AIA.COM.HK
Comprehensive accident protection exclusively for you
We assure you and your
loved ones get covered
from every angle
PROTECTION
LIFESTYLE VIP PLAN
Beneits Schedule
Beneits
Coverage (US$)
Plan 1
Plan 2
Plan 3
Accidental Death &
Dismemberment
$500,000
$1,000,000
$1,500,000
Permanent Total
Disability
$500,000
$1,000,000
$1,500,000
Overseas Double
Indemnity
$500,000
$1,000,000
$1,500,000
Accidental
Medical Expenses
Reimbursement
(max. per accident)
$10,000
$20,000
$30,000
Compassionate
Death Beneit
$1,300
$1,300
$1,300
Emergency Medical
Evacuation/
Repatriation of
Remains
Unlimited
Unlimited
Unlimited
24-hour Worldwide
Assistance
Services
Premium (US$)
One Premium Rate
for all Covered
Occupations
Plan 1
Plan 2
Plan 3
Annual Monthly Annual Monthly Annual Monthly
1,000
89
2,000
177
3,000
266
*
For Insured at work, the Aggregate Sum Assured shall not exceed 10 times of his/her
annual income.
Beneits
Accidental Death & Dismemberment
What happens if you are seriously injured or even die in an
accident? The last thing you and your family want to worry about is
the inancial burden: heavy medical costs, living expenses, housing
loans, and much more! In the unfortunate event that you suffer from
any of the losses listed below within 180 days after an accident, you
will receive:
Injury
% of the Principal Sum
1. Loss of Life
100%
2. Permanent Total Loss of Sight of Both Eyes
100%
3. Permanent Total Loss of Sight of One Eye
100%
4. Loss of or the Permanent Total Loss of Use of Two Limbs
100%
5. Loss of or the Permanent Total Loss of Use of One Limb
100%
6. Loss of Speech and Hearing
100%
7. Permanent and Incurable Insanity
100%
Injury
% of the Principal Sum
8. Permanent Total Loss of Hearing of
(a)
Both Ears
75%
(b)
One Ear
25%
9. Loss of Speech
50%
10. Permanent Total Loss of the Lens of One Eye
50%
11. Loss of or the Permanent Total Loss of Use of Four Fingers and
Thumb of
(a)
Right Hand
70%
(b) Left Hand
50%
12. Loss of or the Permanent Total Loss of Use of Four Fingers of
(a)
Right Hand
40%
(b) Left Hand
30%
13. Loss of or the Permanent Total Loss of Use of One Thumb
(a)
Both Right Joints
30%
(b) One Right Joint
15%
(c)
Both Left Joints
20%
(d)
One Left Joint
10%
14. Loss of or the Permanent Total Loss of Use of Fingers
(a)
Three Right Joints
10%
(b) Two Right Joints
7.5%
(c)
One Right Joint
5%
(d)
Three Left Joints
7.5%
(e)
Two Left Joints
5%
(f) One Left Joint
2%
15. Loss of or the Permanent Total Loss of Use of Toes
(a)
All-One Foot
15%
(b) Great-Both Joints
5%
(c)
Great-One Joint
3%
16. Fractured Leg or Patella with Established Non-union
10%
17. Shortening of Leg by at least 5 cm
7.5%
18. Third Degree Burns
Area
Damage as Percentage of Total Body Surface Area
Head
Equals to or greater than 8%
100%
Equals to or greater than 5% but less than 8%
75%
Equals to or greater than 2% but less than 5%
50%
Body
Equals to or greater than 20%
100%
Equals to or greater than 15% but less than 20%
75%
Equals to or greater than 10% but less than 15%
50%
Permanent Total Disability*
What happens if you are totally and permanently disabled within
180 days after an accident? You will lose your earning ability, you
will have dificulty in maintaining your usual standard of living and
much more... “Lifestyle VIP Plan” will pay you 1% of the Principal
Sum each month during such permanent and total disability starting
on the 13
thmonth up to a maximum of 100 months.
AH
U
AI
F6
5(0
8/
10
)
“We”, “us”, “our”, “AIA” or the “Company” as used in this brochure refers to American International Assurance Company (Bermuda) Limited (Incorporated in Bermuda with limited liability).
This brochure is only an illustrative proposal, not a contract of insurance. Please refer to the policy for exact terms, conditions and exclusions.
Overseas Double Indemnity
If you are seriously injured or unfortunately die in an accident during
a trip outside Hong Kong, Macau or your Home Country, the amount
payable of “Accidental Death & Dismemberment”/“Permanent Total
Disability” will be doubled.
