大童总部-高端医疗msh和经典计划

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经典个人全球医疗保险个人投保地INDIVIDUALHEALTHPLANAPPLICATION地保险总公司地址：浦东新区民生路1199弄（证大五道口广场）1号楼8楼,200135CCICHeadOffice:8thFloor,TowerOneLane1199MinshengRoad,PudongDistrict,ShanghaiChina200135Inorderforyoutofullyunderstandtheinsuranceappliedforandsoastoprotectyourrightsandinterests,pleaseasksalesrepresentative/brokerforthepolicywordinganddetailedexplanationsofthepolicywording,particularlyintermsofimportantcontentssuchasbenefitsandexclusionsbeforeapply.Pleasemakeyourapplicationdecisiononlywhensalesrepresentativehasexplainedthepolicywording;youhavecarefullyreadrelevantinsurancecontentsandpolicywording;andyouhavefullyunderstoodimportantissueslikebenefits,exclusions,honestdisclosureandcontractcancellation.本公司各项询问，投保人、被保险人须如实告知，本公司承诺对投保资料内容。TheApplicationForm,andotherfilesdeemednecessarybytheInsurer(hereinafter“applicationfiles”)arebasisfortheInsurertoissuetheInsuranceContractandwillbeanimportantpartoftheInsuranceContract.ForallinquiresoftheInsurer,thePolicyholderandtheInsuredshoulddisclosehonestly,theInsurerguaranteetokeepoftheapplicationfiles.Theapplicationformmayonlybesignedbythepolicyholder.Nootherparty maysignonbehalfoftheIfyoufillinandsigntheapplicationfiles,itshouldberegardthatyoufullyunderstandthepolicywordingandagreetoabideby、、Youandyourdependents(ifany)mustresidewithin,,Macaoandforatleast8months.Pleaseinformbrokers/agency/salesrepresentativeandtheInsurerifyouareunsurenotabletomeetresidentialrequirement.显现症状的疾病或者损伤。请注意，您在第三部分“健康问卷”披露的信息将用于评估您连续投保的保险保障。ThepurposeoftheMedicalQuestionnaireistoevaluatethehealthconditionsforyouandyourdependents(ifany)andtodeterminecoverage,pleaseanswerthequestionsbelowastruthfullyandthoroughlyaspossible.Pre-existingconditions,ifany,willnotbecoveredunlessapprovedbytheinsurer.Forthepurposeofyourhealthinsurance,Pre-existingconditionsaredefinedas“anyIllnessorInjury,physicalormentalcondition,forwhichanInsuredreceivedanydiagnosis,medicaladviceortreatment,orhadtakenanyprescribeddrug,orwheredistinctsymptomswereevidentpriortotheeffectivedate.”PleasepayattentiontheinformationyoudisclosedinSection3MedicalQuestionnairewillbeappliedtoevaluateyourcoverageforthecontinuouspolicyyear.Uponreceivingyourinsurancepremium,youandyourdependentsifanywillbegivenaninsurancecard.Theinsurancecardcanbeusedatour“directbillingproviders”wheretheprovidersendstousfordirectsettlement.Ifyouwishtoaccesstothedirectbilling,pleasecompleteConfirmationLetter.However,ifadirectbillingproviderisused,foranyexpensesnoigibletobecoveredbythepolicyandnotcollectedbytheprovider,youshouldpaythecorrespondingexpensestotheCompanywithin30daysfromthedayofnotificationbytheCompanyoritsbehalf.Otherwise,theCompanyhastherighttocanceldirectbillingservicesorevencancelthecontractwithnorefundofpremium.IherebyacknowledgethatIhaveread,understandandagreetothetermsandconditionsstated投保人签名Applicant 日期（月/日/年）Date第一部分：投保人及被保险人信息Section1投保人ApplicantNameofCompanyor 传真地址及PermanentAddress&邮寄地址及MailingAddress&保险联系人NameofInsuranceContact 电邮主被保险人Primary姓Last 名生日(月/日/年)DateofBirth 身高Height

体重Weight国籍 或护照号码IDorPassport职业Occupation 公司 传真 电子邮件居住地址Residential居住城市Cityof 的邮寄地址PreferredPostalAddress 紧急情况联系人Emergency ephone电子邮件附属被保险人姓Last 名生日(月/日/年)DateofBirth 身高Height

