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家 傭 至 專 寶 - 申請表

此保險由「藍十字(亞太)保險有限公司」承保

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閣下須注意及遵守的部份特別重要事項 :
  1. 計劃A為保障僱主在《僱員補償條例》下須承擔的法律責任,所有僱傭(包括兼職家務助理)均可參加,申請時無需填寫受保僱傭姓名。
  2. 計劃B及計劃C只適合全職海外家庭傭工參加。
  3. 家傭的投保年齡為18至60歲,可續保至65歲。
  4. 此計劃的受保事故須於香港特別行程區境內發生。
  5. 門診保障、住院及手術保障、中斷服務現金津貼及牙科保障均設有等侯期,即由保單生效日起計15天。
  6. 每份保單只適用於一位受保家傭。
  7. 本網上投保程式只接受Visa或MasterCard作網上信用卡付款。
  8. 中、英文本如有歧異,概以英文本為準。

Agent Code: A-4803
* 此欄必須填寫 (此表格必須以英文填寫)
Employer 僱主
Name of Applicant (Employer)
投保人姓名 (僱主)*
Last/Family 姓* First/Given 名*
H.K.I.D. Card /Passport No.
香港身分證/ 護照號碼*
Contact Telephone No.
聯絡電話*
Fax
傳真號碼
Email Address
電郵地址*
Correspondence Address
通信地址*

Hong Kong (HKSAR), China 中國香港
Policy Effective Date (Policy effective date subject to Company's underwriting acceptance)
保單生效日期 (保單生效日期須經本公司核保審批)*
From
Coverage 保障部分
計劃A
全職或兼職家務助理
For all Domestic Helpers including part-timers
計劃B
只適合海外僱傭
For Overseas Domestic Helpers only
計劃C
只適合海外僱傭
For Overseas Domestic Helpers only
一年保費 HK$ 350
二年保費 HK$ 630
一年保費 HK$650
二年保費 HK$1,170
一年保費 HK$750
二年保費 HK$1,350
The Overseas Domestic Helper 閣下之海外家庭傭工 (Applicable for Plan B & Plan C Only 只適用於計劃B及計劃C)
Name of Overseas Domestic Helper
海外家庭傭工姓名*
Last/Family姓   First/Given名*
Nationality (except HK/China)
國籍 (非香港或內地) *

其他﹐請列明﹕
H.K.I.D. Card / Passport No.
香港身分證/ 護照號碼 *
Date of Birth(MM/DD/YYYY )
出生日期 ( 月/日/年)*
Place of Employment
家庭傭工工作地點*
Same As Correspondence Address 與通信地址相同

Hong Kong (HKSAR), China 中國香港
Declaration 聲明
I, HEREBY DECLARE AND AGREE THAT:
本人,謹此聲明並同意:
  1. 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.
    上 述 所 有 問 題 的 答 案 包 括 所 有 資 料 及 細 節 均 是 準 確 無 誤 , 真 實 及 為 事 實 之 全 部 , 並且 是 盡 本 人 所 知 及 所 信 而 作 答 的 。 本 人 並 沒 有 隱 瞞 任 何 重 要 資 料 及 同意 此 申 請 書 之 內 容 及 聲 明 將 成 為 此 項 保 險 合 約 之 承 保 根 據 。 本 人 在 此 確 認 ,如 未 能 提 供 真 實 及 準 確 無 誤 之 資 料 或 通 知 藍 十 字 (亞 太)保 險 有 限 公 司 (「貴 公 司」) 任 何 有 關 此 保 險 申 請 之 重 要 資 料 ,將 可 能 導 致 貴 公 司 不 能 接 受 或 處 理 此 保 險 申 請 或 令 本保單失效 。

  2. 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.
    一概保障項目必須在本申請獲接納後並已將應付保費繳交予貴公司後始 可生效 。

  3. 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.
    本人未曾於投保同類型家傭保險時被拒絕申請/ 續保,或被增加附帶條款 。

  4. 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.
    本人已獲受保傭工授權提供本保單所需之資料,就一切有關於受保人按本申請所簽發之保單的相關事宜,與貴公司進行交涉,並向其接收或索取與受保人有關之資料。本人並確認受保人已獲明確通知,其個人資料將會轉介予貴公司作辦理本申請之用,同 時亦已知會受保人在有關個人資料(私隱)條例保障下所享有的一切權利。

  5. 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.
    受聘於本人的家傭現在健康良好,並無任何身體缺陷,虛弱 及參與任何危險性活動。 當本人所聘用的家傭或以上述情況有所改變時, 本人將以書 面通知貴公司有關資料。
Personal Information Collection Statement 收集個人資料聲明
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.
本人/ 我們明白並同意由貴公司收集或持有的任何個人資料 (不論是否載於此或由其他途徑取得) ,均可供使用、儲存、透露或轉交予 (香港境內或境外)任何與貴公司有關人士/ 機構或貴公司認為有需要的任何第三者 ,包括其他從事與保險或再保險業務有關的公司、中介人、理賠調查員、醫療機構、與保險業務有關的服務供應商、專業顧問、政府機關、或保險業組織或聯會 ,用於﹕(1) 處理此申請/ 要求及提供有關保險或財務的產品或服務 ,或該等產品或服務的增加、更改、轉變、取消、更新或復效﹔ (2) 任何關乎保險範圍的事項、賠償審理、調查、分析及資料配對﹔(3) 任何貴公司及相關聯公司的財務產品或服務推廣﹔(4) 與本人/ 我們/ 受保人或貴公司認為合適的有關機構/ 人士的通訊﹔及 (5) 符合法例或法庭頒令的資料披露規定﹔或根據監管或其他有關機構所發出的指引而作出披露。本人/ 我們有權查閱及要求更正貴公司持有有關本人/ 我們的個人資料。本人/ 我們明白如不接受將個人資料用於上述第 (3) 點目的 ,本人/ 我們可隨時通知貴公司。該(等)要求或通知應以書面向貴公司的個人資料保障主任提出 ,地址為香港九龍觀塘道 418 號創紀之城 5 期東亞銀行中心 29 樓。


I Agree to the Terms and Conditions. 本人已閱讀及同意以上所有條款及聲明。

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 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.
注意事項: 本「家傭至專寶」保險是以電子保單形式完成。一般情況下,當成功完成付款程序後,在瀏覽器畫面上按下「MaidSafe E-Cert」按鈕,保單便會顯示出來。 貴客必須列印該電子保單,以作存檔紀錄之用,方為有效。 交易資料經由 SSL 128 位元加密傳送。
所有的保險項目必須在香港安排
AuspharmTrading (H.K.) Limited (Insurance Agent Reg 96903619)
[ Insurance Agent for Blue Cross(Asia Pacific) Insurance Limited & American Home Assurance Company ]

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