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INFORMATION DISCLOSURE AND AUTHORIZATION FORM |
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個人資料披露及授權表格 |
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ALL RESPONSES MUST BE COMPLETED IN ENGLISH. NON-ENGLISH ANNOTATIONS ARE INCLUDED ON THE FORM AS A COURTESY |
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ONLY. 所有回覆都必須以英文填寫。 表格上英文之外的翻譯只是為了方便提供。 |
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SECTION 1: PERSONAL INFORMATION 第一章節：個人資料 |
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Name in English 英文姓名: Name in Chinese (if any) 中文姓名（如有）: |
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Alias, Former Name or Maiden Name 別名/ 原名: |
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Date of Birth 出生日期 (DD/MM/YYYY): Gender 性別: ☐ Male 男 ☐ Female 女 |
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Country of Issue 簽發國家: |
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/ / |
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Identification No. 身份證號碼: |
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Passport No. 護照號碼: Country of Issue 簽發國家: |
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Place of Birth 出生國家: Date of Expiry 有效日期 (DD/MM/YYYY): |
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Country(ies) of Citizenship 國籍: |
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Holding other passport / Residency status 持有其他國家護照 / 居民身份: ☐ Yes 是 ☐No 否 |
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If Yes, which country 若是，請填寫國家: ______________________________ |
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Status 身份: ☐ PR 永久居民 ☐ Working Visa 工作簽證 ☐ Citizen 公民 |
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Phone No. 電話號碼: Email Address 電郵地址: |
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Current Permanent Residential Address 現居地址: |
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No. of Years If <5 years, please provide previous Residential Address 若於現有住宅地址居住少於 5 年請提供前居住 |
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居住年期: 地址： |
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If <10 years and you have resided in a different country, please state previous country of residence 若您於現有住宅地址居住少 |
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於 10 年及曾在其他國家居住， 請填寫之前的居住國家： |
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Correspondence Address 郵寄地址: ☐Same as Current Permanent Residential Address 與現居地址相同 |
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Highest Academic Qualification 最高學歷: |
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☐ Primary or below 小學或以下 ☐ Secondary 中學 ☐ Post-Secondary or above 大專或以上 |
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Institution (s) 學院: _____________________________________________ Course of Study 學科: __________________________ |
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Language Proficiency 熟練語言: |
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Oral Comprehension 口語理解: ☐ English 英語 ☐ Mandarin 國語 ☐ Cantonese 粵語 ☐ Others 其他: ___________________ |
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Reading Ability 閲讀能力: ☐ English 英文 ☐ Chinese 中文 ☐ Others 其他: _________________ |
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V3.202505 P. 1 of 11 |
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SECTION 2: FAMILY BACKGROUND 第二章節：家庭背景 |
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Relationship Name Age Occupation Marital status Dependent |
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關係 姓名 年齡 職業 婚姻狀況 受撫養人 |
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(Y 是 / N 否) |
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Father 父親 |
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Mother 母親 |
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Spouse 配偶 |
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Son(s) 兒子 |
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Daughter(s) 女兒 |
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Brother(s) 兄弟 |
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Sister(s) 姐妹 |
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SECTION 3: POLITICALLY EXPOSED PERSON INFORMATION 第三章節：參政人員資料 |
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Do you or have you, your family member, close relative* or any individual closely associated (social, business, ☐ Yes 是 |
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professional or otherwise) with you ever held a position in any government, public/civil service, political party, ☐ No 否 |
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military, tribunal, government-owned corporation or international organization? (Close relative, whether living or |
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deceased, means parent, stepparent, child, step-child, adopted child, spouse, domestic partner, spouse or domestic |
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partner of a child, spouse or domestic partner of a step-child, spouse or domestic partner of an adopted child, |
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sibling, step-sibling or adopted sibling.) |
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您或您的家人、近親*或與您密切相關（社交、商業、專業或其他）的人是否曾在政府、公共／公務員、 |
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政黨、軍隊、法院、國有企業或國際機構任職?（當事人的近親， 無論在世或已故， 指生父母、繼父母、 |
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子女、繼子女、養子女、配偶、同居伴侶、子女的配偶或同居伴侶、繼子女的配偶或同居伴侶，養子女的 |
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配偶或同居伴侶、兄弟姊妹、繼兄弟姊妹或養兄弟姐妹。） |
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If Yes, please provide details 若是，請提供具體細節： |
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Name of Individual Position and Duties Country Relationship Starting Ending |