Accidental Medical Expenses
Reimbursement
What happens if you are accidentally injured, causing you to incur
enormous medical bills?
“Lifestyle VIP Plan” assists you to deal
with the high medical, hospital and surgical expenses to alleviate
you from the inancial burden.
Compassionate Death Beneit
In case of death, “Lifestyle VIP Plan” will provide “Compassionate
Death Beneit”.
Emergency Medical Evacuation/
Repatriation of Remains
Essential medical advice, facilities and services may not be easily
obtained abroad. When you are seriously ill or injured while
travelling outside of Hong Kong, Macau or your Home Country,
American International Assistance Services (AIAS) will provide
en-route medical care and transportation when it is necessary to move
you to another location or back to Hong Kong for medical treatment
with unlimited coverage. In the unfortunate event that you die while
travelling, AIAS will arrange for the return of your remains back to
Hong Kong.
24-Hour Worldwide Assistance Services
As our valued customer of the “LifeStyle VIP Plan”, you will
automatically become a member of the “American International
Assistance Services” (AIAS) network which provides you with free
telephone access on such travel assistance matters of:
• Medical Advice Assistance Service
• Medicine Delivery
• Lost Baggage/ Passport Assistance Service
• Travel Emergency Legal Assistance
• Emergency Ticket Service
• Embassy and Consulate Information
• Emergency Cash Transfers
And many more…
Occupational Classes
The following Occupational Class Table is for illustration only,
please contact AIA representatives for detailed information.
Class 1
Ofice type occupations with no real hazards involved
Class 2
Jobs involving minor risks like outdoor work
Class 3
Skilled or semi-skilled occupations including those
using light machinery
Class 4
Industrial jobs using heavy machinery or unskilled jobs
One premium applies to all eligible Insureds of the above classes.
Important Notes
•
Insured must be between 16 and 65 years of age at the time of application. The plan is
renewable up to 74 years of age.
•
The highest aggregate limit for Compassionate Death Beneit is US$1,300/HK$10,000
per Insured irrespective of the number of policies carried with the Company.
•
To enjoy “Overseas Double Indemnity” and “Emergency Medical Evacuation/
Repatriation of Remains”, the Insured’s normal place of residence and/or place of
regular employment must be in Hong Kong.
General Exclusions
•
Suicide, self-inlicted injury; professional sports;
•
Pregnancy, childbirth or miscarriage;
•
Disease or illness;
•
Dental care or surgery unless necessitated by injury caused by an accident to sound
natural teeth;
•
Engaging in air travel except as a fare-paying passenger in a properly licensed private
and/or commercial aircraft;
•
In the event of an Insured who is being assaulted, murdered or suffered from any
accidental consequence caused by riot, civil commotion, strikes or making an arrest
while performing duty at work as a policeman or a member of the Correctional Services
Department;
•
In the event of an Insured who is being assaulted, murdered or suffered from any
accidental consequence caused by riot, civil commotion or strikes while performing
duty at work as a ireman;
•
In the event of an Insured who is being assaulted, murdered or suffered from any
accidental consequence caused by riot, civil commotion or strikes while performing
duty as a jewellery worker;
•
Losses directly or indirectly related to a pre-existing condition including injuries or
illnesses that occurred prior to the Policy Issue Date;
•
War or warlike operations; service in the armed forces; illegal acts, etc.
AIA.COM.HK
保障
特為尊貴的您而設之全面意外保障
我們為您和摯愛提供
全方位保障
貴族行
保障一覽
保障惠益
保額 (美金)
計劃1
計劃2
計劃3
意外死亡及斷肢賠償
$500,000
$1,000,000 $1,500,000
永久完全殘廢賠償
$500,000
$1,000,000 $1,500,000
海外雙倍賠償
$500,000
$1,000,000 $1,500,000
意外醫療賠償
(每次意外最高賠償)
$10,000
$20,000
$30,000
身故體恤津貼
$1,300
$1,300
$1,300
緊急醫療運送/
運返費用
不設限額
不設限額
不設限額
24小時全球支援服務
保費 (美金)
受保職業，劃一保費
計劃1
計劃2
計劃3
年繳 月繳 年繳 月繳 年繳 月繳
1,000
89
2,000 177 3,000 266
* 在職人士投保，總投保額之上限為個人之10倍年薪。
保障惠益
意外死亡及斷肢賠償
一旦遇上意外而嚴重受傷，甚至喪失生命，您和您的家人可
能會為繁重的經濟負擔如醫療費用、各項日常生活的大小開
支、樓宇按揭的支出等等而憂心。倘您不幸遇上意外，並在
意外後180日內導致以下創傷，可獲得下列之賠償：
創傷
基本保額之百分比
1.
