China Pacific Life Insurance Personal Life Insurance Application Form

Personal insurance personal insurance policy

Application number:

-

| Types of insurance ||

| - | - |

||||||| Name of the applicant ||||| ID number|||| Relationship with the insured ||

|| - | - | - |

|||||||| Address |||||| Postal Code||||| Telephone ||

| - | - | - | - | - | - |

||||| Name |||| Age||| Gender||| ID number||

|| - | - | - | - | - |

| Address |||||| Postal Code|||| Telephone

| - | - | - | - |

|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||

| - | - | - | - | - | - |

|||||||||| Time of collection ||||| Method of collection |||| Amount of collection |

| - |

| Insurance period | From noon of the current month 12 to noon of the current month 12 |

| - |

| Basic insurance amount | Additional insurance amount |

| - | - |

|||||||||||||||||||||||||||||||||||

||||||| | | | | |

|||||||| Amount of sickness and disability insurance ||||

|||||||| |

|||||||| |

|||||||| Additional risks ||

||||||| Insurance amount |

||||||| Exchange rate||

| - | - |

Insurance premium ||

| - | - |

Insurance principal ||

| - | - |

| Payment form | One-time payment □ Annual payment □ Semi-annual payment □ Quarterly payment □ Monthly payment □ Other: |

| - | - |

|||||||| Payment method |||

| - | - | - | - |

||||||||||||||||

-

-

Special agreement: |

||

||

||

| - |

Health status of the insured: |

| 1. Are you still on sick leave? □ Yes □ No |

|2. Rest due to illness or reduce workload due to illness? □ Yes □ No |

|3. Unable to work full-time or often absent from work due to other chronic diseases? □ Yes □ No |

|4. Any serious medical history? □ Yes □ No |

|5. Cancer, liver cirrhosis, epilepsy, concussion, psychosis, heart disease, hypertension, arteriosclerosis, sexually transmitted diseases, etc. □ Yes □ No |

||

| Is the insured healthy? □ Yes □ No |

||

| - |

Insurance statement: |

| 1) All the contents in this insurance policy are true, which can be used as the basis for your company to issue an insurance policy and become a group of both parties |

In the future, if it is found to be inconsistent with the facts, even if the policy is issued, your company may not assume any responsibility. |

|2) If you tick in the box of this application form, it will be regarded as the applicant's "agreement" or "yes" reply. |

|3) The insured should fill in the actual age when applying for insurance. The calculation of the age of the insured shall be based on the ID card, and the calculation method shall be based on the insured.

After the birthday, I began to calculate the age of one full year. If the age is wrong, you should apply for correction at any time and pay the premium and interest, otherwise you will be issued.

When paying, the due benefits shall be calculated according to the ratio of the premium paid by the insured according to the actual age to the premium payable. |

||

| Date of applicant (signature) |

||

-

(The following shall be filled in by the insurance company)

-

| Audit opinion: |

||

||

| Approver (Seal) Company Seal |

||

| - |

Insurance policy number: signer code: signing date: year month day.

-

Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.