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1、甲部甲部投保人資料投保人資料 Part A Personal Details of The Proposer 投保人姓名 Name of Proposer 通訊地址 Mailing Address 聯絡電話 Contact No. 電郵地址 E-mail Address乙部乙部投保物業資料投保物業資料 Part B Details of Premises Insured 保險地址 Insured Location 樓宇年齡 Age of Building 建築面積（平方呎） Gross Floor Area (In Square Feet) 佔用性質自住出租 OccupationOwner-o
2、ccupiedTenant-occupied 該樓宇過往有否進行任何裝修工程？是否 Have the building been renovated? YesNo 閣下如在上述回答“是“，請詳述。 If your answer is “Yes“, please give full details.保單生效日期由至(起訖兩日均包括在內) Period of Insurance (dd/mm/yy)FromTo(Both dates inclusive) *本公司並不接納待修理或已接獲政府修葺令之樓宇之投保。The company would not accept the Proposal if
3、the Building is waiting for renewal / have received the Repair Order from the Government.丙部丙部基本保障基本保障 Part C Basic Protection每宗事故保障額 Limit of Indemnity (any one occurrence) 全年保障額（港幣） Limit of Indemnity (any one period)丁部丁部保費保費 Part D Premium20年以下 Under 20 years 20年以上35年以下 Over 20 years Under 35 year
4、s 35年以上40年以下 Over 35 years Under 40 years 40年以上 Over 40 years *本公司亦提供建築面積超過1,000平方呎之樓宇單位。假若閣下有此需要，請電市場部熱線(852) 2137 7631。To Be Negotiated建築面積為建築面積為1,000平方呎以下平方呎以下 Gross Floor Area Under 1,000 Square Feet港幣 HK$ 400.00樓宇年齡 Age of Building保費 Premium住宅業主責任 Premises Liability住宅業主責任 Premises Liability港幣 H
5、K$ 7,500,000不設上限 Unlimited住住 宅宅 業業 主主 責責 任任 保保 險險 投投 保保 書書 Premises Liability Insurance Proposal Form港幣 HK$ 900.00另議港幣 HK$ 600.002137 7631.The Company also covers premises with gross floor area in excess of 1,000 square feet. If You have any needs, please contact the Marketing Department via telepho
6、ne number (852)戊部戊部風險評估風險評估 Part E Risk Assessment 項目 Item(s) 1. 是否有任何特殊情況會提高本保險保障的風險？ Are there any circumstances connected with the risks which would render the Insurance more than normally hazardous? 2. 閣下是否曾申請住宅業主責任保險？ Have you ever insured for Premises Liability Insurance? 3. 閣下是否在申請上述保險或續保時被拒絕
7、撤回取消或附加特別條款？ Have you ever been declined, cancelled, refused or imposed special terms when you apply or renew the above mentioned Insurance? 4. 在過去五年內閣下是否有因本保險保障之風險而蒙受損失？ Have you sustained any loss during the past five years from any of the perils now proposed to cover? 閣下如在上述任何一項回答 “是“, 請詳述。 If yo
8、ur answer is “Yes“ in any of the above question, please give details.己部己部付款方式付款方式 Part F Payment Method支票付款 Cheque劃線支票抬頭人請填寫“中國太平洋保險(香港)有限公司“Please cross your cheque and make it payable to “CHINA PACIFIC INSURANCE CO., (H.K.) LTD.“現金付款 Cash請親臨中國太平洋保險(香港)有限公司 地址 :香港灣仔港灣道18號中環廣場4301室Please pay at the
9、office of China Pacific Insurance Co., (H.K.) Ltd. Address:Suite 4301, 43/F., Central Plaza, 18 Harbour Road, Wanchai, Hong Kong.收集個人資料聲明收集個人資料聲明 閣下提供的資料，為本公司提供保險業務所需，並可能使用於下列目的： 任何與保險或財務有關的產品或服務或該等產品或服務的任何更改、變更、取消或續期Personal Data Collection Statement The information you provide to us is collected t
10、o enable us to carry on insurance business and may be used for the purpose of any insurance or financial related product or service or any alternations, variations, cancellation or renewal of them. any claim or analysis of it.聲明聲明 本人謹此聲明，根據本人所知及所信，上述所有資料均屬實無訛且為事實之全部，而所有能影響該項申請評估的事實因素均已呈報。Declaration
11、是 Yes否 No否 No是 Yes否 No是 Yes否 NoI understand that proposal will not become effective until it has been accepted by China Pacific Insurance Co., (H.K.) Limited and agree that this proposal and declaration should be the basis of the contract between me and China Pacific Insurance Co., (H.K.) Limited.任何
12、索償或索償分析及可能轉移予現存或不時成立的任何有關的公司或任何其他從事與保險或再保險業務有關的公司或與保險業務有關的中介人或索償或調查或其他服 務提供者或任何保險公司的協會或聯會。 閣下有權查閱及要求更正由中國太平洋保險(香港)有限公司持有有關閣下的個人資料，如有此項要求，可向本公司的個人資料(私隱)條例監察主任提出。 聯絡電話(852) 2541 4338本人明白本投保書在中國太平洋保險（香港）有限公司接納後，保單始正式生效。本人亦同意此投保書及聲明將會作為本人與中國太平洋保險（香港）有限公司之間的合 約基礎。I declare that the information given abov
13、e is true and complete to the best of my knowledge and believe that all the material facts affecting the assessment of this application has been disclosed.You have the right to obtain access to and to request correction of any personal information concerning yourself held by China Pacific Insurance
14、Co., (H.K.) Ltd. Requests for such access can be made to our Personal Data (Privacy) Ordinance Compliance Officer. The contact number is (852) 2541 4338.And may be transferred to any related business partners, companies carrying on insurance or reinsurance related business or an intermediary or a cl
15、aims or investigation or other service provider providing services relevant to insurance business or any association or federation of insurance companies that exists or is formed from time to time.是 YesAccount HandlerRemarkTotal PremiumOfficial Use Only投保人簽署 Signature of Proposer日期 DateAgent CodeClient CodeRate and Excess