喪失生命
100%
2.
永久完全喪失雙眼視力
100%
3.
永久完全喪失一眼視力
100%
4.
喪失兩肢或永久完全喪失其功能
100%
5.
喪失一肢或永久完全喪失其功能
100%
6.
喪失說話能力及失聰
100%
7.
永久及不能痊癒的精神失常
100%
8.
永久完全失聰
(a) 雙耳
75%
(b) 一耳
25%
9.
喪失說話能力
50%
10. 永久完全喪失一眼球之晶體
50%
11. 喪失任何一手四指及拇指或永久完全喪失其功能
(a) 右手
70%
(b) 左手
50%
創傷
基本保額之百分比
12. 喪失任何一手四指或永久完全喪失其功能
(a) 右手
40%
(b) 左手
30%
13. 喪失任何一手拇指或永久完全喪失其功能
(a) 右手兩節關節
30%
(b) 右手一節關節
15%
(c) 左手兩節關節
20%
(d) 左手一節關節
10%
14. 喪失任何一手手指或永久完全喪失其功能
(a) 右手三節關節
10%
(b) 右手兩節關節
7.5%
(c) 右手一節關節
5%
(d) 左手三節關節
7.5%
(e) 左手兩節關節
5%
(f) 左手一節關節
2%
15. 喪失任何一腳腳趾或永久完全喪失其功能
(a) 一腳所有腳趾
15%
(b) 拇趾兩節關節
5%
(c) 拇趾一節關節
3%
16. 腿骨或膝蓋骨折裂而不能復原
10%
17. 任何一腿畸短五厘米或以上
7.5%
18. 三級燒傷
身體部位 燒傷部份佔全身皮膚面積百分比
頭
不少於 8%
100%
不少於 5% 但少於 8%
75%
不少於 2% 但少於 5%
50%
身體
不少於 20%
100%
不少於 15% 但少於 20%
75%
不少於 10% 但少於 15%
50%
永久完全殘廢賠償*
一旦遇上意外，並在意外後180日內導致永久完全殘廢而無
法再工作，不但難於保持以往的生活水平，更甚的是要面對
長期的經濟困局...。在殘廢期間，
「貴族行」
會支付相等於
保額1%的每月賠償，最長可達100個月。首次賠償在持續殘
廢的第13個月開始支付。
*
「永久完全殘廢賠償」不適用於學生。
海外雙倍賠償
若您於海外時(除香港、澳門或您擁有公民身份之國家)遇上
意外，並嚴重受傷或不幸死亡，
「貴族行」
之「意外死亡及
斷肢賠償」/「永久完全殘廢賠償」將會雙倍計算。
意外醫療賠償
一旦遇上意外而需要龐大的醫療費用亦無需憂心。
「貴族
行」
助您應付所涉及診治的昂貴費用、住院費用及手術費，
以減輕您的經濟重擔。
於此產品簡介內，「本公司」
、
「
AIA
」或「我們」是指美國友邦保險（百慕達）有限公司（於百慕達註冊成立之有限公司）。
此產品簡介只作介紹用途，詳細保單條款及不保事項請參閱保單。
身故體恤津貼
倘不幸身故，
「貴族行」
將提供「身故體恤津貼」。
緊急醫療運送/運返費用
在海外求診，若遇上當地醫療設施不夠完善而未能獲得洽當
的醫療服務，往往令人擔憂。因此假若您旅遊或公幹時(除
香港、澳門或您擁有公民身份之國家)患重病或嚴重受傷，
需送往其他地方或送返香港治理，即使您身在偏遠的地方，
「美國國際支援服務會」亦會安排緊急醫療運送及運送途中的
醫療護理。倘您在旅途中不幸身故，「美國國際支援服務會」
可安排遺體或骨灰運返香港。
24小時全球支援服務
投保
「貴族行」
的客戶，均可自動成為「美國國際支援服務會」
會員，免費享有由該會提供的電話旅遊支援服務，包括以下
及其他多項服務：
• 醫療支援服務
• 緊急藥物運送
• 行李/旅遊證件遺失支援服務
• 緊急法律諮詢服務
• 緊急票務服務
• 大使館及領事館資料
• 緊急現金調動服務
職業等級
下表為一般職業等級指引，詳情請詢問友邦業務代表。
等級一
辦公室工作而絕無危險性的職業
等級二
具輕微危險性的職業，如經常要在戶外工作
等級三
熟練或半熟練技術人員
等級四
須使用重型機械工作之工人或一般工人
以上職業等級人士均可享劃一保費。
注意事項
• 受保成人之投保年齡須介乎16歲至65歲。本計劃可續保至74歲。
• 每名受保人獲賠償之「身故體裇津貼」，其賠償總和以受保人在本公司所持保單之同一
保障項目不超過美金1,300元/港幣10,000元為限。
• 受保人需於香港居住或工作方可獲得「海外雙倍賠償」及「緊急醫療運送/運返費
用」。
不保事項
• 自殺或企圖自致之傷害；專業運動；
• 懷孕、分娩或流產；
• 任何疾病；
• 任何形式的牙齒護理或手術，惟因意外受傷而須接受的治療不在此限(假牙及有關費用
不包括在內)；
• 參與空中飛行，以須付費之乘客身分乘搭私人持牌飛機及商業客機除外；
• 警務人員或懲教署人員被謀殺、受襲擊、於暴動或民事騷亂、罷工或進行逮捕時遇上
意外；
“LifeStyle VIP Plan” Application Form
貴族行
投保申請書
Policy No.