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個人姓名 職銜和職責 國家 關係 Year Year |
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結束年 |
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起始年 |
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V3.202505 P. 2 of 11 |
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Have you plan to be a politician/ government official/ member of labor union/ uniformed force / judiciary？您是 ☐ Yes 是 |
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否計畫擔任為政治家／政府官員／工會成員／軍警人員／司法部門成員？ ☐ No 否 |
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If Yes, please provide details 如是， 請說明詳情：________________________________________ |
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If the last 5 years, have you declared or been petitioned into personal or corporate bankruptcy? 在過去5年， 您 ☐ Yes 是 |
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是否曾宣佈或申請個人破產或公司破產？ ☐ No 否 |
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If Yes, please provide details 如是， 請說明詳情：________________________________________ |
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SECTION 4: THIRD PARTY INFORMATION 第四章節：第三方資料 |
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In completing this questionnaire, are you acting on the instructions of a third party? 在完成這份問卷時，您是 ☐ Yes 是 |
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否按照第三方的指示行事? ☐ No 否 |
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If Yes, please provide details |
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如是，請說明詳情： |
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Name of Individual, company, or organization Date of Birth (DD/MM/YYYY) *for an Individual |
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個人 / 組織 / 公司名稱 出生日期 (日/ 月/ 年) *個人適用 |
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Incorporation number *for a corporation / / |
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註冊商號 *公司適用 |
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Primary Address Jurisdiction of registration *for a corporation |
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主要地址 註冊管轄區 *公司適用 |
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Principal business or occupation of this individual, company, or organization |
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個人職業或公司/ 組織的主營業務 |
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Relationship of this individual, company, or organization |
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與申請人關係 |
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SECTION 5: TRAVEL AND RESIDENCY 第五章節：旅遊及居住地 |
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Travel pattern for the past 2 years 過去兩年的旅遊詳情: |
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Country / Cities Duration of Stay and Purpose of Travel |
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國家 / 城市 Frequency (p.a.) 旅遊的目的 |
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逗留時間及頻率 |
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(Business / Leisure / Others, please specify) |
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(出差/休閒/其他，請說明) |
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V3.202505 P. 3 of 11 |
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Travel pattern for the next 2 years 未來兩年的旅遊詳情： |
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Country / Cities Duration of Stay and Purpose of Travel |
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國家 / 城市 Frequency (p.a.) 旅遊的目的 |
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逗留時間及頻率 |
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(Business / Leisure / Others, please specify) |
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(出差/休閒/其他，請說明) |
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Do you plan to change your country of residence within the next 2 years? 您是否計畫今後兩年變更居住地？ ☐ Yes 是 |
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If Yes, please provide Future Residential Address如是，請提供未來居住地址： ☐ No 否 |
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_____________________________________________________________________________________________ |
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Reason & Duration for Change in Residence遷居原因及居住期: |
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_____________________________________________________________________________________________ |
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Do you plan to return to your current country of residence? 您是否打算回到目前的居住國家? |
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☐ Yes 是 ☐ No 否 ☐ N.A. 不適用 |
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Do you own additional residential properties (vacation home, second home, time share, etc.)? 您是否擁有額外 ☐ Yes 是 |
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的住宅物業（度假屋、第二寓所、分時度假房） ☐ No 否 |
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If Yes, please provide details如是，請提供具體細節: |
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Property Purpose Full Address Amount of time spent there p.a. |
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物業用途 完整地址 每年居住的時間 |
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Please let us know if you and/or any other individual that you provide information to us are subject* of the EU ☐ Yes 是 |
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or EEA so that we can take steps to ensure that the relevant laws are complied with where it relates to the ☐ No否 |
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information that we collect from you and the services that we agree to provide to you 請告訴我們您或是您提 |
