团体被保险人个人告知声明书DECLARATIONOFHE

单证号：01006团体被保险人个人告知声明书DECLARATIONOFHEALTH由被保险人填写正反面并由其本人签名TobecompletedbytheInsuredandpleasesigntheDeclarationoverleaf被保险人姓名InsuredName.(NameonChinaIDCard)姓/Surname：名/Givenname:性别□男性MaleSex□女性Female出生日期(DateofBirth)年Y月M日D基本月薪(MonthlySalary)RMB元/Yuan□身份证号码ChinaIDNo.□其它证件(Othercertificate)请在下面空格处填写对应号码:Pleasefilltherelatednumberintheblank:＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿婚姻状况（MaritalStatus）□未婚Single□已婚Married□离婚Divorced□丧偶Widowed职位（Position）工种（Occupation）工作范围/Duties:您是否有机动车辆驾驶执照?(如有，请详述驾照类型)DoyouhaveanyDrivingLicense?If“yes”,pleasegivethetypeofthelicense.您是否有驾车肇事记录？Doyouhaveanyrecordofcausinganaccident?您是否参加危险性或比赛性运动，请在此详述。Doyouengageinanyhazardousororganizedsports?If“yes”,pleasegivedetails.您现在是否有任何人身保险？如有，请详述险种名称、保额、保险公司。Doyouhaveanylifeorhealthinsurancenow?If“yes”,pleasegivetheplan,suminsuredandinsurer.身高Height体重Weight过去12个月之体重改变Anyweightchangeduringthepast12months改变原因ReasonforChange请清楚回答下列问题Pleaseanswerthefollowingquestionscarefully米/m公斤/kg+/-公斤/kg以下问题必须选择“是”或“否”(AllQuestionsmustbeanswered“Yes”or“No”)是/否Y/N1)您是否全职工作及现在是否正常工作？Areyounowonafull-timebasisandactiveinyourjob?2)就您所知，您是否有身体缺陷、畸形、或身体不正常？Tothebestofyourknowledge,doyouhaveanyphysicalimpairmentordeformityordeparturefromgoodhealth?3)在过去五年内，您是否接受或被建议接受X光检查，心电图或血液检验（例如胆固醇、后天免疫缺乏症，肝炎包括乙型肝炎、贫血等）？HaveyouhadorbeenadvisedtohaveanX-ray,ECGorbloodtest(e.g.,Cholesterol,AIDS,HepatitisincludingHepatitisB,anaemiaetc)inthelastfiveyears?4)在过去五年内，您是否进行过外科手术或疗养或接受治疗？Haveyouhadasurgicaloperationorbeenconfinedortreatedinanyhospital,sanatoriumorotherinstitutioninthelastfiveyears?5)您是否接受过下列疾病之治疗或被报告曾患下列疾病：高或低血压，心脏、静脉或动脉问题，风湿热，昏倒病，肺部或呼吸问题，哮喘，气肿，胸膜炎，结肠炎，溃疡，胃、胆囊、肝或直肠问题、疝气，糖尿病，任何结核病，肾胰脏、膀胱或生殖及泌尿系统问题，甲状腺，性病、梅毒，精神或神经的问题，羊癫病，痛风，脑部疾病，关节炎或风湿病，骨骼、神经痛，背部或脊骨问题，癌症，肿瘤，畸形，瘫痪，丧失听觉、视觉或肢体，任何其他以上未提及的健康情况，损伤及病症，后天免疫力缺乏症（艾滋病），与艾滋病有关的并发症或状况？Haveyoueverbeentreatedfororbeentoldtohavehighorlowbloodpressure;heart,veinorarterytrouble;rheumaticfever;faintingspells;lungorotherrespiratorytrouble;asthma;emphysema;pleurisy;colitis;ulcers;stomach,gallbladder,liver,intestinalorrectaltrouble;hernia;diabetes;anyformoftuberculosis;kidney,pancreas,bladderorgenito-urinarytrouble;thyroidtrouble;venerealdisease,syphilis;mentalornervoustrouble;epilepsy;gout;braindisorders;arthritisorrheumatism;bonetrouble;sciatica;backorspinaltrouble;cancer;tumoursoranyformofgrowth;anydeformities;paralysis;lossoforlossoftheuseofaneyeorlimb;anyphysicalconditions;orinjuriesnotpreviouslymentioned,oranysymptomofillhealth,AIDS,AIDS-relatedcomplicationsorAIDS-relatedconditions?6)您现时是否正接受医生的诊治，外科手术或药物治疗？