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友邦团体保险被保险人最新个人资料通知书MemberUpdateInformationNotice保险合同编号/PolicyNo:投保人名称/Policyholder:被保险人编号/MemberNo:被保险人姓名/NameofApplicant:A．被保险人告知事项（请勾选或填写以下各项目）DeclarationofApplicant(pleasetickorfillin)是/Y否/N1．被保险人是否已购买人身保险合同？若“是”，请详述：Doyouhaveanylifeinsurance?If‘Y’,plsspecify公司名称:保险金额:生效日:Insurer:InsuranceAmount:EffectiveDate□□2．被保险人的人寿保险、人身意外或健康保险申请是否曾被拒保、推迟、加费或作任何形式修改？若“是”，请说明。Haveyouhadanyapplicationforinsurancebeendeclined,postponed,ratedupormodified?If‘Y’,plsspecify____________________________________________________________________________________□□3．被保险人是否曾向任何保险公司提出保险金给付申请？若“是”，请说明。Haveyouclaimedfromanyinsurancecompany?If‘Y’,plsspecify:________________________________________________________________________________________□□4．正在或试图参加私人性质飞行，或携带氧气瓶潜水、或登山、或从事危险性的运动？若“是”，请填妥相关问卷，连同此通知书一并并回本公司。Areyouengagingordoyoucontemplatetoengageinanyprivateflying,scuba-diving,mountainclimbing,oranyhazardoussports?If‘Y’,plscompletetherelatedquestionnaire,andsubmittogetherwiththisapplicationform.□□5．在非州、加勒比海地区、印度、缅甸及泰国持续居住超过三个月或正拟往上述国家？若“是”，请说明：Haveyouresidedinthefollowingcountriesformorethan3monthsorplannedtogotothere:Africa,regionofCaribbeanSea,India,MyanmarorThailand?If‘Y’,plsspecify:________________________________________________________________________________________□□6．是否正计划前往其他国家或海外地区旅行、工作或居住？若“是”，请详述？Areyouplanningtogotoothercountriesoroverseasfortraveling,workingorliving?If‘Y’,plsspecifybelow:时间Date:________________________目的地Destination:________________________□□7．平均每年搭乘飞机在250小时以上？Willyouspendmorethan250hoursayearonflight?□□8．现从事职业及日常职务？Presentoccupationanddailyduty________________________________________________________________________________________9．目前常住地址及户口所在地？请详述：Pleasestateyourpresentresidentialaddress,andcountryoforigin________________________________________________________________________________________B．被保险人健康资料：（请勾选或填写以下各项目）HealthDeclarationofApplicant(pleasetickorfillin)1．a.目前身高、体重height&weightb.在过去一年内体重之增减情况Changeofweightinthepastyeara.身高height________厘米cm;体重weight________公斤kgb.增/减increase/decrease_________公斤kg原因：Reason:_______________________________________是Y否N2．是否曾或正在接受药物治疗、外科手术或服用药物？Haveyoubeenorareyoureceivinganymedicaltreatment,surgicaltreatment,orprescribedmedicine?□□GMD01210(2009/10/01)3．a.是否吸烟或曾吸烟？若“是”，请填写Doyousmokeorhaveyousmoked?If‘Y’,plsstate:吸烟duration______年year;数量quantity_______支pieces/日day。若现已停止吸烟，请说明。Ifyouhavestoppedsmoking,pleasestate停止吸烟原因及时间thereasonanddate___________________________________________________b.