友邦团体保险被保险人健康告知书.pdf

友邦团体保险被保险人健康告知书友邦团体保险被保险人健康告知书 Member Health Declaration Form 保险公司填写保险公司填写 投保人填写投保人填写 保险合同编号/Policy no：G 投保人名称/Policyholder： 员工/成员编号/Employee / Member No： 被保险人姓名/Name of Proposed Insured： 身份证件号码/ID Card No. or Passport No. 出生日期/Date of Birth MM /DD /YY 性别/Sex: □ 男性 Male □ 女性 Female 国籍/Nationality 婚姻状况/Marital Status □单身 Single □丧偶 Widowed □已婚 Married □离婚 Divorced 号码/Telephone No. 办公 Office: 移动 Mobile: A．保障内容．保障内容 Details Of Life Insurance Applied For：： 1．友邦环球精英团体医疗险总保额/AIA Group High End Product Total Sum Assured 友邦工作人员填写友邦工作人员填写/For AIA user only 2．累计寿险保额/Group Life Sum Assured 寿险 NEL 额度 Group Life NEL 3．累计重大疾病险保额/Critical Illness Sum Assured 重大疾病 NEL 额度 Critical Illness NEL 4．累计意外伤害险保额/ADD Sum Assured 意外伤害险 NEL 额度 ADD NEL B．被保险人告知事项．被保险人告知事项（请勾选或填写以下各项目）：Declaration of Proposed Insured Member (please tick or fill in): 是/Yes 否/No 1．被保险人是否已购买人身保险合同？ 若“是”，请详述 Do you have any life insurance coverage? If ‘Yes’, please specify: 公司名称： 保险金额： 购买日期: Name of the insurance company: Amount of Insurance: Effective Date: 2．被保险人的人寿保险、人身意外或健康保险申请是否曾被拒保、推迟、加费或作任何形式修改？若“是”，请说明 Have you had any application for life insurance ever been declined, postponed, rated up or modified? If ‘Yes’, please specify 3．被保险人是否曾向任何保险公司提出保险金给付申请？若“是”，请说明： Have you claimed from any insurance company? If ‘Yes’, please specify： 4．正在或试图参加私人性质飞行，或携带氧气瓶潜水、或登山、或从事危险性的运动？若“是”，请填妥相关问卷， 连同此通知书一并并回本公司。

Are you engaging or do you contemplate to engage in any private flying, scuba-diving, mountain climbing, or any hazardous sports? If ‘Yes’, please complete the related questionnaire, and return to the Company together with this application form. 5．在非州、加勒比海地区、印度、缅甸及泰国持续居住超过三个月或正拟往上述国家？若“是”，请说明： Have you resided in the following countries for more than 3 months or planned to go to there: Africa, region of Caribbean Sea, India, Myanmar or Thailand. 6．是否正计划前往其他国家或海外地区旅行、工作或居住？若“是”，请详述时间及具体前往的国家/海外地区： Are you planning to go to other countries or overseas for traveling, working or living? If ‘Yes’, please specify the date and the destination. 7．是否曾在过去 12 个月里或计划在未来的 12 个月里，前往美国、加拿大或西欧连续居住 90 天或以上？ 是的，从 至 地点 . In the past 12 months, have your ever been resided or have you planned in the coming 12 months to reside consecutively for 90 days or longer in the United States, Canada or Western Europe? Yes, From to Where . 资料类型：□NA □NR □MP □ME □PMM-P □PMM-X 客户编号： 补充件：□是 □否 初始收件日： 其他： 收件日期盖章 8．平均每年搭乘飞机在 250 小时以上？Will you spend more than 250 hours a year on flight? 9．现从事职业及日常职务？Present occupation and daily duty 10．目前常住地址及户口所在地？请详述： Please state your present residential address, and country of origin: C．被保险人健康资料．被保险人健康资料（请勾选或填写以下各项目）：Health Details of Proposed Insured Member (please tick or fill in): 是 Yes 否 No 1. a. 目前身高、体重 身高 厘米 体重 公斤 Body height b. 眼、耳、鼻、喉或口腔的疾病；disease of eye, ear, nose, throat, or mouth; c. 癫痫、重症肌无力、肌营养不良症、多发性硬化症、帕金森氏综合症、肌肉萎缩、脊髓灰质炎、精神病、聋 哑、四肢机能障碍、下肢静脉曲张、智能障碍及其它类型畸形或残缺；epilepsy, myasthenia gravis, muscular dystrophy, multiple sclerosis, Parkinsonism, poliomyelitis, mental disorders, deafness, dumb, functional deficit of four limbs, varicose veins, disorders of intelligence, and any other deformity or defects; d. 血管畸形、脑动脉血管瘤、视网膜出血或剥离、视神经病变、虹膜睫状体炎、青光眼、白内障、 失明、高度近视 800 度以上、眼底病变； malformation of blood vessels, cerebral aneurysm, retinal haemorrhage or detachment, optical neuropathy, iridocyclitis, glaucoma, cataract, blindness, myopia above 800 degree, retinopathy; e. 慢性支气管炎、哮喘、肺脓肿、肺栓塞、胸膜炎、肺气肿、支气管扩张、肺结核、尘肺、矽肺； chronic bronchitis, asthma, lung abscess, pulmonary embolism, pleurisy, emphysema, bronchiectasis, pulmonary tuberculosis, pneumoconiosis, silicosis; f. 高血压病、缩窄性心包炎、心内膜炎、风湿性心脏病、先天性心脏病、缺血性心脏病、心肌梗塞、心肌肥厚、a. b. c. d. e. f. 主动脉血管瘤、脑血管意外、心律失常、心肌病； high blood pressure, constrictive pericarditis, endocarditis, rheumatic heart disease, congenital heart disease, ischemic heart disease, myocardial infarction, myocardial hypertrophy, aortic aneurysm, cerebral vascular accident, arrhythmia, cardiomyopathy; g. 肝炎病毒携带者、肝硬化、肝脓肿、肝内结石、肝炎、肝脾肿大、脂肪肝、胆囊炎、胆结石、化脓性胆管炎、 消化道溃疡、出血及穿孔、溃疡性结肠炎、胰腺炎、肛管疾病； hepatitis carrier, liver cirrhosis, liver abscess, liver stone, hepatitis, hepatosplenomegaly, fatty liver, cholecystitis, gall stone, pyogenic cholangitis, ulcer, bleeding or perforation of digestive tract, ulcerative colitis, pancreatitis, anal disorders; h. 肾炎、肾病综合症、肾功能异常、尿毒症、肾囊肿、肾下垂、尿路结石、尿路畸形； nephritis, nephrotic syndrome, abnormal renal function, uraemia, kidney cysts, nephroptosis, renal stone, deformity of urinary tract; i. 糖尿病、痛风、肢端肥大症、垂体机能亢进或减退、甲状腺或甲状旁腺机能亢进或减退、肾上腺机能亢进或减 。