選卓越個人醫(yī)療保障投保書全面醫(yī)學(xué)問卷

1、安盛天平': 95550:保險“ 卓越 ”個 人 醫(yī) 療 保 障 計(jì) 劃 投保書 I n d i v i d u a l S M A R T C A R E E X C L U S I V E H e a l t h I n s u r a n c e A p p l i c a t i o n F o r m重要注釋 Important Notes：1.在填寫本投保申請前，您可以要求業(yè)務(wù)向您提供保險條款。請仔細(xì)閱讀條款，尤其是除外責(zé)任、賠償限額、免賠額、審閱期、保險責(zé)任終止等黑體字標(biāo)注的條款內(nèi)容，并聽取業(yè)務(wù)的說明，如對業(yè)務(wù)的說明有不明白或有異議的，請?jiān)谔顚懕就侗沃跋驑I(yè)務(wù)進(jìn)行詢問，

2、如未詢問，視同已經(jīng)對條款內(nèi)容完全理解并無異議。Please ask youral consultant for the insurance clause before fill in this application form. Please carefully read the clause, especially for policyexclusions, annual limit, deductible, free-look period, cancellation/termination of cover, and the others which are all highlighte

3、d in bold. You can enquire of your consultant if need any clarification before fill in this application form, otherwise you are deemed to fully understand the clause and have no objection.2. 請如實(shí)填寫本表內(nèi)容并確定所填寫的內(nèi)容全部正確無誤，根據(jù)保險法和相關(guān)規(guī)定，如您未履行如實(shí)告知義務(wù)，則可能會導(dǎo)致保險合同被解除或者本公司不承擔(dān)相關(guān)保險責(zé)任。Under Insurance Law or any subseq

4、uent amendment, you are to disclose in the Application form, fully and faithfully, all the facts which you know or ought to know, otherwise the policy issued may be void.3. 投保人對被保險人應(yīng)當(dāng)具有保險利益，否則依據(jù)保險法合同無效。A policyholder shall own the insurable interest in the objects of insurance, otherwise the insuran

5、ce contract shall be invalid.4.本投保單為保險合同的重要組成部分。請用筆簽字?；蚝谏P以中文或英文正楷填寫，不得涂改，并由投保人、被保險人（或其法定監(jiān)護(hù)人）親This application form is an important part of the insurance contract. Please fill in it inor English block letters with blue or black ink, and shall notalter. There must be handwritten signature of the po

6、licyholder and the insured(s) (or legal guardian).5.請完整填寫下列所有問題，并在適當(dāng)?shù)目崭駜?nèi)填上“X”，遺漏，則該問題被視為回答“否”。Please complete this form by answering carefully all questions and “X” the boxes where appropriate. Any question not answered on this form will be taken as an answer in the negative.6.退保時，若保險期間內(nèi)無理賠，則按條款列明的退

7、費(fèi)比例退還保費(fèi)。若已有理賠，則退還保費(fèi)為零。For cancellation, premium will be refund according to “premium refund table” stated in the clause provided that no claims have been made during the insurance period. No premium refund if any claim has been made.7.對于直接服務(wù)，任何計(jì)算錯誤或不屬保障范圍的項(xiàng)目，您有義務(wù)接受理賠款的最終調(diào)整。For direct billing service

8、, you are obligated to accept the final adjustment in charges and actions if there is any miscalculation or uncovered item according to the terms and conditions of the Policy.8.若任何被保險人停止在中國居住超過連續(xù)三的話，請及時通知本公司。本公司保留改變保費(fèi)或拒絕承保的權(quán)利。Please inform us immediately if any of the insureds leave China for a peri

