Business Travel Package Insurance Plan Application Form

 

投保单位资料Information of Applicant

投保人 Name of Applicant:

办公地址 Business Address:      邮政编码 Postcode:

营业范围 Business Scope:       联络人 Contact Person:       手机MP:

联系电话 Contact Tel. No:     传真号码 Fax No:

电子邮箱: E-Mail Address:

保险单资料Policy Information

 (详细的保障计划以投保人最后确认的报价单为准

Benefits details shall refer to the quotation accepted by the Applicant.)

 

保险期间Proposed Policy Period 由From:        00:00 时hrs.

(年/月/日YYYY/MM/DD)    至To:                   24:00时 hrs.

(年/月/日YYY/MM/DD)

说明：保险期间最早开始于投保人签署本投保单的次日零时零分。

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.

 

保障计划内容 Insurance Coverage of the Package:

保障项目Coverage      

保险责任Limit of Liability  (RMB：yuan)

一、商务旅行公众责任保险 Public Liability During Business Travel      

二、监管行动及诉讼保障保险 Regulatory Action Protector

三、团体旅行意外综合保险 Group Travel Accident      

保险金额 / 人 (人民币：元)  Sum Insured/Limit  (RMB：yuan)

每次差旅/Per Trip

黄金计划Gold       铂金计划Platinum    钻石计划Diamond     至尊计划Privilege

1.意外身故、烧伤及残疾保障 Accidental Death, Burns and Dismemberment

2.双倍给付意外伤害(仅适用境外) Double Indemnity (only for outbound )    

3. 紧急医疗费用 Emergency Medical Expenses - Accident & Sickness  

*其中境内旅行的疾病医药赔偿限额

Limit of Sickness Medical Reimbursement for Domestic Travel 

 

4. 每日住院津贴 (境内仅包含意外住院) Hospital Cash （domestic for accident only）    

5. 紧急医疗运送及医疗遣返 Medical Evacuation & Repatriation   

6. 遗体遣返和丧葬费用 Body Repatriation （funeral fee）    

7. 家属紧急旅行费用 Emergency Travel Expenses for Family Member 

8. 个人钱财 Loss of Money      

9. 随身财产及旅行证件遗失 Loss of Baggage & Personal Documents  

*每件手提电脑赔偿限额 Limit per laptop computer       

*每件或每套物品赔偿限额 Limit per item or set of items

*证件遗失赔偿限额 Limit for Personal Documents  

10.已交运行李损失 Checked Baggage Loss      

*每件或每套行李赔偿限额 Limit per item or set of items

11.家居保障 Home Guard  (每件或每套物品赔偿限额:RMB       ) 

12.行程延误 Travel Delay  (每四小时延误赔偿额:RMB      ;

RMB      for every 4 hours of delay)   

 

13.行李延误 Baggage Delay  (每八小时延误赔偿额：      ；

RMB      for every 8 hours of delay)   

 

14.个人责任 Personal Liability

保险费率表 Premium Table

保障项目Coverage       保险费（人民币：元）Premium (RMB： Yuan )

1. 商务旅行公众责任保险Public Liability During Business Travel         / 每张保单全年

2. 监管行动及诉讼保障保险 Regulatory Action Protection            / 每张保单全年

3. 团体旅行意外综合保险 Group Travel Accident  

黄金计划       铂金计划       钻石计划       至尊计划

Gold          Platinum       Diamond       Privilege

 

预估投保人数 Number of insured person                       

保险单全年预估总保费 Total premium per policy    

 

投保须知 Important Information:

请仔细阅读以下划线标注免除或减低本公司给付或赔偿责任的项目

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.  团体旅行意外综合保险承保的被保险个人年龄最高为18 周岁至80周岁。71至80周岁的被保险人,其“意外身故、烧伤及残疾保障”和“双倍给付意外伤害”的保险金额为本计划既定保险金额的一半。

   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. 商务旅行公众责任保险及团体旅行意外综合保险均仅适用于投保人为業務需要派遣其已投保本综合保障计划的董事、监事、董事会秘书、合伙人及员工等前往其日常工作所在的直辖市或省的市级行政区域之外的目的地，执行下列任务的商务旅行：

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:

 

拜访客户或供应商；to visit customers or suppliers;

参观或参加商品交易会；to visit or participate in a trade fair;

参加会议或研讨会；to participate in meetings or seminars; or

接受在职培训安排或或进行市场研究的旅行。

for on-the-job training program or market research.

