Chartis Insurance Hong Kong Limited 旅遊保險附加契約投保Travel ... - PDF by zhangyun

VIEWS: 55 PAGES: 2

									Chartis Insurance Hong Kong Limited
46/F, One Island East, 18 Westlands Road, Island East, Hong Kong
852 3666 7022 Telephone 852 2838 4180 Facsimile


                                                                Chartis Insurance Hong Kong Limited
                                                          旅遊保險附加契約投保 Travel Insurance Rider Application Form
                                                                                   (請以英文正楷填寫 Type or print in English block letters.)


This Travel Insurance Rider Application Form shall form part of the original Policy to which it is attached and serves as a Premium receipt after receipt of the
appropriate premium for this application and validated by a Travel Agent. This receipt is not valid unless cheque/draft is cleared for payment.

申請人姓名 Name of Applicant:_____________________________________________________________________________________________________________________________

附加保障保費表(港幣)ADDITIONAL BENEFITS PREMIUM TABLE (HK$)
請” ”保障計劃及圈出適當保費 Please “ ” the selected plan(s) and circle the respective premium
                                                                                                           計劃 Plan A                                                                    計劃 Plan B

個人意外 Personal Accident                                                                                  HK$500,000                                                                 HK$1,000,000
保障期 Period of Insurance                                                          個人 Individual                            家庭 Family                             個人 Individual                        家庭 Family
1-8 日 days                                                                             $80 x                                   $160                                  $160 x                               $320
9-17 日 days                                                                           $170 x                                  $340                                   $340 x                               $680
18-31 日 days                                                                          $310 x                                  $620                                   $620 x                              $1,240
每增 1 星期 Each additional week                                                   $80 x ___星期 weeks                      $160 x ___星期 weeks                     $160 x ___星期 weeks                  $320 x ___星期 weeks


                                                                                                           計劃 Plan C                                                                   計劃 Plan D
取消旅程保障 Journey Cancellation                                                                              HK$30,000                                                                   HK$50,000
旅程阻礙保障 Journey Interruption                                                                              HK$30,000                                                                   HK$50,000
郵輪旅程取消保障 Cruise Cancellation                                                                             HK$30,000                                                                   HK$50,000
保障期 Period of Insurance                                                          個人 Individual                             家庭 Family                           個人 Individual                         家庭 Family
1-8 日 days                                                                             $117 x                                  $234                                  $195 x                               $390
9-17 日 days                                                                            $139 x                                  $278                                  $232 x                              $464
18-31 日 days                                                                           $164 x                                  $328                                 $274 x                                $548
每增 1 星期 Each additional week                                                   $31 x ___星期 weeks                       $62 x ___星期 weeks                     $52 x ___星期 weeks                   $104 x ___星期 weeks

                                                                                                  計劃 Plan E
                                                                                                HK$2,000                                                 *運動器材—
                                                                                       每件/每對/每套 per article/pair/set                                       只限於下列運動之器材:
個人物品保障—運動器材*                                                                      個人 Individual             家庭 Family                                      高爾夫球、潛水、滑雪
Personal Effects Coverage – Sports Equipment*                                            $63 x                  $126                                     *Sports Equipment –
                                                                                        $120 x                 $240                                        limited to equipment of the following sports:
                                                                                        $195 x                 $390                                        Golf, Scuba Diving, Skiing
                                                                                $50 x ___星期 weeks      $100 x ___星期 weeks
受保人姓名 Name of Insured Person(s):                          Same as stated in the basic travel insurance application form, policy no. as stated below
保障期 Period of Insurance:                                  Same as stated in the basic travel insurance application form, policy no. as stated below

聲明 Declaration
茲申請「旅遊保險附加契約」,並聲明本申請表內之陳述及提供之細節均為完整及真實無訛,而本申請表將會構成本人與美亞保險香港有限公司所簽署合約之依據。本人同意保險須為申請獲接納後方始作實。
I hereby apply for Travel Insurance Rider and declare that the statements and particulars given in this Rider application are, to the best of my knowledge and belief, true and complete and that this Rider application will form
the basis of my contract with Chartis Insurance Hong Kong Limited. I understand and agree that no insurance will be effected until the application is approved.
申請人現確認及保證申請人及任何其他受保人均不得悉任何可能導致已安排之旅程取消或提早結束的狀況、原因或因素。
The Applicant hereby acknowledges and warrants that neither the Applicant nor any other Insured Person covered under this insurance knows of any condition, cause or circumstance existing that may necessitate the
cancellation or curtailment of the planned insured Journey.
本人清楚及及明白此附加契約投保書上已選之保障項目、附加賠償金額及背頁列明之保障條文、條款及不保事項均會構成保單之一部份。除上述所選之項目外,其餘保單上之一切則不變。
I hereby declare and understand that the selected benefits, coverage, exclusions, limitation, provisions and terms of this Rider shall form a supplementary part of the original policy and subject otherwise and in accordance
with the exclusions, limitations, provisions and terms of the original policy.
本人明白及同意本申請一經接納,保費將不獲退還。I understand and agree no refund of premium is allowed once this Rider has been accepted.
如中文譯本與英文有異,一概以英文為準。In the event of differences between the English and Chinese version, the English version shall prevail.