保單號碼
:
P
Details of Producers 營業組別 情 Agent Name 營業員 Code 編號
Area Code 辦 處 Agent Name 營業員 Code 編號
Agent’s Contact Phone Number 營業員之聯絡電 Agency Name 營業組別 Code 編號 :
IMPORTANT NOTE: You have to disclose in this application ALL material facts, which shall form the basis of the contract between you and our Company, otherwise the policy issued may be void or voidable. If you are in doubt as to whether a fact is material, please disclose it on the application.
重要指示 您與本 司之合約 以 投保申請書所填報之 實為 據，所以您必需填報 實，否則所 之保單 告無效 如您不清楚某 項是否重要，也請 項在 投保申請書 說明
PLEASE TYPE OR PRINT IN ENGLISH BLOCK LETTERS. 請以英文 楷填寫
* Please delete if not applicable. 請 去不適用者
A.
PERSONAL DETAILS OF THE PROPOSED INSURED
準
保人資料
D.
DETAILS OF APPLICANT (OWNER) ; IF OTHER THAN THE PROPOSED
INSURED
申請人
(
保單持
人
)
資料
倘與準
保人不
1.
Full Name (as shown on I.D. Card/Passport. Please underline the Family Name.)
以身 證
/
護照所載為準，並請於 氏
橫線
1. Full Name (as shown on I.D. Card/Passport)
以身
證
/
護照所載為準
:
a. English
英文
:
2.
Relationship to the Proposed Insured
與準 保人關
:
b. Chinese
中文
:
3.
a. I.D. Card/Passport* No.
身 證
/
護照
*
號碼
:
2.
a. I.D. Card/Passport* No.
身 證
/
護照
*
號碼
:
b. Date of Birth
出生日期
:
/ /
c. Age
年齡
:
b. Date of Birth
出生日期
:
/ /
c. Age
年齡
:
M / D日 / Y年M / D日 / Y年
3.
a. Sex
性別
:
Male
男
Female
女
4.
a. Sex
性別
:
Male
男
Female
女
b. Citizenship (if other than Hong Kong SAR)
民身
若非香港特別行政
:
b. Citizenship (if other than Hong Kong SAR)
民身
若非香港特別行政
:
c. Nationality
國籍
:
c. Nationality
國籍
:
U.S. Citizens or Residents, please give U.S. Taxpayer I.D. No.美國 民或居民請填寫美國繳稅人身
證號碼
:
U.S. Citizens or Residents, please give U.S. Taxpayer I.D. No.
美國 民或居民請填寫美國繳稅人身 證號碼
:
4.
a. Residential Address
住址
:
E.
HEALTH AND OTHER DETAILS OF THE PROPOSED INSURED
準
保人之健康
資料
情
1.
What other personal accident, life and/or hospital insurance do you carry or have
applied for?
您現時是否擁
或 在申請
個人意外
人壽
/
或住院保險
?
Contact Telephone Numbers
電
號碼
:
b. Office
司
:
c. Home
住宅
:
Plan Name
Company
Sum Assured (HK$)
Date Issued
計劃
稱
承保
司
保額
(
港幣
)
生效日期
d. Mobile
手電
:
e. Fax
傳真
:
f. Email address
電郵地址
:
5.
