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(yíng)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(hào)碼 Fax No:
電子郵箱: E-Mail Address:
保險(xiǎn)單資料Policy Information
 (詳細(xì)的保障計(jì)劃以投保人最后確認(rèn)的報(bào)價(jià)單為準(zhǔn)
Benefits details shall refer to the quotation accepted by the Applicant.)
 
保險(xiǎn)期間Proposed Policy Period 由From:        00:00 時(shí)hrs.
(年/月/日YYYY/MM/DD)    至To:                   24:00時(shí) hrs.
(年/月/日YYY/MM/DD)
說(shuō)明：保險(xiǎn)期間最早開始于投保人簽署本投保單的次日零時(shí)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(jì)劃內(nèi)容 Insurance Coverage of the Package:
保障項(xiàng)目Coverage     
保險(xiǎn)責(zé)任Limit of Liability  (RMB：yuan)
一、商務(wù)旅行公眾責(zé)任保險(xiǎn) Public Liability During Business Travel     
二、監(jiān)管行動(dòng)及訴訟保障保險(xiǎn) Regulatory Action Protector
三、團(tuán)體旅行意外綜合保險(xiǎn) Group Travel Accident     
保險(xiǎn)金額 / 人 (人民幣：元)  Sum Insured/Limit  (RMB：yuan)
每次差旅/Per Trip
黃金計(jì)劃Gold       鉑金計(jì)劃Platinum    鉆石計(jì)劃Diamond     至尊計(jì)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(fèi)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(yùn)送及醫(yī)療遣返 Medical Evacuation & Repatriation  
6. 遺體遣返和喪葬費(fèi)用 Body Repatriation （funeral fee）   
7. 家屬緊急旅行費(fèi)用 Emergency Travel Expenses for Family Member
8. 個(gè)人錢財(cái) Loss of Money     
9. 隨身財(cái)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(yùn)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(shí)延誤賠償額:RMB      ;
RMB      for every 4 hours of delay)  
 
13.行李延誤 Baggage Delay  (每八小時(shí)延誤賠償額：      ；
RMB      for every 8 hours of delay)  
 
14.個(gè)人責(zé)任 Personal Liability
保險(xiǎn)費(fèi)率表 Premium Table
保障項(xiàng)目Coverage       保險(xiǎn)費(fèi)（人民幣：元）Premium (RMB： Yuan )
1. 商務(wù)旅行公眾責(zé)任保險(xiǎn)Public Liability During Business Travel         / 每張保單全年
2. 監(jiān)管行動(dòng)及訴訟保障保險(xiǎn) Regulatory Action Protection            / 每張保單全年
3. 團(tuán)體旅行意外綜合保險(xiǎn) Group Travel Accident 
黃金計(jì)劃       鉑金計(jì)劃       鉆石計(jì)劃       至尊計(jì)劃
Gold          Platinum       Diamond       Privilege
 
預(yù)估投保人數(shù) Number of insured person                      
保險(xiǎn)單全年預(yù)估總保費(fèi) Total premium per policy   
 