9、od of three consecutive months. We reserve the right to revise the premium or to decline.9.投保時請?zhí)峁┩侗Ｈ思八斜槐ｋU人的有效的護(hù)照或件復(fù)印件。Please provide valid passport / ID copy of policyholder and all the insureds.10.請您了解本公司的償付能力充足率已達(dá)到了監(jiān)管要求，若需進(jìn)一步了解本公司最新季度的償付能力信息及風(fēng)險綜合評級結(jié)果，安盛天平保險公司官網(wǎng)，該信息可以作為您決定是否投保的參考信息。Please be aware

10、 that the insurers solvency ratio is well matched with regulatory requirements. For detailed information if needed in the insurers solvencyreport and comprehensive risk rating report in the latest quarter, please access to the insurers official website information can be taken as significant referen

11、ce when applying for the insurance. The solvency related11.若英文譯本與中文有異，以中文版本為準(zhǔn)。Should there be any inconsistencies betweenand English versions, theversion shall prevail.第一部分 投保人信息（如您的通訊地址有所更改，請及時通知我們）Part 1 Particulars of Policyholder (please keep us informed of any change of your address.)(IDH-essen

12、tial 2017.7)Page 1 of 5(必須與或護(hù)照相同)：Name (as on ID or passport):國籍：Nationality:Gender:男M女 F狀況 Marital Status： 單身 Single已婚 Married通訊地址：Correspondence Address:：Post Code:件或護(hù)照號碼：Passport or ID #:出生日期（日/月/年）Date of Birth (dd/mm/yyyy)行業(yè)及職業(yè)/職位：Industry and Occupation/ Job Position:您目前在中國是： 工作生活學(xué)習(xí)Currently y

13、ou arefor:workinglivingstudying手提：Mobile No.:電子郵箱：:第二部分 主被保險/附屬被保險人信息（投保人應(yīng)當(dāng)對下列被保險人具有保險利益，附屬被保險人應(yīng)當(dāng)為主被保險人的家屬，即配偶和）Part 2 Particulars of Main Insured / Insureds (The policyholder shall own the insurable interest in the objects of insurance. The Insuredsshall be the Main Insureds spouse and/or children）

14、注 Note：1. 未滿 6 周歲的必須與父親或母親一起投保； 6 周歲至 18 周歲的可由父親或母親作為投保人單獨(dú)受保。Children under 6 years old must be enrolled together with the parent(s); children from 6 to 18 years old could be the main insured alone provided the policyholder is the parent.2. 首次投保的為出生后 15 天至 65 周歲，續(xù)保最高可至 99 周歲。Entry age is from 15 day

15、s to 65 years old, and can renew up to 99 years old.3. 附屬被保險人應(yīng)為主被保險人的配偶或，且附屬被保險人的保障范圍及承保區(qū)域不得高于主被保險人的保障范圍及承保區(qū)域。Dependents are the main insured's spouse / child(ren), and the dependents' coverage and benefits must be equivalent or lower than the main insured's.Page 2 of 5 (IDH-essential 20

16、17.7)AXA Tianping Property & Casualty Insurance Company Limited主被保險人Main Insured附屬被保險人1 Insured1附屬被保險人2 Insured2附屬被保險人3 Insured31)Name2)Gender3)或護(hù)照號碼ID or Passport NO.4) 出生日期（日/月/年）Date of Birth (dd/mm/yyyy)5) 國籍Nationality6) 身高 / 體重Height (cm) / Weight (kg)7) 行業(yè)及職業(yè)/職位Industry and Occupation / J

17、ob Position8) 目前在中國是： Currently you are for:工作 Working 生活 living 學(xué)習(xí) Studying工作 Working生活 living學(xué)習(xí) Studying工作 Working生活 living學(xué)習(xí) Studying工作 Working生活 living學(xué)習(xí) Studying9) 關(guān)系說明Relationship與投保人關(guān)系Relationship to Policyholder本人 Policyholder配偶 SpouseChild父母 Parent其它 Other 與主被保險人關(guān)系Relationship to Main Insur