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供個人資料給我們的其他任何人是否為歐盟或歐洲經濟區的個體*，因此我們可以採取措施以確保我們向 |
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您收集的資料以及我們同意提供的服務遵守相關的法規。 |
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*The term "subject" is not defined in the relevant legislation but is commonly understood to refer to a resident of and |
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anyone with a place of residence in the relevant jurisdiction. 「個體」 一詞沒有相關法律定義， 但一般被理解為相關管 |
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轄區的居民及任何在該區有居所的人。 |
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V3.202505 P. 4 of 11 |
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SECTION 6: LIFESTYLE 第六章節：生活方式 |
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Have you ever been charged with driving conviction? 您是否曾被指控駕駛罪？ ☐ Yes 是 |
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If Yes, please provide details and dates 如是，請說明詳情和日期： ☐ No 否 |
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☐ Yes 是 |
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Do you have any pending charges, or have you ever been charged with or convicted of any criminal offense, or ☐ No 否 |
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are you currently on probation, parole or statutory release? 您目前或以往是否曾因任何刑案被檢控或判罪？ |
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或者您目前是否正處於緩刑、假釋或法定釋放？ ☐ Yes 是 |
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If Yes, please provide details and dates 如是，請說明詳情和日期: ☐ No 否 |
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____________________________________________________________________________________________ |
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Have you ever used tobacco or nicotine products in any form (including and not limited to cigarettes, cigars, |
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cigarillos, pipe,chewing tobacco, vapour products, marijuana, nicotine patches/gum, hookah or shisha)? 您是否 |
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曾經使用過任何形式的煙草或尼古丁產品 (包括但不限於香煙、雪茄、小雪茄、煙斗、咀嚼煙草、大麻、 |
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尼古丁貼片/口香糖、水煙或電子煙)? |
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If Yes, please provide details: 如是，請說明詳情: |
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Product(s) 產品 Amount(s) and Current 當前/ Past 過去 Date(s) last used上次使用日 |
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frequency of use 期 (dd/mm/yyyy) |
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用量和使用頻率 |
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Do you exercise on a regular basis? ☐ Ball games 球類運動 ☐ Gym 健身 ☐ Brisk Walking 健走 |
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您是否有定期做運動？ ☐ Jogging 慢跑 ☐ Others 其他: _______________________________ |
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Duration & Frequency 持續時間及頻率： |
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Do you engage in or intend to ________________________________________________________ |
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engage in any hobby(s) or activity(s)? |
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您是否參與或打算參與任何業餘愛 ☐ Reading 閱讀 ☐ Music 音樂 ☐ Gardening 園藝 |
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好或活動？ |
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Do you engage in or intend to ☐ Dancing 跳舞 ☐ Others 其他：_______________ |
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engage in any hazardous activity(s)? |
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您是否參與或打算參與任何危險活 ☐ Aviation 航空飛行 ☐ Sky Diving 跳傘 ☐ Scuba Diving 潛水 |
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動？ |
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☐ Powerboat racing 賽艇 ☐ Sports car 賽車 ☐ Motorcycle 摩托車 |
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☐ Rock or Mountain climbing 攀岩或登山 |
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☐ Others 其他: |
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_________________________________________________________________________ |
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If Yes, complete relevant Questionnaire. 如有，請完成相關問卷。 |
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SECTION 7: MEDICAL ADVISOR / CLINIC / HOSPITAL INFORMATION 第七章節：醫療詳情 |
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Name of personal physician, medical clinic, healthcare advisor or hospital consulted私人醫生/醫院名稱： |
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Street Address 地址: |
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State / Province 州/省: Country / City 國家/城市: Postal Code 郵遞區號: |
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Name on file (if different than legal name) 姓名 (如果與法定名稱不同): Date last visited上次訪問日期: |
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Reason for last medical consultation 上次就醫的原因: |
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Treatment on medication prescribed and results of any tests completed 處方藥物治療和任何測試的結果: |
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V3.202505 P. 5 of 11 |
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If you have no personal physician or health care advisor, please provide details of why you last consulted any medical clinic, |
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health care advisor or hospital. 如果您沒有私人醫生或醫療保健顧問，請提供您上次諮詢任何醫療診所、醫療保健顧問或 |
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醫院的詳細原因。 |
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Name of personal physician, medical clinic, healthcare advisor or hospital consulted 私人醫生、醫療診所、醫療保健顧問或醫 |
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院名稱: |
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Street Address 地址: |
