximum HK$1,000 per accident)�可附加保障跌打及針灸治療�(每次意外保額為HK$1,000)
Plan 1計劃一(HK$)
Plan 2計劃二(HK$)
Plan 3計劃三(HK$)
Benefits投保項目
Plan 1計劃一(HK$)
Plan 2計劃二(HK$)
Plan 3計劃三(HK$)
Items 1-3 per student�保障1-3項 每人
Items 1-4 per student�保障1-4項 每人
150,000
8,000
100
2,000
600
680
400
480
300
380
500,000
12,000
300
2,000
300,000
10,000
200
2,000
釋義
「意外受傷」�
指因外在明顯的意外因素,並經由完全非受保人所能控制之事故所引致的身
體受傷。
「永久完全傷殘」� �
指意外後十二個月內,受保人因受傷而無法從事其正常工作;而此情況於持
續不少於五十二周後,仍無康復希望。
「意外醫療費用」� �
指受保人於意外受傷後,因接受註冊西醫或護士替其進行醫療而所須支付的
合理費用。
「每天住院現金津貼」��
指受保人如因意外受傷而入院留醫,於住院期間可獲每天現金津貼,惟以三
百六十五天為限。
�
Who is Eligible?�
All full-time unmarried students between the ages of 3 to 23.
投保資格�
凡年齡由三至二十三歲之未婚全職學生均可投保。
C M Y K MD031/05.2005
STUDENT PERSONAL ACCIDENT PROTECTION PLAN 學生意外保障計劃
Accidental Death/Permanent Total Disablement Benefits Schedule�意外死亡/永久完全殘廢賠償表
Insured Events�事故�
1. Accidental Death 意外身故
2. Permanent Total Disablement 永久完全殘廢
3. Permanent and Incurable Paralysis of all Limbs�四肢永久癱瘓及無法痊癒
4. Permanent Total Loss of Sight of both Eyes�永久完全喪失雙眼視力
5. Permanent Total Loss of Sight of one Eye�永久完全喪失一眼視力
6. Loss of or Permanent Total Loss of use of two Limbs�喪失雙肢或雙肢完全失去功能
7. Loss of Permanent Total Loss of use of one Limb�喪失任何一肢或任何一肢完全失去功能
8.�Permanent Total Loss of Speech and Hearing�永久完全不能言語及失聰
Percentage of�Sum Insured�投保額賠償率
100%�
100%
100%
100%
50%
100%
50%
100%
�
Protection Highlights
1.Covers Accidental Injury, Medical Expenses & Hospital Income
2.24-hour worldwide protection
3.Any hospital & doctor you may choose
保障特點
1.�保障意外身故、傷殘、意外醫療或受傷住院之費用
2.�二十四小時全球保障
3.�可自由選擇醫院及醫生
Definitions
Accidental Injury -�
means bodily injury arising from an event occurring entirely beyond the
Insured Person's control and caused by violent external and visible
means.
Permanent Total Disablement -�
means an injury which within 12 months of the date of the accident
prevents the Insured Person from engaging in any occupation and
without hope of any improvement subject to the disability lasting for a
minimum of 52 consecutive weeks.
Accidental Medical Expenses -�
means the actual medical expenses necessarily incurred by the Insured
Person for medical treatment performed by a registered medical
practitioner/nurse from the date of the accident resulting in the injury
concerned.
Daily Hospital Income -�
means in the event the Insured Person is confined to hospital for
treatment of bodily injury for which compensation is payable for a period
not exceeding 365 days.