18、ed配偶 SpouseChild與主被保險人關(guān)系Relationship to Main Insured配偶 SpouseChild與主被保險人關(guān)系Relationship to Main Insured配偶 SpouseChild10) 您吸煙嗎？Are you a Smoker?是，有年吸煙史Yes,Years of Smoking否 No是，有年吸煙史Yes,Years of Smoking否 No是，有年吸煙史Yes,Years of Smoking否 No是，有年吸煙史Yes,Years of Smoking否 No11) 保險計(jì)劃選擇Insurance Plan Selected計(jì)

19、劃Essential Plan 臻選計(jì)劃Essential Plus Plan計(jì)劃Essential Plan 臻選計(jì)劃Essential Plus Plan計(jì)劃Essential Plan 臻選計(jì)劃Essential Plus Plan計(jì)劃Essential Plan 臻選計(jì)劃Essential Plus Plan12) 免賠額選擇Deductible Selected住院無免賠Inpatient Nil Deductible住院 15,000 免賠Inpatient 15,000 Deductible住院無免賠Inpatient Nil Deductible住院 15,000 免賠Inpa

20、tient 15,000 Deductible住院無免賠Inpatient Nil Deductible住院 15,000 免賠Inpatient 15,000 Deductible住院無免賠Inpatient Nil Deductible住院 15,000 免賠Inpatient 15,000 Deductible13) 年繳保費(fèi)() Annual Premium(RMB)注釋: 保費(fèi)以我司出具的保單為準(zhǔn)，詳細(xì)請我司當(dāng)時現(xiàn)行有效的費(fèi)率表。Note: The premium should subject to the policy. For details, please refer to t

21、he in force premium table at that time.第三部分 醫(yī)療問卷Part 3 Medical QuestionnairePart A -請務(wù)必如實(shí)您的個人健康狀況。遺漏，則該問題被視為回答“否”。You must declare your medical history fully and faithfully. Any question not answered on this form will be taken as an answer in the negative.Page 3 of 5 (IDH-essential 2017.7)AXA Tianpi

22、ng Property & Casualty Insurance Company Limited請每位被保險人根據(jù)下列問題選擇“是/否”中的一項(xiàng)。Please consider the following questions as they apply to each of the insureds. Answer each question by clearly ticking one of the corresponding Yes/No boxes and completing the details where required.主被保險人MainInsured附屬被保險人1

23、Insured1附屬被保險人2 Insured2附屬被保險人3 Insured31.是否有任何生理缺陷或畸形、先天性疾病、遺傳性疾病、發(fā)育異常？Has any one of the applicants ever had any physical defects or infirmity, or abnormality, or congenital conditions, or hereditary conditions, or heteroplasia?是否YesNo是否YesNo是否YesNo是否YesNo2.任何被保險人是否 Has any one of the applicants e

24、ver,2-a).曾經(jīng)住過院或接受過護(hù)理或做過外科手術(shù)？Stayed in a hospital or nursing home or had a surgical operation?是否YesNo是否YesNo是否YesNo是否YesNo2-b).被診斷需要做醫(yī)療檢查、住院或手術(shù)，但以上各項(xiàng)均還未實(shí)施？Been advised to have any diagnostic test, hospital confinement or surgical operation which has not yet been performed?是否YesNo是否YesNo是否YesNo是否YesNo

25、3.任何被保險人是否曾經(jīng)患有或 知或正在接受由于以下任何 而需要接受任何治療或觀察：Has any one of the applicants ever had or been told to have, or currently undergoing any medical treatment for, ever been treated for, under observation for any of the following conditions :3-a).哮喘、過敏癥、慢性支 炎、 、肺結(jié)核、呼吸 、肺部疾病、或其它呼吸系統(tǒng)疾病？Asthma, allergy, chronic

26、bronchitis, hemoptysis, tuberculosis, dyspnea, any lung trouble, or the other troubles related to respiratory system ?是否YesNo是否YesNo是否YesNo是否YesNo3-b). 耳、眼、鼻、喉、口腔疾病、皮膚疾??？Ears, eyes, nose, throat and nonnasality troubles, skin condition ?是否YesNo是否YesNo是否YesNo是否YesNo3-c).胸痛、心律失常、心肌炎、心絞痛、心臟病、靜脈曲血脂、高血壓、