是否饮酒或曾饮酒，若“是”，请填写Doyoudrinkorhaveyoudrunkalcohol?If‘Y’,plsstate:饮酒duration______年year;种类typeofdrink_______，数量quantity________两ml/周week若现已停止饮酒，请填写Ifyouhavestoppeddrinking,pleasestate：停止饮酒原因及时间thereasonanddate__________________________________________________c.是否曾接到医生对您吸烟、饮酒的建议和警告，若有，请详述Haveyoubeenadvisedorwarnedbyyourattendingdoctorsregardingyoursmokinganddrinkinghabit?If‘Y’,plsstate:_____________________________________________________________________________________a□b□c□□□□4．过去五年曾Inthepastfiveyears,haveyoureceiveda.接受X光、CT、MRI、心电图、活体检查、血液、超声波、内窥镜或其他特殊检查？X-ray,CT,MRI,ECG,biopsy,bloodtests,ultrasound,endoscopeexaminationoranyotherinvestigations?b.接受诊疗、外科手术、住院治疗？Consultation,surgicaltreatment,hospitalization?a□b□□□5．是否有身体残障状况：Doyouhaveanyphysicaldisability:a.四肢、五官、手指、足趾缺损？fourlimbs,facialfeatures,lossoffingersortoes?b.视力、听力或中枢神经系统障碍？vision,hearing,ordisturbanceofcentralnervoussystem?c.脊柱、胸廓、四肢或手指、足趾畸型、跛行、脊髓灰质炎所致缺陷及其他缺陷？Spine,thorax,deformityoffourlimbs,fingersortoes,limping,anyphysicaldefectscausedbypoliomyelitis,otherphysicaldefects?a□b□c□□□□6．是否曾有下列症状、曾被告知患有下列疾病或因此接受治疗:Haveyousufferedfrom,orhaveyoubeentoldtohave,orhaveyoureceivedtreatmentforthefollowingconditions:a.反复头晕、反复头痛、晕阙、胸闷、胸痛、心慌、气急、不能平卧、紫绀、不明原因皮下出血点、鼻衄、反复齿龈出血、咳血、呕血、浮肿、腹痛、肝区疼痛、便血、血尿、蛋白尿、肿块、眼睛胀痛、视力或听力明显下降、视物不清、不明原因的声嘶、关节红肿、关节酸痛；recurrentdizziness,recurrentheadache,fainting,chestdiscomfort,chestpain,palpitation,shortnessofbreathe,unabletorecline,cyanosis,idiopathicpurpura,epistaxis,recurrentgumbleeding,hemoptysis,hematemesis,oedema,abdominalpain,rightupperquadrantpain,bloodinstool,bloodinurine,proteinuria,mass,eyepain,impairedvisionorhearing,blurringvision,idiopathichoarseness,swellingjoints,painfuljoints;b.眼、耳、鼻、喉或口腔的疾病；diseaseofeye,ear,nose,throat,ormouth;c.癫痫、重症肌无力、肌营养不良症、多发性硬化症、帕金森氏综合症、肌肉萎缩、脊髓灰质炎、精神病、聋哑、四肢机能障碍、下肢静脉曲张、智能障碍及其他类型畸形或残缺；epilepsy,myastheniagravis,musculardystrophy,multiplesclerosis,Parkinsonism,poliomyelitis,mentaldisorders,deafness,dumb,functionaldeficitoffourlimbs,varicoseveins,disordersofintelligence,andanyotherdeformityordefects;d.血管畸形、脑动脉血管瘤、视网膜出血或剥离、视神经病变、虹膜睫状体炎、青光眼、白内障、失明、高度近视800度以上、眼底病变；malformationofbloodvessels,cerebralaneurysm,retinalhaemorrhageordetachment,opticalneuropathy,iridocyclitis,glaucoma,cataract,blindness,myopiaabove800degree,retinopathy;e.慢性支气管炎、哮喘、肺脓肿、肺栓塞、胸膜炎、肺气肿、支气管扩张、肺结核、尘肺、矽肺；chronicbronchitis,asthma,lungabscess,pulmonaryembolism,pleurisy,emphysema,bronchiectasis,pulmonarytuberculosis,pneumoconiosis,silicosis;f.高血压病、缩窄性心包炎、心内膜炎、风湿性心脏病、先天性心脏病、缺血性心脏病、心肌梗塞、心肌肥厚、主动脉血管瘤、脑血管意外、心律失常、心肌病；high