Business Travel Package Insurance Plan Application Form 投保單位資料Information of Applicant 投保人 Name of Applicant: 辦公地址 Business Address: 郵政編碼 Postcode: 營業(yè)范圍 Business Scope: 聯(lián)絡(luò)人 Contact Person: 手機(jī)MP: 聯(lián)系電話 Contact TeBusiness Travel Package Insurance Plan Application Form
投保單位資料Information of Applicant
投保人 Name of Applicant:
辦公地址 Business Address: 郵政編碼 Postcode:
營業(yè)范圍 Business Scope: 聯(lián)絡(luò)人 Contact Person: 手機(jī)MP:
聯(lián)系電話 Contact Tel. No: 傳真號碼 Fax No:
電子郵箱: E-Mail Address:
保險單資料Policy Information
(詳細(xì)的保障計劃以投保人最后確認(rèn)的報價單為準(zhǔn)
Benefits details shall refer to the quotation accepted by the Applicant.)
保險期間Proposed Policy Period 由From: 00:00 時hrs.
(年/月/日YYYY/MM/DD) 至To: 24:00時 hrs.
(年/月/日YYY/MM/DD)
說明：保險期間最早開始于投保人簽署本投保單的次日零時零分。
Remark: The Policy Period shall start not earlier than the time of 00:00 on the next day of the date this Application Form is signed by the Applicant.
保障計劃內(nèi)容 Insurance Coverage of the Package:
保障項目Coverage
保險責(zé)任Limit of Liability (RMB：yuan)
一、商務(wù)旅行公眾責(zé)任保險 Public Liability During Business Travel
二、監(jiān)管行動及訴訟保障保險 Regulatory Action Protector
三、團(tuán)體旅行意外綜合保險 Group Travel Accident
保險金額 / 人 (人民幣：元) Sum Insured/Limit (RMB：yuan)
每次差旅/Per Trip
黃金計劃Gold 鉑金計劃Platinum 鉆石計劃Diamond 至尊計劃Privilege
1.意外身故、燒傷及殘疾保障 Accidental Death, Burns and Dismemberment
2.雙倍給付意外傷害(僅適用境外) Double Indemnity (only for outbound )
3. 緊急醫(yī)療費用 Emergency Medical Expenses - Accident & Sickness
*其中境內(nèi)旅行的疾病醫(yī)藥賠償限額
Limit of Sickness Medical Reimbursement for Domestic Travel
4. 每日住院津貼 (境內(nèi)僅包含意外住院) Hospital Cash （domestic for accident only）
5. 緊急醫(yī)療運送及醫(yī)療遣返 Medical Evacuation & Repatriation
6. 遺體遣返和喪葬費用 Body Repatriation （funeral fee）
7. 家屬緊急旅行費用 Emergency Travel Expenses for Family Member
8. 個人錢財 Loss of Money
9. 隨身財產(chǎn)及旅行證件遺失 Loss of Baggage & Personal Documents
*每件手提電腦賠償限額 Limit per laptop computer
*每件或每套物品賠償限額 Limit per item or set of items
*證件遺失賠償限額 Limit for Personal Documents
10.已交運行李損失 Checked Baggage Loss
*每件或每套行李賠償限額 Limit per item or set of items
11.家居保障 Home Guard (每件或每套物品賠償限額:RMB )
12.行程延誤 Travel Delay (每四小時延誤賠償額:RMB ;
RMB for every 4 hours of delay)
13.行李延誤 Baggage Delay (每八小時延誤賠償額： ；
RMB for every 8 hours of delay)
14.個人責(zé)任 Personal Liability
保險費率表 Premium Table
保障項目Coverage 保險費（人民幣：元）Premium (RMB： Yuan )
1. 商務(wù)旅行公眾責(zé)任保險Public Liability During Business Travel / 每張保單全年
2. 監(jiān)管行動及訴訟保障保險 Regulatory Action Protection / 每張保單全年
3. 團(tuán)體旅行意外綜合保險 Group Travel Accident
黃金計劃 鉑金計劃 鉆石計劃 至尊計劃
Gold Platinum Diamond Privilege
預(yù)估投保人數(shù) Number of insured person
保險單全年預(yù)估總保費 Total premium per policy
投保須知 Important Information:
請仔細(xì)閱讀以下劃線標(biāo)注免除或減低本公司給付或賠償責(zé)任的項目
Please read carefully the items especially the underlined parts which reduce the Company’s liability or exempting the Company from liability under the insurance.