27、或其它心臟疾??？Chest pain, arrhythmia, myocarditis, angina pectoris, any heart trouble, varicose vein, hyperlipidemia, hypertension, or the other troubles related to heart and vascular system ?是否YesNo是否YesNo是否YesNo是否YesNo3-d).中風(fēng)、癲癇、神經(jīng)系統(tǒng)疾病、腦部疾??？Stroke, epilepsy, neurological disease, disease of the brain ?是

28、否YesNo是否YesNo是否YesNo是否YesNo3-e).胃、食管、腸、肝臟、膽囊、胰腺、腎、消化性潰瘍、疝氣、或其它消化系統(tǒng)疾病、生殖泌尿系統(tǒng)疾?。縎tomach, oesophagus, bowel, liver, gall bladder, pancreas, kidney, bladder, prostate, peptic ulcer, hernia, or the other troubles related to digestive system and genitourinary ?是否YesNo是否YesNo是否YesNo是否YesNo3-f).、痛風(fēng)、甲狀腺疾病或其它

29、內(nèi)系統(tǒng)疾??？ Diabetes, gout, hypothyroid disease, or the other troubles related to endocrine system ?是否YesNo是否YesNo是否YesNo是否YesNo3-g).風(fēng)濕、關(guān)節(jié)炎、四肢、肩、頸、背部、脊椎、骨骼、關(guān)節(jié)、肌肉？Rheumatism, arthritis, limbs, shoulder, neck, back, spinal, skel, joints, muscle ?是否YesNo是否YesNo是否YesNo是否YesNo3-h).腺腫大、 、良性或 、血液紊亂、心理 、精神疾?。縀nl

30、arge glands, cancer, any form of tumor, disorder of the blood, mental health disorder, psychiatric ?是否YesNo是否YesNo是否YesNo是否YesNo3-i).成癮、吸毒及其相關(guān)癥狀？alcoholism, drug addiction, druggy, AIDS, HIV, any AIDS related condition ?是否YesNo是否YesNo是否YesNo是否YesNo3-j).女性適用( 15歲及以上)：Apply to female insureds (15 year

31、s old and above）:乳腺炎、乳腺增生、乳腺腫瘤、 內(nèi)膜異位癥、 肌瘤、 囊腫、盆腔炎、宮頸檢查異常、 失調(diào)、異常 、或其它乳腺疾病和女性生殖系統(tǒng)疾病 ? Mastitis, fibroadenoma, endometriosis, myoma of uterus, ovarian cyst, pelvic inflammation, cervical disease, menstrual disorder, abnormal bleeding, or the other troubles related to breasts and female generative organ

32、s?是否YesNo是否YesNo是否YesNo是否YesNo3-k).兒童適用（3周歲及以下）：Apply to child (within 3 years old) :生長發(fā)育異常、先天性或遺傳性疾病、畸形、智能低下？ Heteroplasia, congenital conditions, hereditary conditions, abnormality, amentia?是否YesNo是否YesNo是否YesNo是否YesNo4.以上未提及的其它病癥？Any other conditions not mentioned above ?是否YesNo是否YesNo是否YesNo是否Ye

33、sNo5.是否有雖然沒有去醫(yī)院接受檢查但感覺到的任何疾病癥狀？Has any of the applicants experienced any symptoms but not consulted a medical practitioner?是否YesNo是否YesNo是否YesNo是否YesNo6.是否打算近期因健康問題去咨詢醫(yī)生或相關(guān)專業(yè) ？Does any one of the applicants have any known or foreseeable need to consult any doctor or other health professional?是否YesNo