Marital Status
婚姻狀況
:
Single
未婚
Married
已婚
Widowed
鰥寡
Divorced
離婚
2.
Do you have any physical defects, disability, impairment, deformities and/or any condition
affecting mobility, sight, speech and/or hearing? If “Yes”, please provide details below.
您是否 任何身體損傷 殘
殘障
缺陷
/
或
狀況而影響行動 視覺
說
能力
/
或聽覺
?
若 ，請在以 空間提供 細資料
6.
a. Name of Employer
僱主
稱
:
b. Nature of Business
業務性質
:
c. Business Address
辦 處地址
:
YES
是
NO
否
d. Occupation Title
職位
:
3.
Are you left-handed?
您是否左手慣用者
?
YES
是
NO
否
e. Exact Duties
職務
:
F.
FINANCIAL DETAILS OF THE PROPOSED INSURED
準
保人之財政資料
This section serves the purpose of “Large Amount Questionnaire”. Separate “Large
Amount Questionnaire” is not required.
部份為 大額問卷 ，客戶無須另填
大額問卷
f. No. of Years with the Company
任職年期
:
g. No. of Employees in the Company
司人數
:
1.
Income Particulars
入息資料
:
Based on the annual salary during the past 3 years, the proposed Insured’s annual salary
is within the range of (or in HK$ equivalent)
以過往
3
年之每年收入為準，準 保人 年總收入
(
或相等之港幣
)
Note: The Insured must notify the Company of any change in his/her occupation, duties and pursuits resulting in a higher risk of being involved in an accident.
倘 保人之職業 職責或 消遣 任何改變，因而增 遭 意外之可能， 保人必須即時知會本 司
US$50,000 - US$99,999
applicable to Plan 1
適用於計劃
1
7.
Send Correspondence to
聯絡地址
:
Residence
住址
Business Address
辦
處
US$100,000 - US$149,999
applicable to Plan 1-2
適用於計劃
1 2
B.
DETAILS OF THE “LIFESTYLE VIP PLAN” APPLIED FOR
貴族行
申請
情
exceeds or equal to
超過或相等於
US$150,000
applicable to Plan 1-3
適用於計劃
1 3
1.
Please put a
9
at the appropriate box to indicate the plan level applied for and
the mode of payment.
請在適當的方格
9
以指示投保的計劃 保費繳付形式
* For Insured at work the Aggregate Sum Assured shall not exceed 10 times of his/her annual income.
在職人士投保，總投保額之 限為個人之10倍年薪
Premium (US$)
保費
(
美金
)
2.
Assets
資產
:
Address
地址
:
PLAN 計劃 1 PLAN 計劃 2 PLAN 計劃 3Annual 年繳 Monthly 繳 Annual 年繳 Monthly 繳 Annual 年繳 Monthly 繳
1,000
89
2,000
177
3,000
266
Date of Purchase
購買日期
:
(For monthly payment, Applicant is required to pay for the initial 3-month premium. Please complete a Direct Debit
Authorization For Bank Account” or “Direct Debit Authorization For Credit Card Account” and attach with this
application form. 繳者必須預繳首3個 之保費，請填妥 銀行戶 直接付款授權書 或 信用卡戶 直接付款授權
書 ，連 投保申請書 併遞交 )
Purchased Price
購入價
:
Current Value
現值
:
2.
Initial premium amount paid in respect of “LifeStyle VIP Plan” applied for
預繳
貴族行 之保費
:
Owned Residence
自置
Rent Residence
租用
US$
美金
元
for
共
months
個
No. of cars owned
擁 多少部汽車
:
The above information will be used in strict confidential by our Company.
本
司 以
所提供之資料絕
保密
C.
DETAILS OF BENEFICIARY
益人資料
1.
Full Name (as shown on I.D. Card/Passport)
以身 證
/
護照所載為準
:
Note:
For aggregate sum assured exceeds US$1,000,000, the Proposed Insured is required to provide financial supporting documents, such as audited company accounts, notice of salaries tax, bank deposits, or other proof of income and assets.
若投保額超過US$1,000,000，準 保人投保時須遞交經 證之 司賬目 入息稅通知書 銀行存款證明 或 入息 資產 證明
2.
Relationship to the Proposed Insured
與準 保人關
:
Own Estate 遺產繼承人
(If there is no beneficiary designated above, the policy proceeds will be paid to the Owner if the Owner is alive, otherwise to the successor to the Owner's Estate. 如 述並沒 任 益人，而保單持 人尚存，保單 益
屬保單持 人，否則保單 益 屬保單持 人遺產的繼承人 )
DETAILS OF THE “LIFESTYLE VIP PLAN” APPLIED FOR
貴族行
申請
情
“LifeStyle VIP Plan” Application Form
貴族行 投保申請書
Policy No.
