太平人寿保险有限公司环球团体医疗保险员工申请表Employe

EmployeeApplicationFormDetailsofApplicant(FirstInsured)FirstNameSurnameDateofBirthGender(cm)Height(cm)(kg)Weight(kg)IDTypeIDNo.ContactAddressPostcodePhoneEmailHomeCountryNationalityonPassportCountryofResidenceCityofResidenceCompanyNameDateofEmploymentJobTitle30Doyouworkatleast30hoursperweekforthisemployer?YesNoElectedCountry(formajortreatment)DetailsofDependantsNameRelationshiptotheFirstInsuredAgeIDTYPEIDNo.GenderDateofBirth(cm)Height(kg)Weight1/PleasechoosetheinsuranceprogramSelectPremierEliteOtherHealthQuestionnaireImportant:Allmaterialfactsmustbedisclosed.Failuretodosocouldresultintherejectionofaclaim.Materialfactsarethosethatcanbereasonablyregardedaslikelytoinfluencetheassessmentandacceptanceofthisproposal.Ifthereisanydoubtaboutwhethercertainfactsarematerial,thesefactsshouldbedisclosed.1Areyoucurrentlyactiveatworkonafull-timebasis?YesNo2Haveyou(oranyonetobeinsured)everbeenrefusedbyalifeoranyotherformofhealthinsurancecompany,oreverhadapolicypostponed,specialrated,oracceptedonspecialterms?YesNo3Duringthelastfiveyearshaveyou(oranyonetobeinsured)consulted,orbeentreatedorexaminedbyadoctor?YesNo4Duringthelastfiveyearshaveyou(oranyonetobeinsured)undergoneasurgicaloperationorbeenreferredtoanyhospital,clinicetc.,eitherasanin-patientorout-patient,oreitherhad(orbeawaitingfor)anyspecialtestsorinvestigation?YesNo5Areyou(oranyonetobeinsured)currentlytakinganymedicineordrugs(whetherornotprescribedbyadoctor)orreceivinganyothertypeoftreatment?YesNo6/14Doyouhaveorhaveyoupreviouslyhadanyofthefollowingillnesses/disorders?Pleaseticktheappropriateboxandunderlinetheillness/conditionreferredtoORanyotherillnesslastingorrequiringtreatmentformorethan14days?Allquestionsmustbeanswered.YesNo21)Tumours:Benign/Malignant2)//Migraine/NeurologicalDisorders/Epilepsy3)MentalIllness4)EyeDiseases5)///Tuberculosis/Asthma/Allergies/PulmonaryDiseases6)/CardiovascularDiseases/ArterialHypertension7)///Liver/Pancreas/Stomach/IntestinalDiseases8)/Diabetes/otherHormoneDiseases9)/UrinaryTractandKidneyDiseases/DiseasesoftheSexualOrgans10)/Rheumatism/Muscle,JointorBoneDiseases11)BackProblems12)SkinDiseases13)CosmeticOperations14)//AnyotherDiseases/Disorders/Accidents15)HIVHaveyoubeentestedforHIV-antibodiesIfYES,whatwastheresult:HIVHIV-PositiveHIVHIV-Negative26Ifyouhavechosenanswered,“yes”forquestionNo.2~6,pleasegivefulldetailsintotheblocksbelow.Indicatingwhichquestion(s)youareanswering.No.FullnameofpersontreatedFrom(YYYY/MM/DD)To(YYYY/MM/DD)DegreeofRecoveryFullinformationonNatureofIllness/Name,CompleteAddressandTel/FaxNo.ofAttendingDoctorNo.FullnameofpersontreatedFrom(YYYY/MM/DD)To(YYYY/MM/DD)DegreeofRecovery3FullinformationonNatureofIllness/Name,CompleteAddressandTel/FaxNo.ofAttendingDoctorNo.FullnameofpersontreatedFrom(YYYY/MM/DD)To(YYYY/MM/DD)DegreeofRecoveryFullinformationonNatureofIllness/Name,CompleteAddressandTel/FaxNo.ofAttendingDoctorPleasecontinueonaseparatesheetifthespaceisinsufficientNumberofAdditionalPagesAttached:/ApplicantDeclaration1.Ideclarethattothebestofmyknowledgeandbeliefthatthestatementsmadeabovearecompleteand,togetherwiththepolicytermsandconditions,shallformthebasisofthecoverage.2.Iunderstandthatanychangetomyhealth(orthatofanyoneelsetobeinsured)mustbenotifiedtoTaipingLifepriortothecommencementdateofthecontractandthatfailuretodiscloseallmaterialfactsmayresultintherejectionofaclaim.3.Iauthorizeanyorganizationandanymedicalpractitionerinpossessionofmyrecordsormydependants’recordtoprovideTaipingLifewiththeinformationinrelationtothiscoverage.Iauthorizeanylicensedphysician,medicalpractitioner,hospital,clinic,orothermedicalormedicalrelatedfacility,insurancecompany,institutionorpersonthathasanyrecordsorknowledgeofme,mydependantsormyhealthtoprovideTaipingLifewithanyinformationtheymayrequireinrespectofthiscoverage./ApplicantSignatureDateAphotocopyofthisauthorizationshallbevalidastheoriginal./Mail-address1399TaipingLifeTower,No.1399MinshengRd.PudongNewArea,Shanghai,China/Postcode:200135/Tel:[phone]