34、是否YesNo是否YesNo是否YesNo7.近兩年內(nèi)有無體檢？若有，請附上最新的體檢報告。Has any one of the applicants had any Physical Examination in the past 2 years? If yes, please provide the latest medical check-up report.是否YesNo是否YesNo是否YesNo是否YesNoPart B - (需要請另附紙張 If more space is required, please continue on a separate sheet of pape

35、r.)如在上一部分回答“是”的項(xiàng)目，請?jiān)谙铝斜砀裰辛忻骶唧w的健康狀況（或診斷的癥狀）。This part applies if you have indicated “yes” replies in Part A. Please disclose all medical conditions (or undiagnosed symptoms) to which these replies are intended to apply.Part C - 請列明被保險人在過去 5 年中最常用的醫(yī)生/醫(yī)院。如果不適用，請?zhí)顚憽盁o”。Doctors/Hospitals most frequently u

36、sed in the last 5 years. Please fill in “N/A” if not applicable.如以上任何問題回答“是”，請?jiān)谙路搅忻髟敿?xì)資料（包括保險公司名稱、險種名稱）。If the answer to any of the above questions “YES”, please provide details below (including Name of the Insurance Company).第四部分 爭議解決方式Part 4 Dispute Resolution請選擇一種爭議解決方式：Please choose one of the wa

37、ys below for dispute resolution:1. 提交中國國際貿(mào)易仲裁委員會China International Economic and Trade Arbitration Commission, Shanghai Commission2. 有管轄權(quán)的裁決Courts having jurisdiction for judgment.若您不做選擇，則保險合同爭議方式默認(rèn)為第二種。If you do not make the choice, the second one shall be the implied dispute resolution.Page 4 of 5

38、 (IDH-essential 2017.7)AXA Tianping Property & Casualty Insurance Company LimitedPart D - 請回答以下問題：Please answer each of the questions below:主被保險人Main Insured附屬被保險人1 Insured1附屬被保險人2 Insured2附屬被保險人3 Insured31.被保險人是否持有仍然生效的人壽或醫(yī)療保險單？Does anyto be insured have any Life or Health insurance policy curr

39、ently in force?是Yes否No是Yes否No是Yes否No是Yes否No2.被保險人是否曾經(jīng)由于受傷或疾病而獲得任何保險公司的理賠？Has any one of the applicants ever made a claim against any Insurer in respect of bodily injury or sickness?是Yes否No是Yes否No是Yes否No是Yes否No3.被保險人是否曾經(jīng)在投保人壽、意外或醫(yī)療保險時被保險公司拒絕、延期，在特別條款的情況下被接受，或拒絕續(xù)保? Has anyto be insured ever had a Life

40、, Accident or Health insurance Policy cancelled, renewal refused, declined, postponed, withdrawn, subject to special terms and conditions?是Yes否No是Yes否No是Yes否No是Yes否No主被保險人Main Insured附屬被保險人1 Insured1附屬被保險人2 Insured2附屬被保險人3 Insured3最常用醫(yī)生/醫(yī)院Doctors/Hospitals地址 Address被保險人姓名Name of the InsuredpartA中的問題

41、序號Question no. in partA疾病/傷殘名稱以及接受過何種治療Name of illness/disability and treatment received病癥發(fā)生的日期及持續(xù)時間Date and duration of the disability治療/手術(shù)的類型及結(jié)果Type and Result of treatment/surgery就診醫(yī)院名稱/醫(yī)生姓名 Name and address of the Doctor/hospital visited第五部分 投保人Part 5 Declaration1.本人（我們）同意此投保單人（我們）與安盛天平保險訂立保險合同的

42、依據(jù)。本人（我們）特此申明，投保單內(nèi)所投保之資料，根據(jù)本人（我們）所知并確定全部正確無誤。I/We agree that this Application form shall be the basis of the contract between me/us and AXA Tianping Property & Casualty Insurance Company Limited. I/We declare that the statements made in this Application are true, correct and complete to the best