1. 團(tuán)體旅行意外綜合保險承保的被保險個人年齡最高為18 周歲至80周歲。71至80周歲的被保險人,其“意外身故、燒傷及殘疾保障”和“雙倍給付意外傷害”的保險金額為本計劃既定保險金額的一半。
The Group Travel Insurance covers Insured Persons between 18 to 80 years of age. For any Insured Persons at the age between 71-80, only half of the insured amounts designated in the respective travel insurance plans under items of Accidental Death, Burns & Dismember Benefit, Double Indemnity Benefit shall be provided.
2. 商務(wù)旅行公眾責(zé)任保險及團(tuán)體旅行意外綜合保險均僅適用于投保人為業(yè)務(wù)需要派遣其已投保本綜合保障計劃的董事、監(jiān)事、董事會秘書、合伙人及員工等前往其日常工作所在的直轄市或省的市級行政區(qū)域之外的目的地，執(zhí)行下列任務(wù)的商務(wù)旅行：
The insurance For Public Liability During Business Travel and the Group Travel Accident Insurance shall apply only to a Business Travel that any Insured Person undertakes to perform the following business assigned by the Applicant in a destination away from the province or municipality where the Insured Person ordinarily works:
拜訪客戶或供應(yīng)商；to visit customers or suppliers;
參觀或參加商品交易會；to visit or participate in a trade fair;
參加會議或研討會；to participate in meetings or seminars; or
接受在職培訓(xùn)安排或或進(jìn)行市場研究的旅行。
for on-the-job training program or market research.
前述商務(wù)旅行應(yīng)在出發(fā)前依內(nèi)部管理程序獲得核準(zhǔn)，其中每次境外（指中國大陸以外的國家和地區(qū)，包括臺灣、香港和澳門）承保旅程最長期限為從旅程開始（在保險期間內(nèi)）起算的連續(xù)90天， 但境內(nèi)承保旅程最長期限為從旅程開始（在保險期間內(nèi)）起算的連續(xù)30天，最遲均不超過承保明細(xì)表記載的保險期間。
An approval for any such Business Travel must have been granted in accordance with the internal management procedures prior to the commencement of such travel. The maximum period of one trip covered is a consecutive 90-day period for an overseas trip (including trips to Taiwan, Hong Kong and Macao areas)；or a consecutive 30-day period for a domestic trip, both shall commence and end within the Period of Insurance shown in the Schedule to the Package Policy.
3. 本保障計劃不承保任何直接或間接由于前往或途經(jīng)阿富汗、緬甸、古巴、剛果民主共和國、伊朗、伊拉克、利比里亞、蘇丹、敘利亞、以色列、索馬里、也門、利比亞或及其它處于戰(zhàn)爭狀態(tài)或已宣布為緊急狀態(tài)的國家或地區(qū)，或在上述國家旅行期間發(fā)生的保險事故。This package policy will not cover any loss, injury, damage or legal liability arising directly or indirectly from: Travel in, to, or through Afghanistan, Burma(Myanmar), Cuba, Democratic Republic of Congo, Iran, Iraq, Liberia, Sudan, Syria, Israel, Somalia, Yemen, Libya, or other countries or areas in war or declared to be in the state of emergency.
4. 如果由于貿(mào)易或經(jīng)濟(jì)制裁或其它類似法律禁止本公司、本公司的母公司或最終控股公司提供本保障計劃的承保范圍，在禁止范圍內(nèi)本保障計劃即不適用。
This package policy does not apply to the extent that trade or economic sanctions or other similar laws or regulations prohibit the Company, the Company’s parent company or ultimate controlling entity from providing coverage provided by this package policy.