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State / Province 州/省: Country / City 國家/城市: Postal Code 郵遞區號: |
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Name on file (if different than legal name) 姓名（如果與法定名稱不同）: Date last visited上次訪問日期: |
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Reason for last medical consultation 最後一次就醫的原因: |
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Treatment on medication prescribed and results of any tests completed 處方藥物治療和任何測試的結果: |
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SECTION 8: TAX RESIDENCY 第八章節：稅務居住地 |
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Country / Jurisdiction of TIN If no TIN available, please enter If Reason B is selected, pls explain why |
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Tax Residency 稅務編號 the Reason A, B or C^ you are unable to obtain a TIN |
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國家 / 稅務管轄區 如沒有提供稅務編號, 請填寫理 如選擇理由 B, 請在以下的方框填寫不 |
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由 A、B 或 C^ 能提供稅務編號的原因 |
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1) |
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2) |
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3) |
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*"TIN" (including "functional equivalent”) 「稅務編號」（包括具有等同功能的識辨編號）: |
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The term "TIN" means Taxpayer Identification Number or a functional equivalent in the absence of a TIN. A TIN is a unique combination of letters or |
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numbers assigned by a jurisdiction to an individual or an Entity and used to identify the individual or Entity for the purposes of administering the |
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tax laws of such jurisdiction. Further details of acceptable TINs can be found at the OECD automatic exchange of information portal. |
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包含英文字母或數字的組合， 由司法管轄分配給個人或實體， 用以在其稅務管理上作識辨個人或實體之用。更多關於稅務編號的詳情可 |
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在經濟合作與發展組織的自動交換資料網站找到。 |
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^If a TIN is unavailable, please provide the appropriate reason A, B or C where indicated below: |
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如沒有提供稅務編號， 必須填寫合適的理由A,B或C |
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Reason A - The country/jurisdiction does not issue TINS to its residents |
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理由A －居留司法管轄區並沒有向其居民發出稅務編號。 |
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Reason B - I am unable to obtain a TIN or equivalent number (Please explain why you are unable to obtain a TIN in the below table if |
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you have selected this reason) |
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理由B －本人不能取得稅務編號。如選取這一理由， 請解釋不能取得稅務編號的原因。 |
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Reason C - No TIN is required (Only this reason if the domestic law of the relevant jurisdiction does not require the collection of the |
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TIN issued by such jurisdiction) |
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理由 C －本人毋須提供稅務編號。居留司法管轄區的主管機關不需要帳戶持有人披露稅務編號。 |
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V3.202505 P. 6 of 11 |
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The United States of America ("US") Person Self Declaration 美國人士自我聲明 |
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For the purposes of this declaration, "US Person" means 在此聲明中，美國人士的意思是： |
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(i) any natural person who is a US citizen (including dual or multiple citizenship/passport holders); or任何是美國公民 |
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的自然人（包括雙重或多重公民身份或護照持有者）；或 |
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(ii) any natural person who is "US resident alien" (e.g. Green Card Holder, in possession of a US alien registration card as |
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a lawful permanent resident issued by the US citizenship and immigration Service); or |
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任何是「美國居住外國人」（例如綠卡持有者，由美國公民及移民服務局簽發可作為合法永久居民的美國外 |
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國人登記卡之持有者）的自然人；或 |
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(iii) any natural person who is a lawful US permanent resident for immigration purposes; or |
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任何就移民而言是美國合法永久居民的自然人；或 |
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(iv) any natural person who meets a "substantial presence test" (e.g. present in the US for at least 183 days in the |
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current year); or |
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任何符合實際存在測試（例如該年度在美國至少有183日）的自然人；或 |
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(v) any natural person who is a tax resident of the US (e.g. dual residency, spouse filing jointly); or |
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任何是美國稅務居民（例如雙重居民身份、配偶聯合報稅）的自然人；或 |
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(vi) any natural person who is a US citizen by operation of relevant laws of the US. |
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任何是由美國相關法律實施的美國公民的自然人。 |
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Based on the above definition, I confirm and declare that (Please check the applicable status): |
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根據以上定義， 本人確認及作出聲明 (請選擇適當身分): |
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☐ I am not a US Person本人不是美國人 |
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☐ I am a US Person本人是美國人 |