体重Weight国籍 或护照号码IDorPassport居住城市Cityof ephone姓Last 名生日(月/日/年)DateofBirth 身高Height

体重Weight国籍 或护照号码IDorPassport居住城市Cityof ephone姓Last 名生日(月/日/年)DateofBirth 身高Height

体重Weight国籍 或护照号码IDorPassport居住城市Cityof ephone第二部分：投保保障Section2.ProposedEffective(月/日/Note:Pleaseleaveatleast5workingdays(fromthedatesubmittingtheapplicationform)forenrollmentandpayment.Premiumshouldbereceivedbeforepolicyeffectivedate.保险地域范围Geographic大陆及台保障（保障地域：陆、、和地区GreaterChina(Coveragein ,Macao,andGreaterChinaPlus(Coveragein ,Macao,and.EmergencyCoverageoutsideGreater国际保障（保障地域：和以外的所有国家和地区 (WorldwideCoverageexcludeU.S.and国际增强保障（保障地域同国际保障，以及在和发生的紧急医疗费用InternationalPlus(WorldwideCoverageexcludesU.S.andCanada.EmergencyCoverageintheU.S.and (NoArea单身

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家庭Optional其他特殊需求，请注明Anyotherconditions,pleasespecify个人付 alPayment(以主被保险人开具Fapiaoisissuedundertheprimaryinsured’s alpaymentisthedefaultoptionifnot公司付款CompanyPayment(以主被保险人公司中文名开具Fapiaoisissuedundertheprimaryinsured’scompanyChinesename.)依据开具；如仍需以此处所提供的公司名称开具，请提供付款单位与此处所提供的公司之间的关系证明文件。Note:Thecompanynameyoustateheremustbeidenticaltothenameofpayer.ThenameofApplicantwillbeusedforFapiaotitle,ifthenameofthepayerisdifferentfromtheoneyoustatehere;However,Fapiaoundercompany’snamecouldbeissuedifadditionalstatementontherelationshipbetweenthepayerandthecompanyisprovided.币种RMB第三部分：健康问卷Section3.MedicalPleaseanswerYESorNOtoeachofthefollowingquestionsfortheprimaryinsuredandeachofhis/herdependentsifany.Foranyofyouroptionspleasetick"√".ForeachYESanswer,pleaseexplainandprovidedetails. Beenadmittedtoahospital/othermedicalfacilityorhad曾伤残过或治疗费超过40,000元 Beendisabledand/orincurredmedicalcostsexceeding￥40,体检时知有任何异常 Beentoldthattherewasanyabnormityduring曾因病或意外而休病假30日或以上 Sufferedfromadiseaseoranaccidententailing30daysormoresickleaveand/ormedical Scheduledsurgery/inpatienttreatmentinone Hadanyhealthproblemsorcomplaints,beendiagnosedwith,orhadtreatmentforanyoftheA.慢性咳嗽，咯痰，，哮喘，呼吸，支气Chroniccough,expectoration,hemoptysis,asthma,difficultybreathing,bronchieis,pothorax,emphysema,tuberculosis,pleurisy,chronicbronchitis,orotherdiseasesoftherespiratorysystem?是否B.腰痛，尿频，尿急，，排尿 Backpain,frequenturination,urgencyofurination,paininurination,difficultyurinating,bloodorproteinintheurine,abnormalamountofurine,nocturia,kidneyandurinarytractstone, 是否C.返酸，嗳气，，腹胀，腹痛，便秘，腹泻， Belch,nausea,abdominaldistention,abdominalpain,constipation,diarrhea,hematemesis,melena,hematochezia,jaundice,difficultyswallowing,ulcer,colitis,stomachproblems,hernia,rectalproblems,HBVCarrier,liverdisorders,gallbladderdisorder,pancreasproblemsorotherdigestivesystemproblems?是否 hemoptysis,varicoseveinsextremity,fortorpressure,syncope,rheumaticfeverorHeartmurmur,arrhythmia,myocarditis,cardiovasculardisease,myocardialinfarction,stroke,aneurysm,coronaryheartdisease,hypertension,hyperlipaemia,orothersystem是否E.头昏，牙龈，鼻，皮下，紫癜，骨 hemorrhage,purpura,paininbone,anemia,orotherbloodsystemdisorders?