保單號碼
P
G.
REMARKS
附註
DECLARATION AND AUTHORIZATION
I/We hereby understand that:
(a) No information or representation made or given by or to any person shall be binding on American International Assurance Company (Bermuda) Limited (hereafter called “the Company”) unless it is in writing and is presented to and approved by the
Company.
(b) All written information provided by me/us in this application form and in the Company issued questionnaires or other documents signed by me/us in connection with this application and statements and answers made to the Company’s medical examiners
are full, complete and true and I/We understand that the Company, believing them to be such, will rely and act on them, otherwise any policy issued hereunder may be void.
(c) All information and documents provided by me/us (as defined under “(b)”) together with the relevant policy issued shall constitute the entire contract between myself/ourselves and the Company.
(d) Any payment made in connection to this application does not guarantee immediate approval of the coverage applied. This insurance coverage applied for shall only take effect where the relevant policy has been issued and delivered to me/us and the first
premium duly paid during my/the Proposed Insured’s lifetime and good health.
(e) In the event of difference arising in respect of this application form, the English version which is the basis of all policies issued pursuant to this application form is considered absolute and binding.
(f) I/We DECLARE and AGREE that any personal data and other information relating to me/us or my/our policy(ies) or investments contained in this application or collected, obtained, complied or held by the Company by any means from time to time may
be used, maintained, processed, stored, transferred, disclosed and/or shared by the Company for the purposes of processing, administering, implementing and effecting the requests or transactions contemplated in this application or any other applications made by me/us from time to time, promoting or providing subsequent or other services or products to me/us, direct marketing, data matching and/or communicating with me/us. I/We further DECLARE and AGREE that the Company may transfer, disclose, grant access of or share such personal data and other information to or with individuals, entities and/or organizations associated with the Company and/or to or with third parties (including, without limitation, reinsurance companies, claims investigation companies, industry associations or federations, fund management companies, financial institutions, or service providers) selected by the Company, in each case whether within or outside of Hong Kong, for any of the aforesaid purposes and/or for the purposes of providing administrative, data processing, data maintenance or storage, telecommunications, computer, payment or other services to the Company in connection with the operation of its business. I/We understand that I/we have the right to obtain access to and to request correction of my/our personal data held or controlled by the Company. Such request can be made to any of the Company’s Customer Service Centres. If I/we do not wish to receive marketing information or materials, I/we will send an opt-out notice to the Company, in which case my/our personal data and other information would be included in a centralized customer opt-out list that may be shared amongst the Company’s associated partners for reference.
(g) *By purchasing this policy and signing below, I / we represent that I / we are not a U.S. person for purposes of U.S. federal income tax and that I / we are not acting for, or on behalf of, a U.S. person.
*Note: A false statement or misrepresentation of tax status by a U.S. person could lead to penalties under U.S. law. If your tax status changes and you become a U.S. citizen or resident, you must notify us within 30 days. (Clause (g) above is not applicable to U.S. citizens or residents, who must complete IRS Form W- 9.)
(h) I / We confirm and acknowledge that:-
- I / We shall be responsible for observing and complying with any applicable law, regulatory policy and / or other statutory requirement of the country of my / our citizenship, residence or domicile.
- If in doubt, I / we shall consult independent professional advisers concerning possible tax, legal or regulatory consequences of purchasing, holding, withdrawing, redeeming or otherwise disposing the policy issued or exercising any rights of the policy.
- I / We may be required to redeem, surrender or withdraw from the policy if the Company becomes aware that the policy issued is owned directly or beneficially by any person in breach of any applicable law, regulatory policy and / or other statutory
requirement of any country.
- Should I / we be compelled by any applicable law or authority to redeem, surrender or withdraw from the policy, I / we shall bear any costs or loss incurred as a result of such redemption, surrender or withdrawal.
(i) I / We agree to indemnify the Company in respect of any false or misleading information regarding my / our nationality, residence or tax status.
(j) By purchasing this policy, I / we confirm that I / we am / are acting solely on my / our own behalf and not acting on behalf of others in respect of the policy to be issued. In the event that I / we am / are acting on behalf of another person, without limitation,
as trustee, nominee or agent, I / we agree to provide any documentation including but not limited to any copies of identification documents of the principal / beneficial owner and any documentary proof of my / our legal capacity and authority in so acting.