投保須知 Important Information:
請(qǐng)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(xiàng)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(xiǎn)承保的被保險(xiǎn)個(gè)人年齡最高為18 周歲至80周歲。71至80周歲的被保險(xiǎn)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(xiǎn)金額為本計(jì)劃既定保險(xiǎn)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(xiǎn)及團(tuán)體旅行意外綜合保險(xiǎn)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(jì)劃的董事、監(jiān)事、董事會(huì)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(jí)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(huì)；to visit or participate in a trade fair;
參加會(huì)議或研討會(huì)；to participate in meetings or seminars; or
接受在職培訓(xùn)安排或或進(jìn)行市場(chǎng)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(guó)大陸以外的國(guó)家和地區(qū)，包括臺(tái)灣、香港和澳門）承保旅程最長(zhǎng)期限為從旅程開始（在保險(xiǎn)期間內(nèi)）起算的連續(xù)90天， 但境內(nèi)承保旅程最長(zhǎng)期限為從旅程開始（在保險(xiǎn)期間內(nèi)）起算的連續(xù)30天，最遲均不超過(guò)承保明細(xì)表記載的保險(xiǎn)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(jì)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(guó)、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(zhēng)狀態(tài)或已宣布為緊急狀態(tài)的國(guó)家或地區(qū)，或在上述國(guó)家旅行期間發(fā)生的保險(xiǎn)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(jì)劃的承保范圍，在禁止范圍內(nèi)本保障計(jì)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(jì)劃不承保任何國(guó)家或國(guó)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(xiǎn)相關(guān)之重大事實(shí)可能導(dǎo)致保險(xiǎn)人不承擔(dān)保險(xiǎn)責(zé)任。重大事實(shí)系指可能影響保險(xiǎn)決定是否承保或提高保險(xiǎn)費(fèi)率之事實(shí)。如果投保人不能確定某些事實(shí)是否屬于應(yīng)披露之重大事實(shí)，請(qǐng)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�；蛏钲谧C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(jì)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(qǐng)注意監(jiān)管行動(dòng)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(duì)投保的被保險(xiǎn)個(gè)人進(jìn)行中的監(jiān)管行動(dòng)或訴訟？如有，請(qǐng)?jiān)敿?xì)說(shuō)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(xiǎn)個(gè)人目前是否認(rèn)知任何將導(dǎo)致或可能導(dǎo)致未來(lái)監(jiān)管行動(dòng)或訴訟的事實(shí)或情況？如有，請(qǐng)?jiān)敿?xì)說(shuō)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(duì)于基于、起因于或由于在保險(xiǎn)期間開始日之前，已針對(duì)被保險(xiǎn)個(gè)人進(jìn)行中的監(jiān)管行動(dòng)或訴訟或投保人或相關(guān)的被保險(xiǎn)個(gè)人已經(jīng)認(rèn)知可能會(huì)發(fā)生的監(jiān)管行動(dòng)或訴訟，所導(dǎo)致的法律費(fèi)用，保險(xiǎn)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(qǐng)丘博保險(xiǎn)（中國(guó)）有限公司 (以下簡(jiǎn)稱“保險(xiǎn)人”)的“"愛(ài)商旅"商務(wù)旅行綜合保障計(jì)劃”，并聲明以上陳述及各項(xiàng)細(xì)節(jié)均真實(shí)無(wú)訛，且沒(méi)有隱瞞任何重大事實(shí)以影響保險(xiǎn)人評(píng)估風(fēng)險(xiǎn)或接受本投保申請(qǐng)。投保同意本投保單將會(huì)構(gòu)成投保人與保險(xiǎn)人所簽署的保險(xiǎn)合同的依據(jù)，若未能披露與本保險(xiǎn)相關(guān)之重大事實(shí)將可能導(dǎo)致保險(xiǎn)人不承擔(dān)任何保險(xiǎn)責(zé)任(重大事實(shí)系指可能影響保險(xiǎn)決定是否承�；蛱岣弑ｋU(xiǎn)費(fèi)率之事實(shí))。保險(xiǎn)合同生效日期以保險(xiǎn)單所載生效日期為準(zhǔn)，保險(xiǎn)人承擔(dān)保險(xiǎn)責(zé)任須以投保人繳付約定保險(xiǎn)費(fèi)并經(jīng)保險(xiǎn)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(xiǎn)合同規(guī)定，尤其是免除保險(xiǎn)人責(zé)任的規(guī)定，并對(duì)保險(xiǎn)人就保險(xiǎn)合同的內(nèi)容說(shuō)明和提示完全理解，沒(méi)有異議，申請(qǐng)投保。投保人知曉所有保險(xiǎn)責(zé)任均以本保險(xiǎn)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(qǐng)投�；蛟诒ｋU(xiǎn)期間內(nèi)可能提出申請(qǐng)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(xiǎn)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(xiǎn)人并征得其同意，保險(xiǎn)人為本保險(xiǎn)的目的收集或持有投保人的資料及有關(guān)各被保險(xiǎn)人的個(gè)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(xiǎn)人或任何與保險(xiǎn)人有關(guān)的機(jī)構(gòu)或其他人士(不論在中國(guó)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(xiǎn)事宜(2)提供與該保險(xiǎn)有關(guān)之服務(wù),及(3)與投保人或相關(guān)被保險(xiǎn)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(xiǎn)合同時(shí)或因履行本保險(xiǎn)合同發(fā)生爭(zhēng)議時(shí)，投保人/被保險(xiǎn)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(guó)際經(jīng)濟(jì)貿(mào)易仲裁委員會(huì)上海分會(huì)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(xiǎn)條款、保險(xiǎn)單、批單或批注（如有）及其它約定書均為保險(xiǎn)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(qǐng)投保人認(rèn)真閱讀"愛(ài)商旅"商務(wù)旅行綜合保障計(jì)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(xiǎn)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  ）
 
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