                                                                                                                                     介紹人 INTRODUCER
                                                                                              保單號碼 Policy No. of the Original Policy:
                                                                                              o1G - _________ - _________________________________
                                                                                              計劃 Plan A or B             ________
                                                                                              計劃 Plan C or D              ________
____________________________________________________________________
申請人簽署 Signature of Applicant                                                                  計劃 Plan E                   ________
                                                                                              總保費 Total Premium HK$ _______________

____________________________________________________________________                          _________________________________________                  _____________________________________________________
日期 Date                                                                                       經手人及日期 Name of Handling Staff & Date                                 Travel Agent’s stamp & validation


注意:當需要索償時,必須出示已經批核的投保書。
Notice: In the event of claims, Insured Person must present the copy of the approved application as evidence of cover.




JSRI 12/2009
Chartis Insurance Hong Kong Limited
46/F, One Island East, 18 Westlands Road, Island East, Hong Kong
852 3666 7022 Telephone 852 2838 4180 Facsimile




                                                         Chartis Insurance Hong Kong Limited
                                                         Travel Insurance Rider Terms and Conditions
Attached to and forming a supplementary part of the original policy and policy no. stated on the overleaf, notwithstanding anything contained herein to the contrary. It
is hereby declared and agreed that this Travel Insurance Rider shall extend to insure the Insured Person(s) in the manner and to the extent herein below stipulated, and
provided that

     (1)        the Insured Person(s) is(are) named in the basic application form attached herewith;
     (2)        the Period of Insurance is stated in the basic application form attached herewith;
     (3)        only the selected benefits and coverage stated overleaf are provided to the Insured Person(s);
     (4)        appropriate premium applicable for this Rider is paid in advance and received by the Company.

Personal Accident
The benefit limit of Personal Accident payable to any Insured Person whose age is between 17 and 75 at the time of Accident shall be increased by the amount selected
and insured under this Rider.

Journey Cancellation, Journey Interruption & Cruise Cancellation
Journey Cancellation
The benefit limit of Journey Cancellation payable shall be increased by the amount selected and insured under this Rider.

Journey Interruption
The benefit limit of Journey Interruption payable shall be increase by the amount selected and insured under this Rider.

Cruise Cancellation
The Company shall reimburse the Insured Person up to the benefit limit selected and insured under this Rider against loss of deposits or charges paid in advance by the
Insured Person and for which he/she is legally liable and which are not recoverable from any other source consequent upon the cancellation of cruise package by reason
only of the air common carrier in which the Insured Person has arranged to travel to enable the Insured Person to board the cruise being delayed in excess of 24 hours
from the arrival time specified in the itinerary supplied to the Insured Person (“the delay”) being the sole cause of the Insured Person being unable to aboard the cruise.
Such delay must arise from inclement weather, natural disaster, equipment failure, hijack or strike by the employees of the air common carrier on which the Insured
Person has arranged to travel during the Insured Journey.

Exclusions applicable to Cruise Cancellation
No benefits shall be provided for any loss:
•    Arising from failure of the Insured Person to check in according to the itinerary supplied to him/her and obtain written confirmation from the air common carrier
     or their handling agents on the number of hours and the reason for such delay.
•    Arising from strike or industrial action existing on the date when this Rider is purchased.
•    Arising from the late arrival of the Insured Person at the airport or port after check-in or booking-in time (except for the late arrival due to strike).
•    Arising from the Insured Person not getting on-board the first available alternative transportation offered by the air common carrier.

Should a loss arise for which a claim for Cruise Cancellation is payable, no further claims shall be made for benefits of Journey Cancellation and Journey Interruption for
the same loss.

Personal Effects Coverage – Sports Equipment
Sports Equipment is limited to (1) Golf Equipment – golf clubs, bags &/or golf trolleys (other than self-propelled caddie cars and golf balls in plays), (2) Scuba Diving &
related Underwater Apparatus Equipment, &/or (3) Skiing Equipment – skis, ski boots &/or ski poles. The sub-limit of sports equipment per article/pair/set shall be
increased by HK$2,000. The maximum limit per article/pair/set of any other Personal Effects and the benefit limit for Personal Effects Coverage remains unchanged.

Subject otherwise and in accordance with the exclusions, limitation, provisions and terms of the original Policy.




JSRI 12/2009

								
To top