Accidental Death/Permanent Total Disablement Benefits Schedule�意外死亡/永久完全殘廢賠償表
Insured Events事故�
9. Permanent Total Loss of Hearing in 永久完全失聽 a) both ears 雙耳 b) one ear 單耳
10.Permanent Total Loss of Speech 永久完全喪失言語能力
11.Permanent Total Loss of the Lens of one Eye��永久完全喪失一眼角膜
12.Removal of the Lower Jaw by surgical operation��因外科手術切除下顎
13.Loss of or Permanent Total Loss of use of Thumb and four Fingers of ��喪失或永久完全失去四隻手指及姆指功能 a) Right Hand 右手 b) Left hand 左手
14.Loss of or Permanent Total Loss of use of four Fingers of��喪失或永久完全喪失四隻手指功能 a) Right Hand 右手 b) Left hand 左手
15.Loss of or Permanent Total Loss of use of one thumb ��喪失或永久完全喪失一隻姆指功能 a) Both Right Joints 兩個右手關節 b) One Right Joint 一個右手關節 c) Both Left Joints 兩個左手關節 d) One Left Joint 一個左手關節
16.Loss of or Permanent Total Loss of use of Fingers ��喪失或永久完全喪失手指功能 a) Three Right Joints 三個右手關節 b) Two Right Joint 兩個右手關節 c) One Right Joint 一個右手關節 d) Three Left Joint 三個左手關節 e) Two Left Joint 兩個左手關節 f) One Left Joint 一個左手關節* Left hand users can have the coverage percentage left and right hand reversed.*(以左手為慣用手者,賠償額將會左右互調)
17.Loss of Permanent Total Loss of use of Toes��喪失或永久完全喪失腳趾功能 a) All - one foot 一隻腳所有腳趾 b) Great - both Joints 大腳趾一兩個關節 c) Great - Joint 大腳趾一一個關節 d) Other toe 其他腳趾
18.Fractured Leg or Patella with established non-union ��折斷腿部或膝蓋而無法縫合
19.Shortening of Leg by at least 5cm 腳部縮短5厘米
Percentage of�Sum Insured�投保額賠償率
75%15%
50%�
30%
30%
70%
50%
�
40%
30%
30%
15%
20%
10%
10%
7.5%
5%
7.5%5%
2%
15%
5%3%
2%
10%
7.5%
Exclusions
Injury or death resulting from natural death,sicknees, suicide, self-inflicted injury,
pregnancy or childbirth, war, service in the armed forces, flying as a pilot or crew
member in any aircraft and if you are engaged in any professional sports.
不保事項
因自然死亡、疾病、自殺、自傷、懷孕或生育、戰爭、從事紀律部隊工作、
在任何飛機上擔任值勤工作,或參與任何專業體育活動而引致之死亡或受傷。
Schedule of Benefits and Premium Table
投保項目及保費表
Benefits投保項目
1. Accidental Death &�Permanent Total Disablement�意外死亡及永久完全殘廢
2.Accidental Medical Expenses�(maximum per accident/year)�意外醫療費用�(每次意外/每年最高賠償額)
3. Daily Hospital Income (maximum 365 days)�每天住院現金津貼 (最高可達365天)
4. Optional Benefits Chinese Bonesetter &�Acupuncturist treatment�(maximum HK$1,000 per accident)�可附加保障跌打及針灸治療�(每次意外保額為HK$1,000)
Plan 1計劃一(HK$)
Plan 2計劃二(HK$)
Plan 3計劃三(HK$)
Benefits投保項目
Plan 1計劃一(HK$)
Plan 2計劃二(HK$)
Plan 3計劃三(HK$)
Items 1-3 per student�保障1-3項 每人
Items 1-4 per student�保障1-4項 每人
150,000
8,000
100
2,000
600
680
400
480
300
380
500,000
12,000
300
2,000
300,000
10,000
200
2,000
釋義
「意外受傷」�
指因外在明顯的意外因素,並經由完全非受保人所能控制之事故所引致的身
體受傷。
「永久完全傷殘」� �
指意外後十二個月內,受保人因受傷而無法從事其正常工作;而此情況於持
續不少於五十二周後,仍無康復希望。
「意外醫療費用」� �
指受保人於意外受傷後,因接受註冊西醫或護士替其進行醫療而所須支付的
合理費用。
「每天住院現金津貼」��
指受保人如因意外受傷而入院留醫,於住院期間可獲每天現金津貼,惟以三
百六十五天為限。
�
Who is Eligible?�
All full-time unmarried students between the ages of 3 to 23.