5. 本保障計劃不承保任何國家或國際組織認(rèn)定的恐怖分子或恐怖組織成員，或非法從事毒品、核武器、生物或化學(xué)武器交易人員。
This package policy will not cover any terrorist or member of a terrorist organization, narcotics trafficker, or illegal purveyor of nuclear, chemical or biological weapons defined by any country or international organization.
6. 投保人未能披露與本保險相關(guān)之重大事實可能導(dǎo)致保險人不承擔(dān)保險責(zé)任。重大事實系指可能影響保險決定是否承?；蛱岣弑ｋU費率之事實。如果投保人不能確定某些事實是否屬于應(yīng)披露之重大事實，請予以披露。
Failure to disclose a material fact known to the Applicant may cause the Insurer to decline liability under the Policy. A material fact refers to the fact that may influence the decision of the Insurer on whether to accept the risk or increase the premium. In case of doubt as to whether a fact is material, please disclose it.
7. 投保人目前是否在上海或深圳證券交易所以外的任何證券交易所上市？
Does the Applicant currently list in any stock exchange other than Shanghai or Shenzhen Stock Exchange?
如回答否,投保人是否計劃近期在上?；蛏钲谧C券交易所以外的任何證券交易所上市？
If the answer is "No", whether the Applicant is planning for listing in the near future in any stock exchange other than Shanghai or Shenzhen Stock Exchange?
請注意監(jiān)管行動及訴訟保障不適用于任何目前在上?；蛏钲谧C券交易所以外的任何證券交易所上市的投保人。
Please note the RAP Coverage is not applicable to any Applicant listing in any stock exchange other than Shanghai or Shenzhen Stock Exchange.
8. 1/ 目前是否有正針對投保的被保險個人進(jìn)行中的監(jiān)管行動或訴訟？如有，請詳細(xì)說明：
Is there any existing Action brought or maintained against any person proposed for coverage? If yes, please provide details:
2/ 投保人或投保的被保險個人目前是否認(rèn)知任何將導(dǎo)致或可能導(dǎo)致未來監(jiān)管行動或訴訟的事實或情況？如有，請詳細(xì)說明：
Is the Applicant or any person proposed for coverage cognizant of any facts or circumstances which the Applicant or such person has reason to suppose might afford valid grounds for any future Action or indicate the probability of any such Action? If yes, please provide details:
雙方同意對于基于、起因于或由于在保險期間開始日之前，已針對被保險個人進(jìn)行中的監(jiān)管行動或訴訟或投保人或相關(guān)的被保險個人已經(jīng)認(rèn)知可能會發(fā)生的監(jiān)管行動或訴訟，所導(dǎo)致的法律費用，保險人不承擔(dān)賠付責(zé)任。
It is agreed that an Action based upon, arising from, or in consequence of any existing Actions against a person proposed for coverage, or knowledge by the Applicant or the person proposed for coverage of a potential Action, prior to the start date of the Policy Period agreed is excluded from the proposed coverage.
聲明 Declaration:
1.投保人茲申請丘博保險（中國）有限公司 (以下簡稱“保險人”)的“"愛商旅"商務(wù)旅行綜合保障計劃”，并聲明以上陳述及各項細(xì)節(jié)均真實無訛，且沒有隱瞞任何重大事實以影響保險人評估風(fēng)險或接受本投保申請。投保同意本投保單將會構(gòu)成投保人與保險人所簽署的保險合同的依據(jù)，若未能披露與本保險相關(guān)之重大事實將可能導(dǎo)致保險人不承擔(dān)任何保險責(zé)任(重大事實系指可能影響保險決定是否承保或提高保險費率之事實)。保險合同生效日期以保險單所載生效日期為準(zhǔn)，保險人承擔(dān)保險責(zé)任須以投保人繳付約定保險費并經(jīng)保險人同意承保為前提。
We hereby apply to Chubb Insurance (China)Company Limited(the “Insurer”) for "Business" Business Travel Package Insurance Plan and declare that the statements and information given in this application are, to the best of our knowledge and belief, true and complete. Failure to disclose a material fact known may cause Insurer to decline liability under the Policy. A material fact refers to the fact that may influence the decision of the Insurer on whether to accept the risk or increase the premium. We hereby agree that this application will form a part of the basis of the policy with the Insurer. We understand and agree that the insurance contract comes into effective as the effective date of the insurance specified in the Schedule and assuming liability by the Insurer is subject to the approval of the Insurer and collection of premium.
