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HK Uw Fna Saq - Fna

This document is a suitability assessment questionnaire for medical insurance products, specifically for medical and critical illness coverage. It requires the proposed policyholder to provide personal information, insurance objectives, and needs, and to confirm understanding of the personal information collection statement. The form must be completed in block letters and signed, with a warning against leaving any questions unanswered.

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Yang Qiujian
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13 views1 page

HK Uw Fna Saq - Fna

This document is a suitability assessment questionnaire for medical insurance products, specifically for medical and critical illness coverage. It requires the proposed policyholder to provide personal information, insurance objectives, and needs, and to confirm understanding of the personal information collection statement. The form must be completed in block letters and signed, with a warning against leaving any questions unanswered.

Uploaded by

Yang Qiujian
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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醫療保險產品合適性評估問卷 (適用於醫療及危疾保障 – 與 FNA 一併遞交)

SUITABILITY ASSESSMENT QUESTIONNAIRE FOR MEDICAL INSURANCE PRODUCT


(APPLICABLE TO MEDICAL AND CRITICAL ILLNESS COVERAGE – SUBMIT WITH FNA)
(準)保單持有人姓名 (準)受保人姓名 要保書/保單號碼
Name of (Proposed) Policyholder Name of (Proposed) Insured Application/Policy No.

保險中介人資料 INSURANCE INTERMEDIARY’S INFORMATION


保險中介人姓名 Name of Insurance Intermediary

保險中介人編號 Insurance Intermediary’s Code 聯絡電話 Contact No.

重要事項 IMPORTANT NOTES


1. 此表格應由(準)保單持有人以正楷填寫及簽署。This form is to be filled in BLOCK LETTERS and signed by (Proposed) Policyholder.
2. 請在適當的格內填上「」。Please tick the appropriate boxes where applicable.
第一部份 (準)受保人的醫療保險目標及需要
Part I Medical Insurance Objectives and Needs of the (Proposed) Insured
1. 閣下購買醫療保險產品的目標為何？（勾選一項或多項）
What are your objectives for seeking to purchase a medical insurance product? (tick one or more)
□ (a) 為應付未來醫療保健需要 Preparation for future healthcare needs
□ (b) 為應付上漲的醫療保健費用 Preparation for increasing expenses for medical and healthcare services
□ (c) 為應付因傷殘/住院時的收入損失 Preparation for loss of income during disability / hospital confinement
2. 閣下需要的醫療保險產品種類為何？（勾選一項或多項）
What are your insurance needs in respect of any medical insurance product, i.e. types of the products? (tick one or more)
□ (a) 彌償 Indemnity
□ (b) 非彌償 Non-indemnity
□ (c) 混合型 Combo

個人資料收集聲明 PERSONAL INFORMATION COLLECTION STATEMENT


本人/我們確認已閱讀及明白「中國人壽保險（海外）股份有限公司」的收集個人資料聲明。有關最新版本的收集個人資料聲明，可於
www.chinalife.com.hk 下載或向中國人壽保險（海外）股份有限公司索取。
I/We confirm that I/we have read and understood Personal Information Collection Statement (”PICS”) of China Life Insurance (Overseas) Company Limited. For
the latest version of PICS, it can be downloaded from www.chinalife.com.hk or available upon request.

_________________________________  ____________________________________  ______________/___________/____________


保險中介人簽署 (準)保單持有人簽署 年 Year 月 Month 日 Day
Insurance Intermediary’s Signature (Proposed) Policyholder’s Signature

警告：請不要留空任何問題。如有任何未回答的問題未被刪去，請不要在表格上簽署。
WARNING: Do not leave any questions blank. Do NOT sign if any questions are unanswered and have not been crossed out.

注意 Note：
若問卷上填報的資料有重大改變，閣下在保單未簽發前，必須通知本公司。
You are required to inform us (the insurance company) if there is any substantial change of information provided in this questionnaire before the policy is issued.

HK-UW-FNA-SAQ_FNA/202011-01 1/1

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