投保資格�
凡年齡由三至二十三歲之未婚全職學生均可投保。
C M Y K MD031/05.2005
Blue Cross (Asia-Pacific) Insurance Limited
Blue Cross (Asia-Pacific) Insurance Limited (‘Blue Cross’) is a member of the Bank of East Asia Group. With more than 35 years of experience in the insurance industry, Blue Cross provides a comprehensive range of products including life, travel, medical and general insurance, which caters to the needs of both individual and corporate customers.
Blue Cross has a strong track record in the development of new products and tailor-made services. As a pioneer in the development of managed care, Blue Cross is the first insurer to develop a ‘Preferred Provider Organization’ in Hong Kong and introduce preventive health check-up programs for its customers.
Blue Cross has received major awards in recognition of its contribution to the fields of insurance and customer services, such as the Hong Kong Award for Services – Innovation Award of the Year, the Superbrands Award and the Asia Pacific Customer Relationship Excellence Award – Innovative Technology of the Year.
藍十字(亞太)保險有限公司
藍十字(亞太)保險有限公司(「藍十字」)是東亞銀行集團成員,
於香港營運超過35年,提供多元化的保險產品,服務個人及公司
團體客戶,當中包括人壽保險、旅遊保險、醫療保險及一般保險
等,務求滿足客戶的不同需要。
藍十字擅於設計嶄新的保險計劃和服務,成績卓著,率先在香港
成立「醫療護理網絡」,同時是首間為客戶提供預防性身體檢驗
服務的保險公司。
藍十字屢獲殊榮,曾獲頒保險業及服務業多個主要獎項,例如
「香港服務業獎 ─ 創意獎」、「超級品牌」及「亞太顧客服務協會
─ 最佳創意科技獎」等。
29/F, BEA Tower, Millennium City 5, 418 Kwun Tong Road, Kwun Tong, Kowloon, Hong Kong
香港九龍觀塘道418號創紀之城5期東亞銀行中心29樓Tel電話:3608 2888 Fax傳真:3608 2938
www.bluecross.com.hk
MD031/05.2005
CUSTOMER SERVICE HOTLINE客 戶 服 務 熱 線
3608 2988E-mail電郵:[email protected]
Student Personal AccidentProtection Plan學生意外保障計劃
1. I hereby apply for a policy to be based on the above statements. I declare that to the best of my knowledge and belief all answers to the foregoing questions are correctly recorded, and that they are full, complete and true. I further declare that I am/the applicant is now in good health to the best of my knowledge and belief.
2. I / We understand and agree that any personal information is collected or held by Blue Cross (Asia-Pacific) Insurance Limited (“the Company”) to enable the Company to carry on insurance business and may be used, stored, disclosed and transferred (within or outside of Hong Kong) to any individuals / organizations associated with the Company or any selected third party as the Company may consider necessary for the purposes of: (1) any insurance or financial related product or service or any addition, alteration, variations, cancellation or renewal or reinstatement of them; (2) any scope of insurance coverage, claim processing /investigation, any analysis of it and data matching; (3) promotion of financial products or services by the Company and its affiliated companies; and (4) communicating with me/us/ the insured or any relevant organization/person as the Company may consider necessary . I / We have the right to obtain the “Privacy Policy Statement”, access to and to request correction of any personal information concerning myself/ourselves held by the Company. Such request could be made to the Company's Corporate Data Protection Officer at 29th Floor, BEA Tower, Millennium City 5, 418 Kwun Tong Road, Kwun Tong, Kowloon, Hong Kong.