 

前述商务旅行应在出发前依内部管理程序获得核准，其中每次境外（指中国大陆以外的国家和地区，包括台湾、香港和澳门）承保旅程最长期限为从旅程开始（在保险期间内）起算的连续90天， 但境内承保旅程最长期限为从旅程开始（在保险期间内）起算的连续30天，最迟均不超过承保明细表记载的保险期间。

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.  本保障计划不承保任何直接或间接由于前往或途经阿富汗、缅甸、古巴、刚果民主共和国、伊朗、伊拉克、利比里亚、苏丹、叙利亚、以色列、索马里、也门、利比亚或及其它处于战争状态或已宣布为紧急状态的国家或地区，或在上述国家旅行期间发生的保险事故。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. 如果由于贸易或经济制裁或其它类似法律禁止本公司、本公司的母公司或最终控股公司提供本保障计划的承保范围，在禁止范围内本保障计划即不适用。

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.  本保障计划不承保任何国家或国际组织认定的恐怖分子或恐怖组织成员，或非法从事毒品、核武器、生物或化学武器交易人员。

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.  投保人未能披露与本保险相关之重大事实可能导致保险人不承担保险责任。重大事实系指可能影响保险决定是否承保或提高保险费率之事实。如果投保人不能确定某些事实是否属于应披露之重大事实，请予以披露。

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证券交易所以外的任何证券交易所上市？

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海或深圳证券交易所以外的任何证券交易所上市？

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?

 

请注意监管行动及诉讼保障不适用于任何目前在上海或深圳证券交易所以外的任何证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/ 目前是否有正针对投保的被保险个人进行中的监管行动或诉讼？如有，请详细说明：

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险个人目前是否认知任何将导致或可能导致未来监管行动或诉讼的事实或情况？如有，请详细说明：

 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:

 

双方同意对于基于、起因于或由于在保险期间开始日之前，已针对被保险个人进行中的监管行动或诉讼或投保人或相关的被保险个人已经认知可能会发生的监管行动或诉讼，所导致的法律费用，保险人不承担赔付责任。

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.  

 

声明 Declaration:

1.投保人兹申请丘博保险（中国）有限公司 (以下简称“保险人”)的“"爱商旅"商务旅行综合保障计划”，并声明以上陈述及各项细节均真实无讹，且没有隐瞒任何重大事实以影响保险人评估风险或接受本投保申请。投保同意本投保单将会构成投保人与保险人所签署的保险合同的依据，若未能披露与本保险相关之重大事实将可能导致保险人不承担任何保险责任(重大事实系指可能影响保险决定是否承保或提高保险费率之事实)。保险合同生效日期以保险单所载生效日期为准，保险人承担保险责任须以投保人缴付约定保险费并经保险人同意承保为前提。

 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.    投保人确认已经认真阅读保险合同规定，尤其是免除保险人责任的规定，并对保险人就保险合同的内容说明和提示完全理解，没有异议，申请投保。投保人知晓所有保险责任均以本保险合同所载为准。

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.    投保人同意现申请投保或在保险期间内可能提出申请投保的人员，都必须为投保单位的员工/成员。凡提供的参保人员资料或之后的变更，均视为本投保单的部分，也是保险人核保的基础。

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，且将告知相关被保险人并征得其同意，保险人为本保险的目的收集或持有投保人的资料及有关各被保险人的个人资料(该资料不论是从本投保单上或其他地方所获取)并授权可由保险人或任何与保险人有关的机构或其他人士(不论在中国或海外地方)持有、转告及用于(1)处理及审核本投保单或其他保险事宜(2)提供与该保险有关之服务,及(3)与投保人或相关被保险人联络的用途。

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.于订立本保险合同时或因履行本保险合同发生争议时，投保人/被保险人选择以下第    种方式解决:

Regarding any dispute arising from performance of this insurance contract, we select       of the following its resolution:

 

（1） 被告所在地法院诉讼；litigation at the court where the defendant is domiciled;

 （2） 国际经济贸易仲裁委员会上海分会仲裁arbitration at International Economic and Trade Arbitration Commission Shanghai Sub-commission.

 

重要提示  Important Notice

1.本投保单、保险条款、保险单、批单或批注（如有）及其它约定书均为保险合同的构成部分。

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.    请投保人认真阅读"爱商旅"商务旅行综合保障计划投保单, 尤其是备注及声明部分的详细内容，在确保了解并知晓所有保险条款包括责任 免除后再签字确认投保。

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/授权代表及公司（盖章）  Authorized Signature & Company （Chop  ）

 

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