(k) By signing this application below, I / we confirm that the agent / broker or any representative of the Company has solicited insurance business from me / us in Hong Kong SAR and that the signing of this application form has taken place in Hong Kong
SAR.
Furthermore, I hereby irrevocably authorize:
(a) Any organization, institution, or individual that has any record or knowledge of my/the Proposed Insured’s health and medical history or any treatment or advice and that has been or may hereafter be consulted to disclose to the Company such
information. This authorization shall bind my/the Proposed Insured’s successors and remain valid notwithstanding my/the Proposed Insured’s death or incapacity in so far as legally possible. A photocopy of this authorization shall be as valid as the original.
(b) The Company or any of its approved medical examiners or laboratories to perform the necessary medical assessment and tests to underwrite and evaluate my/the Proposed Insured’s health status in relation to this application and any claim arising
therefrom. These tests may include, but are not limited to, tests for cholesterol and related blood lipids, diabetes, liver or kidney disorders, acquired immunodeficiency syndrome (AIDS), infection by any human immunodeficiency virus (HIV), immune disorders or the presence of medications, drugs, nicotine or their metabolites.
_
聲明 授權
本人/我們現明白:
(a) 除以書面形式及經美國友邦保險(百慕達)有限公司(以下稱 貴公司 )發表和批准外，任何其他人士所發表或收到的資料或陳述，貴公司毋須負責。
(b) 本人/ 們於 投保申請書 填寫的資料， 與 投保申請書 關 經本人/ 們簽署，並由貴 司 的問卷或 文件， 本人/ 們 貴 司驗身醫生所作的陳述和答案，乃完 真實，本人/ 們亦明 貴 司以 述資料為依據，審 投保申請 書 如 述資料不屬實，任何 據 投保申請書 的保單，可被視作無效
(c) 本人/ 們提供的任何資料 文件 (如 (b) 所界定的) 關之保單， 為本人/ 們與貴 司之間所簽署合約之 部
(d) 與本投保申請書 關的任何付款，並不保證 申請可即時生效，而所申請之保障 會在保單 出 已繳清首期保費 ，並於本人/準 保人身體健康之情況 遞交 本人/ 們，方為生效
(e) 如 依據本投保申請書而 之所 保單 生異議時，則以英文原本為準
(f) 本人/ 們現聲明並 意貴 司可使用 保留 處理 儲存 轉交 透露 /或共用貴 司所收集 索 整理或保留在 申請表所載或從 途徑 得之任何 關本人/ 們的個人資料或 關本人/ 們的保單或投資資料，用作處理 管理 落實 實 行在 申請表所載或本人/ 們從任何 申請表所提出之要求， 介紹或提供 稍 或 的服務或產品予本人/ 們 直接 銷 資料 /或聯絡本人/ 們之用途
本人/ 們再聲明並 意貴 司可向與貴 司 關的本港或海外的人士 團體 /或機構 /或任何被選的第 機構 包括並不限於再保險 賠償調查 司， 關的行業協會/聯會 基金管理 司 金融機構或提供 關服務之 司 轉交 透露 授權 得 或共用本人/ 們之個人或 資料，用作以 列明之用途 /或貴 司業務運作之用，包括行政 資料處理 資料保存或儲存 通訊 電腦 付款或 服務
本人/ 們明 到本人/ 們 權向貴 司查閱 申請更改貴 司儲存或管理與本人/ 們 關的個人資料 關的申請可於貴 司任何 間客戶服務中心辦理 若本人/ 們不想收到貴 司的銷售資料或刊物，本人/ 們會出信函通知貴 司，而本人/ 們的個人或 資料會存於貴 司之中央資料檔 的非聯絡客戶 單，並會供貴 司 關人士/機構作參考
(g) * 就 關購買 保單 於 方簽署，本人/ 們聲明，就美國聯邦薪俸稅而言，本人/ 們並非美國人， 並不代表美國人行
* 備注﹕ 據美國法 ，任何美國人就 稅務狀況 虛假或失實陳述， 會 到刑罰 若閣 的稅務狀況 更改，並且 為美國 民或居民，請於 日 通知本 司 美國 民或居民必須填寫IRS之W-9表格，而以 g 欄 之 關條款並不適 用