1.本人謹根據以上陳述申請投保人身意外保險。本人聲明,上述問題之所有答案均是根據本人全部所知所信正確填寫,並為完全和真確。此外,本人亦根據全部所知所信作出聲明,本人/受保人現時之健康狀況良好。
2.本人/我們明白並同意藍十字(亞太)保險有限公司("貴公司")可收集或持有本人/我們之個人資料用於保險業務之用途,並可將此等資料使用、儲存、透露及轉交(於本地或以外)予任何與貴公司有關之人士 / 機構或被選定之第三者,作以下用途:(1)有關保險或財務之產品或服務,或該等產品或服務之增加、更改、轉變、取消、更新或復效;(2)任何保障範圍,處理理賠/調查或其有關分析及資料核對;(3)任何貴公司及其附屬公司之財務計劃、商品及服務之推廣活動;及(4)與本人/我們/受保人或貴公司認為有關之機構/人仕聯絡。本人/我們有權致函香港九龍觀塘道418號創紀之城5期東亞銀行中心29樓向貴公司之個人資料保護主任索取「私隱政策聲明」,查詢及要求更正貴公司所持有有關之個人資料。
(Please complete this form in BLOCK LETTERS 請以英文正楷填寫)
Name of Applicant Relationship to Student
投保人姓名� � � 與受保人關係
Correspondence Address Telephone No.
通信地址� � � 電話
Policy Effective Date (dd/mm/yy) - For 1 year
保單生效日期(日/月/年)� � � � � - 為期1 年�
(Policy effective date subject to Company's underwriting acceptance 承保日期以本公司審核為準)
Name of Student to be insured Sex
受保學生姓名� � � 性別
H.K.I.D. Card No. Date of Birth (dd/mm/yy)
香港身分證號碼� � � 出生日期(日/月/年)
Height Weight
身高� � � 體重
Full Name and Address of School Enrolled
就讀學校名稱及地址
Plan selected for one year 所選投保計劃
Applicantion For Student Personal Accident Protection Plan 學生意外保障計劃申請書
Please Tick the Payment Mode 請選擇付款方法
Cash
現金
Cheque - payable to "Blue Cross (Asia-Pacific) Insurance Limited"
支票-收款人為「藍十字(亞太)保險有限公司」
Credit Card(s) VISA Master Card信用卡� � � � VISA 萬事達�
I hereby authorize Blue Cross (Asia-Pacific) Insurance Limited to debit the annual premium
from my credit card account for the insurance policy.
本人茲授權藍十字(亞太)保險有限公司每年從本人的信用卡賬戶扣取應繳的保險費。
Credit Card Account No. Expiry Date
信用卡賬戶號碼� � � 信用卡到期日
Cardholder's Name Cardholder's Signature
持卡人姓名� � � 持卡人簽署
Plan 2
計劃二
$400
$480
Plan 3
計劃三
$600
$680
Plan 1
計劃一
$300
$380
Signature of Insured / Parent / Guardian Date (dd/mm/yy)受保人/家長/監護人簽署� 日期(日/月年)
Notes: 1) All questions must be answered fully.�2) Beneficiary of Personal Accident benefits should be insured's legal estate.
注意:�1) 每條問題必須詳細回答。�2) 保單受益人將會是受保人的合法遺產繼承人。
Benefits and exclusions are only briefly outlined here. For details please refer to the policy.�以上簡介僅供參考之用,實際承保條款以正式保單為準。
The liability of Blue Cross (Asia-Pacific) Insurance Limited does not commence until this�application has been accepted by the Company and the premium has been paid in full.�本申請書須經藍十字(亞太)保險有限公司接受,並在保費繳付後,藍十字(亞太)保險有限公司所承保之責任始行生效。
For Intermediary Use Only - 保險營業員專用
Name of Intermediary Intermediary's Code
中介人姓名� � � 中介人編號
For Office Use Only - 本公司專用
Policy No. Underwriting Approval
保單號碼� 批核人簽署
Premium Payment Ref. No.
付款編號
Declaration 聲明