美 国 利 宝 互 助 保 险 公 司 重 庆 分 公 司

LIBERTY MUTUAL INSURANCE COMPANY CHONGQING BRANCH

中国重庆市渝中区中山三路 131 号希尔顿商务中心 35 层，400015
35/F Hilton Kingrun Tower, 131 Zhongshan San Road, Yuzhong District, Chongqing, 400015,P.R.China
电话(Tel):(8623) 8903 8737 传真(Fax):(8623) 8903 9816

个人意外保险投保申请书
PERSONAL ACCIDENT INSURANCE PROPOSAL FORM
依据《中华人民共和国保险法》第十七条之规定，被保险人必须如实、详尽地填写本投保申请书。否则，由此签署的保单无效。
Statement pursuant the seventeenth Article of The Insurance law of the People’s Republic of China (or any subsequent amendments thereof) -You are to disclose
in this Proposal Form fully and faithfully all facts which you know, otherwise the Policy issued hereunder may be void.

请被保险人如实填写以下内容，并在适当的位置打;确认
Please write and tick ; clearly where applicable

I. 被保险人信息 Insured’s Information

姓名Name: 身份证号码Identity Card: 出生日期Date of Birth:

性别Sex: 联系电话Tel No.: 移动电话Cell Phone:

联系地址Address: 邮编Post code:

工作单位Company:

职业/工种Occupation:
a 在工作中您是否In the nature of your work do you:
(i) 从事车间工人管理工作Superintend manual work? …是YES …否NO
(ii) 从事手工劳作do manual work? …是YES …否NO
(iii)使用某种机器设备use any machinery? …是YES …否NO
b 您是否参与任何危险运动或活动Do you engage in any hazardous sports or activities? …是YES …否NO
如果是，请详细说明if yes, please give details
c 您是否平均一个月内有一次或多次空中旅行Do you travel by air more than once a month on …是YES …否NO
average?
如果是，请详细说明if yes, please give details
d 您是否平均每三个月内有一次或多次到其它国家的旅行Do you travel to other countries more …是YES …否NO
than once every three months?
如果是，请详细说明到访国家及频率if yes, please give details
e 您是否长期派驻其它国家工作Do you take long-term business execution in other countries？ …是YES …否NO
如果是，请详细说明到访国家及频率if yes, please give details
f 您是否拥有自己的汽车或经常驾驶汽车？Do you have your own car or drive frequently? …是YES …否NO

II. 保险经历Insurance History

a. 您在申请投保或续保任何意外保险或人寿保险时，是否曾经
Have you had any accident insurance or life assurance proposal or renewal
(i) 被拒declined? …是YES …否NO
(ii) 被撤销withdrawn? …是YES …否NO
(iii)被提高费率或需要签订特别条件subjected to an increased rate or special conditions? …是YES …否NO
如果是，请详细说明if yes, please give details
b. 您是否已经购买了其它的个人意外保险Will this insurance be additional to any other …是YES …否NO
personal accident policies?
如果是，请详细说明if yes, please give details

III. 健康Health
a. 您是否因曾遭遇意外而在过去五年中必需接受医学治疗 …是YES …否NO
Have you sustained any accidents necessitating medical attention during the last five
years?
如果是，请详细说明if yes, please give details
b. 您是否存在任何身体上的缺陷或衰弱现象，或具有某种患病的倾向？ …是YES …否NO

Personal Accident Proposal CR20051120 1

 Do you suffer from any physical defect or infirmity or have you a tendency to any ailment
or disease?
如果是，请详细说明if yes, please give details
c. 您是否曾因身体伤害向任何保险公司提出过索赔? …是YES …否NO
Have you ever made a claim against any insurer in respect of any bodily injury?
如果是，请详细说明if yes, please give details

IV. 保障范围Benefits Required Class

此栏由本公司填写
For Office Use
a. 基本保障Standard Coverage 保险金额 保费
死亡/残疾/三度烧烫伤Death/Disability/Third Degree Burns* Sum Insured Premium
*总保险金额不能超过人民币1,000,000 the amount shall not exceed 1,000,0000 ￥ ￥
b. 可选保障Optional Benefits:
1. 公共交通事故身故双倍赔偿Double Indemnity for Public Conveyance …是YES …否NO ￥
accidental death?
2. 全残补助金Accidental Total Disability Supplementary Allowance? …是YES …否NO ￥
3. 摩托车驾乘事故扩展责任批单Motor Cycling(including pillion rider)? …是YES …否NO ￥
4. 意外事故医疗费用Medical Expense*
*不能超过基本保障保险金额的50%及人民币50,000 The amount shall not exceed the
50% of the Sum Insured and RMB 50,000 ￥ ￥
5. 意外事故住院津贴（每天）Hospital Allowance (per day)*
* 金额不能超过每天人民币300 The amount shall not exceed RMB 300 per day ￥ ￥
总保费
Total Premium: ￥

V. 身故保险金受益人Beneficiary of Accidental Death Compensation

与被保险人的关系
序号 受益人姓名 受益比例% 身份证号码/出生日期
Relationship with
Sequence Name of beneficiary % Share Insured Identity Card/Date of Birth
1.
2.
3.
注：本公司仅接受指定直系亲属为受益人。
Note: Only direct relatives can be appointed as Beneficiary of accidental death compensation.

VI. 保险期限Period of Insurance

本保单有效期一年，保险责任生效时间详见保险公司正式出具的保单。
This Insurance is valid for one year. The commence date subjects to official Policy issued by the Company.

声明 DECLARATION
本人在此声明并保证以上回答及各项信息均真实无误。本人无隐瞒任何影响保险公司承保的信息，并同意本投保申请书及声明
作为本人与保险公司合同的基础。本人在此一并同意接受保险公司相关保险合同所载的保险条款、除外责任以及保险条件。
WE/I DO HEREBY DECLARE AND WARRANT the answers/information given above in every respect are true and correct and I have not withheld any information likely to
affect the acceptance of this Proposal, and I agree that this Proposal & Declaration shall be the basis of the Contract between the Company and myself and I further agree to
accept the Company's Policy subject to the terms, exclusions and conditions to be expressed therein, endorsed thereon or attached thereto.

被保险人签字Signature of Insured 销售人员签字Signature of Direct Sale

日期Date 保险公司授权人签字Signature of Company

Personal Accident Proposal CR20051120 2