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SECTION 9: EXISTING AND PENDING INSURANCE COVERAGE 第九章節：現有和申請中的保險 |
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Insurance Company Sum Assured (USD) Type of Insurance Pending / Inforce |
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保險公司 總保額 (美元) 保險類型 待批 / 已生效 |
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☐ Life Insurance人壽保險 ☐ Pending待批 |
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☐ Savings Plan儲蓄計劃 ☐ lnforce已生效 |
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☐ Critical Illness重大疾病 Year issued 投保年度: |
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☐ Others 其他_____________ __________ |
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☐ Life Insurance人壽保險 ☐ Pending待批 |
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☐ Savings Plan儲蓄計劃 ☐ lnforce已生效 |
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☐ Critical Illness重大疾病 Year issued 投保年度: |
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☐ Others 其他_____________ __________ |
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☐ Life Insurance人壽保險 ☐ Pending待批 |
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☐ Savings Plan儲蓄計劃 ☐ lnforce已生效 |
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☐ Critical Illness重大疾病 Year issued 投保年度: |
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☐ Others 其他_____________ __________ |
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Ultimate Total Life Insurance coverage intended including inforce and pending applications |
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總人壽保險額包括生效及待批之申請： USD 美元: _________________________________ |
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Total intended Premium for Savings Plan (pending applications only) |
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總儲蓄計劃保費(待批之申請)： USD 美元: ___________________________________ |
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Have you ever been declined, postponed, rated or offered reduced sum assured? 是否曾被拒保、延遲承保、加保 ☐ Yes 是 |
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費或被要求降低保險金額？ ☐ No否 |
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If Yes, please provide details如是，請說明詳情：________________________________________ |
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Is there any intention to replace, revise or use existing insurance to fund current application? ☐ Yes 是 |
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您是否打算替代、修改或使用現有保險以支付是次保險申請？ ☐ No 否 |
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If Yes, please provide details (sum assured/ insurer/ plan type/ year issued) |
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如是， 請說明詳情（保額／保險公司／保險類型／投保年度）： |
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________________________________________________________________________________________________ |
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V3.202505 P. 7 of 11 |
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SECTION 10: EMPLOYMENT DETAILS/ BUSINESS INFORMATION 第十章節：就業詳情／公司資料 |
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Employment Status ☐ Employed 就業 ☐ Homemaker 家庭主婦 ☐ Student 學生 |
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僱傭狀況 ☐ Professional Investor 專業投資者 ☐ Retired 退休 |
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Please provide details of all current and previous employment which are relevant to your current wealth. 提供與您目前的財富有 |
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關的所有當前和以前的工作的詳細資料。 |
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Starting Ending Position & Duties Company (Name, Address and Website) Nature of Business |
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Year Year 職位與職責 公司 (名稱、地址和網址) 業務性質 |
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結束年 |
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起始年 |
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☐ Business Owner 企業擁有人 |
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Company Name 公司名稱： |
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Registered Address 登記地址： |
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Business Address (if different from Registered Address) 營業地址（若與登記地址不同）： |
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Company Website 公司網址： Nature of Business 業務性質： |
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% of Ownership 擁有權比例： Year Established 成立年份 : |
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Position and Duties 職位和職責： No. of Employees 員工數量： |
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Business Type 企業類型 : |
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☐ Corporation (Private/ Public-listed) 公司(私營/上市公司) ☐ Partnership合夥制 ☐ Sole Proprietorship獨資企業 |
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Paid-up Capital 實收資本: Total Assets 總資產: Total Liabilities 總負債: |
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Turnover (last 3 years) Profit after tax (last 3 years) Business Failure/Bankruptcy |
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營業額（過去 3 年）: 稅後利潤（過去 3 年）: 企業倒閉 / 破產： |
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V3.202505 P. 8 of 11 |
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SECTION 11: FINANCIAL DECLARATION 第十一章節：財務申報 |
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a) PERSONAL INCOME STATEMENT (USD) 個人收入報表(美元) |
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☐ Individual 個人 ☐ Joint 聯名 (________%), shared with 與_____________________________ |
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EARNED INCOME 薪酬收入 UNEARNED INCOME 非薪酬收入 |
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Current Year Last Year Current Year Last Year |
