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Application Form

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MaidSafe Insurance - Application Form
This insurance is underwritten by: Blue Cross (Asia-Pacific) Insurance Limited
Hints on use of online transaction procedure:
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Please call Tel. 25987660 for technical support if required.
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| Some Important Matters To Observe : |
- Plan A is designed to meet employers' legal obligation under the Employee's Compensation Ordinance. All domestic helpers including part-timers are eligible. The name of the insured helper is NOT required for application.
- Plan B and Plan C are suitable for full-time overseas helpers only.
- Eligible age of the insured helper for application is 18 to 60, renewable up to age 65.
- Coverage of this insurance plan applies to insured events occuring within the Hong Kong Special Administrative Region only.
- Outpatient Benefit, Hospital and Surgical Benefit, Loss of Service Cash Allowances and Dental Benefit are subject to a 15-day waiting period from the policy effective date.
- Each policy is applicable for only one insured domestic helper.
- Only Visa or MasterCard will be accepted to be settlement for the purpose of online credit card payment under this online insurance application.
- If discrepancy exists between the English version and the Chinese version, the English version shall prevail.
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Agent Code: A-4803
* Fields must be filled in. (This form must be filled in English)
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| Policy Effective Date (Policy effective date subject to Company's underwriting acceptance) * |
From
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Declaration I, HEREBY DECLARE AND AGREE THAT:
- The answers to all of the above questions including all information and particulars given herein are accurate, true and complete and are given to the best of my knowledge and belief. I have not withheld any material information and accept that this application and declaration shall form the basis of the contract between Blue Cross (Asia-Pacific) Insurance Limited ("the Company") and me. I hereby acknowledge that failure to supply true and accurate answers to this application or inform the Company of all material information about my application may render the Company unable to accept or process this application or the insurance policy void.
- The insurance coverage applied for shall only take effect when this application has been accepted by and the required premium has been paid to the Company.
- I have never had any new application/ renewal declined, nor have special terms and conditions been imposed on similar application or renewal for domestic helper insurance submitted by me.
- I have obtained the necessary authorisation from the insured helper(s) to provide the information requested on this application and to deal with, receive or request for information from the Company concerning the insured(s) in relation to any matters arising from the policy issued pursuant to this application. I further acknowledge that the insured(s) has/ have been explicity informed that his/ her/ their personal data will be transferred to the Company for the purpose of this application and of his/ her/ their rights under the Personal Data (Privacy) Ordinance.
- The domestic helper employed by me is in good health and is not suffering from any physical defect or infirmity and will not engage in any hazardous activities. I shall provide full details in written notice to the Company should there be any changes in the employment of the domestic helper or in the condition of the said domestic helper.
Personal Information Collection Statement
I/ We understand and agree that any personal information collected or held by the Company (whether contained herein or otherwise obtained) may be used, stored, disclosed or transferred (within or outside of Hong Kong) to any individuals/ organisations associated with the Company or any third party the Company may consider necessary including any other company carrying on insurance or reinsurance related business, any intermediary, claims investigator, medical facilities, other service providers relevant to insurance business, professional advisor, government authority or industry association/ federation for the purposes of: (1) processing of this application/ request and provision of insurance or financial related product or service or any addition, alteration, variations, cancellation or renewal or reinstatement of them; (2) any scope of insurance coverage, claim processing or investigation or analysis and data matching; (3) promotion of financial products or services by the Company and its affiliated companies; (4) communicating with me/ us/ the insured or any relevant organisation/ person as the Company considers appropriate; and (5) meeting any disclosure requirements imposed by law or court orders or pursuant to guidelines issued by regulatory or other relevant authorities. I/ We have the right to obtain access to and to request correction of any personal information concerning myself/ ourselves held by the Company. I/ We understand that if I/ we do not want my/ our personal information to be used for purpose (3) above, I/ we may notify the Company at any time. Such request(s) or notice(s) can be made in writing to the Company's Corporate Data Protection Officer at 29th Floor, BEA Tower, Millennium City 5, 418 Kwun Tong Road, Kwun Tong, Kowloon, Hong Kong.
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I Agree to the Terms and Conditions. |
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| Note: |
This "MaidSafe" Insurance Certificate is delivered electronically.
According to normal operation, an electronic MaidSafe Insurance Certificate will show up
in your browser by clicking the button "MaidSafe Insurance E-Cert" after your payment
has been successfully processed. You must print out your MaidSafe Insurance Certificate
for your own records. The transaction information is transmitted through SSL 128-bit
encryption keys.
All insurance transactions must be arranged within the territory of the Hong Kong Special Administrative Region.
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