2. 投保人確認(rèn)已經(jīng)認(rèn)真閱讀保險合同規(guī)定，尤其是免除保險人責(zé)任的規(guī)定，并對保險人就保險合同的內(nèi)容說明和提示完全理解，沒有異議，申請投保。投保人知曉所有保險責(zé)任均以本保險合同所載為準(zhǔn)。
We acknowledge that before applying for the insurance, we have read carefully the terms and conditions of this Policy, especially the exclusions, and fully understand the Insurer’s explanations and reminder. We understand that all insurance coverage is subject to the terms and conditions of this Policy.
3. 投保人同意現(xiàn)申請投?；蛟诒ｋU期間內(nèi)可能提出申請投保的人員，都必須為投保單位的員工/成員。凡提供的參保人員資料或之后的變更，均視為本投保單的部分，也是保險人核保的基礎(chǔ)。
We hereby agree that the Insured Persons must be our employees/ members. The statements and information given or to be given regarding the Insured Person(s) or their changes later will form a part of the basis of the Policy, and shall form a part of the basis for underwriting the policy.
4. 投保人同意，且將告知相關(guān)被保險人并征得其同意，保險人為本保險的目的收集或持有投保人的資料及有關(guān)各被保險人的個人資料(該資料不論是從本投保單上或其他地方所獲取)并授權(quán)可由保險人或任何與保險人有關(guān)的機(jī)構(gòu)或其他人士(不論在中國或海外地方)持有、轉(zhuǎn)告及用于(1)處理及審核本投保單或其他保險事宜(2)提供與該保險有關(guān)之服務(wù),及(3)與投保人或相關(guān)被保險人聯(lián)絡(luò)的用途。
We hereby declare and agree, and will inform the relevant insured persons and obtain their consent, that our information and any personal information regarding the insured persons collected or held by the Insurer (contained in this application form or otherwise obtained) may be held, used and disclosed by the Insurer to individuals or organizations associated with the Insurer (within or outside China) for the purposes of (i) processing this application and other insurance related matters, (ii) providing insurance services & (iii) communication with us or the insured persons.
5.于訂立本保險合同時或因履行本保險合同發(fā)生爭議時，投保人/被保險人選擇以下第 種方式解決:
Regarding any dispute arising from performance of this insurance contract, we select of the following its resolution:
（1） 被告所在地法院訴訟；litigation at the court where the defendant is domiciled;
（2） 國際經(jīng)濟(jì)貿(mào)易仲裁委員會上海分會仲裁arbitration at International Economic and Trade Arbitration Commission Shanghai Sub-commission.
重要提示 Important Notice
1.本投保單、保險條款、保險單、批單或批注（如有）及其它約定書均為保險合同的構(gòu)成部分。
This Application Form, policy wording, Schedule, any endorsement attached hereto or marked thereon (if any) and any other written agreement shall form integrated parts of this Policy.
2. 請投保人認(rèn)真閱讀"愛商旅"商務(wù)旅行綜合保障計劃投保單, 尤其是備注及聲明部分的詳細(xì)內(nèi)容，在確保了解并知曉所有保險條款包括責(zé)任 免除后再簽字確認(rèn)投保。
Please sign on this page after you read through this "Business" Business Travel Package Insurance Plan Application Form carefully, especially Remark and Declaration and fully understand and agree the terms and conditions including exclusions.
投保人法定代表人/授權(quán)代表及公司（蓋章） Authorized Signature & Company （Chop ）
日期Date
