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CHINA PING AN INSURANCE (HONG KONG) COMPANY LIMITED
(Incorporated in Hong Kong)
11/F., Dah Sing Financial Centre, 108 Gloucester Road, Wan Chai, Hong Kong.
Tel.: (852) 2827 1883 Fax.: (852) 2802 0018
»*•*« PING AN OF CHINA
MOTOR VEHICLE INSURANCE PROPOSAL FORM H # $ ^ It
Operative Insurance Cover Required fSCft® 11 :
□ Comprehensive
□ Third Party Legal Liabilities
Is insurance cover (damage to the Motor Vehicle only) required for driving in Guangdong Province?
□ Yes g
□ Nog
Period of Insurance ISIRWifl : From
To M
Particulars of Proposer SHSAJIfl-:
Insured/Proposer/Company Name SM^A : Mr/Mrs/Miss / AA I 'MS
Job / Business Nature itNfflSllljttM :
Occupation |$JSI : _
Home Tel	:
Residential Address ftijt :
Daytime Tel BffflWWIS :
Name of Employer SMfc&lI&fRfDiffljh :
Mobile Phone No Ait#® '•
Hire Purchases Owner (if any)	:
e-mail Address	:
Particulars of Motor Vehicle to be Insured	'■
Year of Manufacture
Seating Capacity (excl. Driver)
mmmm m<mw>
Registration Math
jWiaiasss
Vehicle Make
Type of Body
Vehicle Model
Cyliner Capacity (c.c.)
«ff«*(c.c.)
Chassis Number
Engine Number 5IVM8S
Gross Vehicle Weight
Has the Motor Vehicle been modified in any way from manufacturers' standard specifications ?
If Yes Please give details:
□ Yes g □ No ®
Anit-Theft Alarm System (Model / Value)
(S*/«fc)
Estimated Value of the Motor Vehicle including Accessories (Sum Insured)
Particulars of Drivers who will regularly drive the motor vehicle	A±09jW=f" •
Nominated as Named Driver ?
HK1D Card Number
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Number ofyeats has Driver been regularly driving
mmmm
Relationship with Proposer
SUSfcAMS
Occupation
Full Name of Driver
SitMfcg
Age
mm
ff«i
Proposer IS® A
D JKYes □ Nog
□ JSYes ONog
O M Yes DNog
USE OF THE MOTOR VEHICLE - Please "V'more than one if applicable
□ In connection with the Motor Trade <S®^fr^l
□ For social domestic and pleasure purposes
□ For hire or reward
□ For business professional use or for use by employees
MPF/DecOH
Uttllli Driving experience
If your answer is "Yes", please provide full details in the space provided.
State whether you and/or any person who to your knowledge will drive the vehicle
M
5 , ■
No
Yes
Have had any accidents, losses or claims in the past 3 years or are there any police enquiries or prosecutions pending?
o
i.
o
Have been prosecuted or deducted more than 5 driving offence points in total in the last 2 years?
2.
o
o
Have suffered/ been suffering any heart disease, epilepsy or suffer from defective vision or hearing or from any physical or mental infirmity?
3.
o
o
In respect of Motor Insurance, have you or has any person who to your knowledge may drive the Motor Vehicle been declined such application, or been refused renewal or
been terminated such insurance, or been imposed special terms on your/his/her policy by any insurance company?
4.
O
O
Have made any motor claims against other insurance companies in the past 3 years?
5.
O
o
If the answer to any of the above questions (1) to (5) is "Yes", please give details U!._hr8 (1) 33 (5 ) IlHgrfr
;g*sirji"=g •	-
For Comprehensive Insurance cover, please answer the following question:
Secured Car Park
Roadside Meter
mem
Open Area
»*§£«««§ • «®§Ty'JPSSS :
SJft
6.2 Where is the Motor Vehicle parked at night?
O
O
6
O
6.3 Other than the above-mentioned venues, please specify.
DETAILS OF PRESENT MOTOR INSURANCE "NO CLAIM DISCOUNT" (NCD) - Please supply documentary evidence : gjE^fr&®ifc§a»!fIttr(NCD)	SWlTPlBWJtff :
Registration Mark of Motor Vehicle
NCD (%)
NCD JFrffl
Name of Insurer
Present Policy Number
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Transfer the NCD to the Motor Vehicle proposed here?
JWWNCD
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—
DECLARATION
I/We desire to insure with China Ping An Insurance (Hong Kong) Co. Ltd. ("the Company") in respect of the
Motor Vehicle as detailed herein and hereby declare that:
(Sit) fng&mM±S6i4«M»m*9i®T :
(t) The Motes-Vehicle is in good condition;
(S) I/We hereby agree that this Proposal and Declaration shall be incorporated in and taken as the basis of the
proposed contract between me/us and the Company; am!
ft;
(6) 1/We agree to accept a policy in the Company's usual insurance policy form for this class of insurance.
(2) The Motor Vehicle will not be driven by any person who to my/our knowledge does not hold a foil valid (7) I/We hereby declare and agree that any personal information in this proposal form or otherwise obtained is
provided by me/us and may be held, used and disclosed to enable the Company to carry on insurance &
financial services business; and may be transferred to any individuals, related companies, any other
organizations, any independent third party and other services providers for the purpose of (i) processing this
application and providing subsequent services for this or other products and services, and or (H) direct
driving licence or has been disqualified from holding such driving licence,
(3) The particulars given in this Proposal Form are true and nothing materially affecting the insurance risk has
been concealed by me/us;
11-
marketing and/or (iii) data matching, and/or (iv) communication with me/us for such purposes.
towa • Jt&iMsifiw] • jtffiMWt •
(4) If any particulars or answers in this Proposal Form are not in my/our handwriting, the person or persons
filling in such particulars and answers shall be deemed to be my/or agent for that purpose;
m ■	■
Proposer's Signature SHfcA^tg
Authorized Agent
Date BW :
(1) Failure to supply true answers to this Proposal Form or inform die Company of all material information about your insurance proposal may render the insurance policy invalid.
IMPORTANT
NOTICES
- mmmfm •	•
(2) Please attach copy of (a) Vehicle Registration Document; (b) Owner's ID Card and Driving Licence; (c) Named Drivers' ID Card and Driving Licence.
imx	: (a) jmmm - o>)	> (o	•	
Proposal - Moto
IMPORTANT NOTES TO PROPOSER
of the insurance cover you are requesting
be disclosed. Should you have any doubt about what vow should disclose, do not
1.
agent/broker. We recommend you keep a record (including copies of letters) for your future reference of any additional information given. Providing correct sowers and makmg sure we are informed is for your own protection, as failure to disclose such
information may
that your policy will not provide you with the cover you require and may even invalidate the policy altogether.
Personal Information collection Statement
2.
The information you provide to us is collected to enable us to cany on
•	any inswance of financial related product or service or any alterations, variations, cancellation or renewal of i
•	any claims or analysis of it
and may be transferred to any related company or any other company carry ing cat
association or federation of i
You have the right to obtain
and may be used for the purpose of
or reinsurance related business or an intermediary or a claim or investigation; or other service provider providing services relevant to insurance business; or my
that exists or is formed from time to time.
concerning yourself kept by China Ping An
(Hong Kong) Company Limited. Requests for such access can be made to our Personal Data Protection Officer.
3. Our company is
to developing products to meet your personal instsance requirements. As you are a valued
i either now or in the future, please write and tell us.
of our company we will keep you informed of new products and services when they become available. If you do not
to

								
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