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本年度 上年度 本年度 上年度 |
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Salary 薪酬 Interest 利息 |
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Bonus 花紅 Dividends 股息 |
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Rentals 租金 |
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Other |
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其他 |
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Total Earned Income Other |
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薪酬收入總顗 其他 |
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Total Unearned Income |
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非薪酬收入總額 |
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TOTAL ANNUAL INCOME 年度總收入：_________________________________________________ |
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b) PERSONAL BALANCE SHEET (USD}個人資產負債報表（美元） |
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☐ Individual 個人 ☐ Joint 聯名 (________%), shared with 與____________________________ |
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ASSETS 資產 LIABILITIES 負債 |
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Cash and Fixed Deposits Personal Loans |
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現金與定期存款 個人貸款 |
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Margin Account |
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Investments 保證金帳戶 |
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投資 |
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Loan Guarantees |
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Real Estate房地產* 貸款擔保 |
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(Residential/ Commercial) |
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( 住宅 / 商業） Mortgages |
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Net Business Interest 按掲 |
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淨商業利益 Others |
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其他 |
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Personal Properties and Others |
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個人財產及其他 Total Liabilities |
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總負債 |
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Total Assets |
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總資產 |
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TOTAL NETWORTH (ASSETS - LIABILITIES) 總資產淨值 (總資產－總負債): ______________________ |
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*Real Estate (USD)房地產（美元） Date of Purchase Mortgage Current Value |
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Purchase Price 按揭 現值 |
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Address 購買日期 |
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地址 購買價格 |
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V3.202505 P. 9 of 11 |
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SECTION 12: SOURCE OF FUNDS/ SOURCE OF WEALTH 第十二章節：資金來源 / 財富來源 |
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Premium Payor ☐ Self# 本人# |
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保費支付人 ☐ 3rd party, please provide Name and Relationship 若不是閣下， 請提供付款人姓名和關係: |
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__________________________________________________________________________________________ |
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Sources of ☐ Employment 個人收入 ☐ Business Earnings 商業收益 ☐ Inheritance 遺產 |
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Wealth# ☐ Investments 投資 ☐ Others, please specify 其他，請註明:____________________________________ |
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財富來源# |
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Source of ☐ Own Income 個人收入 ☐ Savings 儲蓄 ☐ Premium Financing 保費融資 |
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Funds ☐ Others, please specify 其他，請註明: _________________________________________________________ |
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資金來源 |
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Premium ☐ Yes 是 ☐ No 否 |
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Financing If Yes, please provide details 如是，請說明詳情: |
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保費融資 ___________________________________________________ |
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Has all taxes been paid on the funds that you intend to use for premium payment？ ☐ Yes 是 |
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用來支付保費的資金的相關稅金是否都已支付？ ☐ No 否 |
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If No, please provide details若答[否] ， 請說明詳情: |
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_______________________________________________ |
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Have you ever been investigated or committed tax fraud in any jurisdiction(s)？ ☐ Yes 是 |
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是否曾於任何國家觸犯稅務欺詐或因此而被調査？ ☐ No 否 |
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If Yes, please provide details如是， 請說明詳情: |
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__________________________________________________ |
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#Notes: 1. "Self" includes payment by/ through a structure (PIC/Trust) controlled by you. |
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2. "Source of Wealth" refers to the economic activities which have generated your net worth. |
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＃註: 1. 「本人」包括由自己控管的架構（私人投資公司／信託）支付或透過該架構進行支付。 |
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2.「財富來源」意指為您帶來資產淨值的經濟活動。 |
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SECTION 13: BANKING RELATIONSHIPS 第十三章節：銀行關係 |