(h) 本人/ 們確認 知悉 -
-本人/ 們 責任遵守就本人/ 們為 民或居民或作為住所的國家之 關法 監管政策 /或 法例要求
-本人/ 們如 疑問，本人/ 們 徵詢獨立 業顧問 關購買 持 提款 贖回或以 方式處置所 保單或行使保單 的權 可能引 的稅務 法 或法規 的 果 -如貴 司 現所 保單因由任何人 直接或實益擁 而 反任何國家之適用法例 監管政策 /或 法例要求，本人/ 們可被要求贖回或退保 保單或被要求作出提款 -如本人/ 們被 關法例或監管機構強制贖回或退保 保單或作出提款，本人/ 們願意承擔因 而引 的費用或損失
(i) 就 關本人/ 們之國籍 居住地或稅務狀況，如 任何虛假或誤 資料，本人/ 們 意 貴 司作出賠償
(j) 藉購買 保單，本人/ 們確認本人/們是僅以按本人/ 們的 義行 ，並不是代表 人購買 保單 倘若本人/ 們是代表人行 ，不論作為信 人 代 人或代理人，本人/ 們 意提供任何文件，包括但不限於任何 人/實益擁 人的身 證明 文件副本 任何授予本人/ 們 法 身 和授權的證明文件
(k) 就簽署 投保申請書，本人/ 們確認貴 司的保險營業員/經紀或 代表是在香港特別行政 向本人/ 們推銷保險業務，而 申請書亦是在香港特別行政 簽署 再者，本人茲授權 :
(a) 任何知悉或擁 本人/準 保人之健康狀況 病 或任何治療或諮詢 錄， 為或 為本人/準 保人 治之機構 組 或人士 向貴 司透露 關資料，不得撤回 即使本人/準 保人死亡或喪失能力， 授權書仍然存 法 效力，而本人/準 保人之 繼承人亦會 授權書約束 授權書之 本與副本 屬 效
(b) 貴 司或任何 認可之驗身醫生或 驗所， 本人/準 保人進行所需之醫療評估測試，並 本人/準 保人之健康狀況進行審 評估，作為處理本申請 與之 關的賠償 宜，不得撤回 等 驗會包括，但並不限於膽固醇 關之血脂肪 糖 尿病 腎或肝 能失常 愛滋病或感染人體免疫力缺乏病毒 免疫系統失常或體 藥物 毒品 尼 代產物之含量等 驗
CANCELLATION RIGHT AND REFUND OF PREMIUM(S)
撤銷保單
退還保費
I understand that I have the right to cancel and obtain a refund of any premium(s) paid by giving written notice. Such notice must
be signed by me and received directly by the Customer Service Centre of American International Assurance Company (Bermuda)
Limited at 12/F, AIA Tower, 183 Electric Road, North Point, Hong Kong within 21 days after the delivery of the policy or issue of a
Notice to me or my representative, whichever is the earlier.
本人明
，本人
權以書面通知撤銷
保單並
回已繳保費
關書面
通知必須由本人簽署，並確保由交付新保單予本人或本人的代表
或
出通知書予本人或本人的代表
起計
天
(以較先者
為準)，呈交
香港
角電氣
號
邦
場
樓之美國
邦保險
慕
限
司客戶服務中心
Signed at
Hong Kong SAR
香港特別行政
on
Please do not sign on blank form
請勿在空 表格
簽署
簽署於
Place
地方
日期
M D
Y
Signature of the Proposed Insured
準
保人簽署
日
年
(whose age is 18 or above 18歲或以 人士必須簽署)
_
_
Signed at
Hong Kong SAR
香港特別行政
on
Please do not sign on blank form
請勿在空 表格
簽署
簽署於
Place
地方
日期
M D
Y
Signature of the Applicant (Owner); If other than the Proposed Insured
申請人 (保單持
人) 簽署
倘與準
保人不
日
年
I certify that the information and facts stated above are actually furnished by the Proposed Insured and/or Applicant (Owner) on the date of this application.
本人證實以 資料均由準 保人 /或申請人(保單持 人)提供 填報於投保申請書的簽署日
Signed at
Hong Kong SAR
香港特別行政
on
Signature of Agent(s)/Broker(s) as Witness
簽署於
Place
地方
日期
M D
Y
營業員/經紀 (即見證人) 簽署
日
年
Company Endorsement Only
司批
SL-VPA1, SL-VPA2, SL-VPA3
SL-WSVPA1, SL-WSVPA2, SL-WSVPA3
First Premium Payment must accompany Application. All cheques must be payable to “American International Assurance Company (Bermuda) Limited”.
首次保費須連 投保申請書 併遞交 所 支票抬頭請填寫 美國 邦保險( 慕 ) 限 司