Areyounowreceivingorcontemplatingtoreceiveanymedicalorsurgicaltreatmentortakinganymedication?7)您是否曾购买人寿或医疗保险而被拒绝，或保留须加保费，更改或被拒绝延续？Haveyoueverbeenrefusedofanyformoflifeorhealthinsuranceoreverhadapolicyrated,modifiedorrenewalrefused?8)您是否吸烟，服用药物，毒品或含酒精饮料？如有，请列明种类及份量。Doyousmoketobacco,takedrugsornarcoticsoralcohol?If“Yes”,typeandquantity.9)您的父母，兄弟姐妹是否患过这些疾病：糖尿病，肾病，心脏病，中风，高血压，冠状动脉病，精神病或癌症？Haseitherparentoranybrotherorsistereverhaddiabetes,kidneydisease,heartdisease,stroke,highbloodpressure,coronaryarterydisease,mentalillnessorcancer?如果回答“是”请将详细说明列下：（如下列空位不足，请将详情写在另一白纸上一并交回）PLEASEPROVIDECOMPLETEDETAILSOFEACHQUESTIONANSWERED“YES”(ifinsufficientspacebelow,pleaseattachaseparatesheet)问题编号QuestionNo.病人姓名及疾病说明请列明病发次数及病程NameofpersontreatedanddetailsoftheinjuryorsicknessNumberofattacksandseverity;治疗Duration日期dates由from到to治疗/手术名称请列明结果/Nameofoperation/Treatment&andResult诊治医生姓名及地址NameandAddressofAttendingDoctor声明及授权：本人知道除非金盛保险同意接受本人的保险申请，否则该保险不生效。本人声明（1）上述一切陈述及问题的答案，不论是本人亲笔所写，就本人所知，均为完整且准确无误；（2）金盛保险可以在任何情况下核对金盛保险所收集或持有本人相关资料且可以使用、储存透露、转移这些资料给金盛保险认为有需要之人士，不受限制地包括金盛保险之任何关联公司、再保险公司或任何与金盛保险有关之人士或机构，以（i）审核及评估此投保书及任何其它投保申请；（ii）提供所有服务（不论与此投保书是否相关）及推广、改善及进一步推广关于金盛保险及其关联公司所提供所需服务；（iii）用于和相关人士任何其它目的之沟通及/或遵从任何适用相关的法律。本人授权（1）任何雇主、西医、医院、诊所、保险公司、银行、政府机构、或其它组织凡知道或持有本人，或曾诊验或可能诊验本人，均可将该等资料提供给金盛保险；（2）金盛保险或任何其指定医生、医疗人员或化验所，可就投保申请或任何与之有关的赔偿申请替本人进行医疗评估及测试，作为审核本人的健康状况。复印件与正本有同等效力。Declaration&AuthorisationIHEREBYUNDERSTANDthattheinsuranceshallnotbeinforceunlessthisapplicationisacceptedbyAXA-MinmetalsAssuranceCo.Ltd.(“thecompany”).IHEREBYDECLAREANDAGREEonbehalfofmyselfthat(1)allstatementsandanswerstoallquestionswhetherornotwrittenbymyownhandaretothebestofmyknowledgeandbeliefcompleteandtrue;(2)mypersonaldatacollectedorheldbytheCompany(whethercontainedinthisdeclarationorotherwise)maybeusedinconnectionwithmatchingforwhateverpurposewithsuchotherpersonaldataand/ofmaybeused,stored,disclosed,transferred(whetherwithinoroutsideChina)tosuchpersonsastheCompanymayconsidernecessaryincludingwithoutlimitationanyofitsaffiliatedcompanies,reinsurersoranyindividuals/organisationsassociatedwiththeCompanyto(i)underwriteandevaluatetheapplicationandanyotherapplicationforinsurance;(ii)provideallservices(whetherrelatedtotheapplicationornot)andpromote,improveandfurtherpromotionofservicesbytheCompanyanditsaffiliatedcompanies;(iii)communicatewiththerelevantpersonsforanyotherpurposeand/orcomplywiththelawsofanyapplicablejurisdiction.IHEREBYAUTHORISEonbehalfofmyself(1)anyemployer,medicalpractitioner,hospital,clinic,insuran