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Name of Bank 銀行名稱 Name of Contact 聯絡人姓名 |
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Introducer 介紹人 Type of Account 帳戶類型 Years of Banking 銀行業務年份 |
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☐ Yes 是 ☐ No 否 Name of Contact 聯絡人姓名 |
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Name of Bank 銀行名稱 |
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Introducer 介紹人 Type of Account 帳戶類型 Years of Banking 銀行業務年份 |
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☐ Yes 是 ☐ No 否 |
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SECTION 14: ACKNOWLEDGEMENT AND AUTHORISATION 第十四章節：確認及授權 |
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I acknowledge that the personal information disclosed in this form and any ancillary forms (including medical information) may |
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be used by my appointed representative as a basis for making submission for life insurance on my life and assessment of |
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insurability. |
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本人確認被委任代表可根據此表格及其他附加表格上披露的個人資料（包括醫療資料）來為本人提交人壽保險申請及 |
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評估可保性。 |
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I authorize the below contact person to discuss and/or release my personal information including copies of any records for the |
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purpose of processing my insurance applications. |
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本人授權下述聯絡人討論和/或發放本人的個人資料，包括任何記錄的副本，以便處理我的保險申請。 |
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Name of Institution 機構名稱: _____________________________________________ |
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Name of Contact Person 聯絡人: _____________________________________________ |
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V3.202505 P. 10 of 11 |
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I represent that the information and answers I have provided are complete, correct, and true to the best of my knowledge and |
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belief. |
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本人聲稱以上本人提供的資料及回答就本人所知及所信全是完整、正確和屬實。 |
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I understand that this duty to disclose all information in good faith extends to all information and facts (medical and financial) |
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relating to me. |
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本人明白，本人有責任就關於本人的資料與實情（醫療與財務）作誠實披露。 |
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I understand that the recommendations are based on the information furnished to your company (in particular, the information |
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furnished in the Information Disclosure and Authorization and other ancillary forms) which have been disclosed to your |
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company by me. |
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本人明白貴公司提供的建議是根據本人提供給貴公司的資料（尤其於個人資料披露及授權表格和其他附加表格）而作 |
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出的。 |
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In the event there is any omission of material information or incomplete / inaccurate information has been provided, this can |
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affect: |
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若本人所提供的資料存在任何重要資料的遺漏或不完整 / 不準確，也可能會影響： |
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(a) the results of underwriting in relation to the insurance application; and/ or |
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保險申請的相關承保結果，及 / 或 |
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(b) the validity of the insurance policy that is subsequently issued |
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隨後發出之保單的有效範圍。 |
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I understand that I must notify the insurer of any changes in the facts contained in this form (including but not limited to change |
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in the state of health of any person named in it) before the issue of the policy. Otherwise, it will be assumed that there is no |
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change to the information provided. |
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本人明白，本人必須在保單簽發之前，將與此表格有關之事實的更改（包括但不限於此申請表格上列舉之人士的健康 |
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情況）通知保險公司，否則本人所提供的資料則被定為無任何更改。 |
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This questionnaire does not constitute an offer of life insurance coverage, nor is it intended to be a solicitation on behalf of any |
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life insurance company. |
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此問卷不構成人壽保險的要約，也無意代表任何人壽保險公司進行招攬。 |
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__________________________________________ __________________________________________ |
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Signature of Client/ Date Name of Client |
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客戶簽署 / 日期 客戶姓名 |
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__________________________________________ __________________________________________ |
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Signature of Appointed Representative/ Date Name of Appointed Representative |
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被委任代表簽署 / 日期 被委任代表姓名 |
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V3.202505 P. 11 of 11 |
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