43、 of my/our knowledge and belief.本人（我們）已經(jīng)仔細(xì)閱讀保險條款，尤其是黑體字部分的條款內(nèi)容，并對保險公司就保險條款內(nèi)容的說明和提示完全理解，沒有異議，申請投保。I/We have carefully read the clause, especially for those content highlighted in bold. I/We totally understand the clause and documents provided to me/us, and apply for this insurance.在填寫本投保單后而在保險公司出具保險合

44、同之前，如果任何被保險人的身體狀況發(fā)生變化，本人（我們）同意立即通知保險公司。2.3.I/We agree that if the health status of the above intended insuredchanges after this application is signed and before insurance company issues apolicy, I/We shall immediately notify the insurance company of the changes.本人（我們）理解并同意保險公司對本投保書有拒絕或者接受的權(quán)利。如果保險公司對

45、本投保申請書沒有提出異議，本人（我們）同意保險公4.司直接安排出具正式保單。本人（我們）愿意按照保單條款的規(guī)定或者通知支付保險費(fèi)。I/We understand and agree that the insurance company has right to accept or decline. If the insurance company does not object, I/we agree to let the insurance company issue the formal policy, and will pay the premium according to the c

46、lause or debit note.5.本人（我們）同意保險合同將在支付了全額保險費(fèi)和獲得安盛天平保險核準(zhǔn)后自保單所注明的生效日期起生效。I/We understand that this Policy shall only be effective following full annual premium payment and subject to the acceptance and approval of this application by AXA Tianping Property & Casualty Insurance Company Limited.6.本人（

47、我們）理解并接受”卓越”個人醫(yī)療保障計(jì)劃的條款、擴(kuò)展條款、除外條款及免賠額，自付比率的規(guī)定。本人明白在收到本保險合同之后享有 14 個工作日的審閱期以審閱本保險合同。若我在審閱期內(nèi)決定本保險合同不適合險合同取消。需求，我可以以形式明確告知并將該保I/We understand and accept the policy wording, extension clauses, endorsements, exclusions, co-payment and deductible, if any, of SMARTCARE EXCLUSIVE Health Insurance. I /We und

48、erstand I/we have a free-look period of 14 working days from the date that I/we receive this Policy to review it. If I/we decide that this Policy does not suit my/our needs, I/we could request to cancel it by giving AXA Tianping Property & Casualty Insurance Company Limited clear, written instru

49、ctions.7.本人（我們）同意，安盛天平保險在理賠過程中要求為我/我們治療、或檢查的任何醫(yī)院、醫(yī)生或其他專業(yè)向安盛天平保險提供相關(guān)疾病或受傷治療或檢查的。任何本的復(fù)印件被視為等同于原件。I/We also agree that in case of any claims, I/we authorize any hospital, physician or otherwho has attended to us, or examined us or is authorizedto maintain medical records to disclose when requested to d

50、o so by AXA Tianping Property & Casualty Insurance Company Limited, any and all information with respect to any illness or injury, medical history or treatment. A photocopy of this authorization shall be considered as effective and valid as the original.本人（我們）理解附屬于保險合同的醫(yī)療卡僅限于在保險合同項(xiàng)的承保范圍內(nèi)使用。如果由于計(jì)

51、算錯誤或不屬保障范圍的項(xiàng)目而產(chǎn)生的醫(yī)療或8.其他費(fèi)用，我/我們同意將此費(fèi)用在 30 天內(nèi)歸還給安盛天平保險。我/我們同意一旦保險合同結(jié)束，附屬于保險合同的醫(yī)療卡將歸還給安盛天平保險。I/We also understand that membership cards issued for the policy are to be used only for admissions to hospitals for treatments falling under the scope of the policy and in the event that charges incurred are not claimable from the policy for any reason, I/we shall undertake to pay AXA Tianping Property & Casualty Insurance Company Limited within 30 days from the receipt of all expenses that are not claimable under the policy. I/We