是否萎缩，神经损害或其他肌肉骨骼／关节疾病？Arthritis,gout,neckpain,backandlumbarpain,cervicalvertebraldisease,lumbarvertebraldisease,myophagism,nervouslesionmusculoskeletal/joint是否，甲状腺疾病，或其他代谢和内系统疾Hyperhidrosis,polyuria,tremoronhands,obesity,pigmentation,amenorrhea,diabetes,thyroiddiseases,orothermetabolismandendocrinesystemproblems?是否识，震颤，，惊厥，瘫痪，感觉异常，癫Dizziness,vertigo,syncope,hypomnesis,disturbanceofvision,disturbanceofconsciousness,tremor,convulsions,seizure,paralysis,sensoryabnormity,epilepsy,lossconsciousnessorothernervesystem是否 疾病，乳腺痛，乳腺炎，不调， Prostatedisorder,mastalgia,mastitis,Irregular abnormalgrowthintheuterus,ovariancyst,Infertility,orotherdiseasesofthemale/femalereproductiveorgans,includingvenereal是否 Cancer,tumorormass,nodules,polyps,cysts,enlargedglands,lymphnodesororgan,disordersoftheskinorpigmentation,abnormalgrowthinthebreastsoranyrelatedconditions?是否K.HIV， HIVinfection,AIDS,AIDS-relatedcomplexorother是否L.酗酒，吸 Alcoholorsubstanceabuse,mental/nervous,behavioral,emotional,oreatingdisorders?是否venerealM.白内障、青光眼或其他眼疾患；损失；任何 a;oranyeyedisorder;hearingloss;oranyearnose,orthroatdisorder?是否N伤残性疾病，身体缺陷，生长发育异常，智力低下意外影响性疾病，遗传性疾病，缺陷，病史Disablingillness,physicaldefect,heteroplasia,amentia,suffersfromtheconsequencesofaccident,Congenitaldisease,hereditarygeneticdefect,anyfamilymedical是否O女性主/P除了以上情况主被保险人或其附属被保险人Femaleprimary/dependentinsuredareOtherthanpreviouslyaa.每天抽烟超过15支或以任何方式食用烟草？Nowb.是否有怀孕并发症？请提供详细资料Smokemorethan15cigarettesperdayorusetobaccoinanyform?Haveanycomplicationsofpregnancy?Ifyes,pleasepresentmedicalrecord.b.在过去5年中，一年内体重增加或减少超过12斤或25磅c.Expecteddateof是Withinthepast5years,gainedorlostmorethan12kgor25lbsduring12months?是AnyothermedicalconditionthathasnotbeendisclosedaboveA-O,regardlessofwhetheradoctororotherhealthcareprofessionalhasbeenconsulted?Ifso,describeindetailbelow.，、，、PleaseexplainanyYESanswersbelow(Attachadditionalpagesifnecessary).Medicalreportmayberequiredifsymptomsor现在情Q.NameoftheinsuredTimeWhattreatmentdidyoureceivewhen?(Pleaseincludedatesandanymedicationprescribed)Current(pleterecovery,stillunderreview,ongoing,recurrentorlikelytorecur?Ifitiscompleterecovery,pleaseinformthetime.)实、完全填写或故意隐瞒与此保险相关的事实会导致保险失效；如果我违背本，保险人终止保险合同且不退还保险费。IdeclarethatIhaveansweredallthequestionstruthfullyandtothebestofmyknowledge.Ifthisformhasbeencompletedonmybehalf,Iagreetothetruthfulnessoftheresponsesgiven.Iunderstandthatanyincorrector pleteanswerortheconcealmentofanyfactsrelevanttothisinsurancemayinvalidatethispolicy.Ialsounderstandthattheinsurershallbeentitledtoretainallpremiumspaidduringthepolicyyearbyvirtueofabreachofthisdeclaration.在此后至保险正式生效日之前，如上述内容发生改变，我应及时通知保险人，保险人进行重新评估IamalsoawarethatIhavetonotifytheinsurerofanyfactmaterialtothisinsurance,whicharisesbetweenthedateofthisdeclarationandtheinceptionofthispolicy. Iherebygrantmyauthorizationforanydoctors,hospitals,insurancecompanies,otherinstitutesorsthatknowor