醫護自選醫療保險計劃保障特點創新一站式自選住院醫療計劃, 保障特設住院費用手術費用手術後護理費用及附加醫療保障以供選擇 65 歲前投保, 可保證續保至 100 歲 1 成功投保可額外尊享 95 折保費優惠無索償折扣優惠高達 15% 2 特設自願性自負額以享高達 50% 額外保費折

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1 公務員及非公務員合約僱員自願參與醫療保險計劃

2 醫護自選醫療保險計劃保障特點創新一站式自選住院醫療計劃, 保障特設住院費用手術費用手術後護理費用及附加醫療保障以供選擇 65 歲前投保, 可保證續保至 100 歲 1 成功投保可額外尊享 95 折保費優惠無索償折扣優惠高達 15% 2 特設自願性自負額以享高達 50% 額外保費折扣 24 小時緊急支援服務, 包括海外醫療電話諮詢服務醫療服務轉介及緊急護士出診支援服務 ( 只限香港 ) 投保手續簡便, 毋須身體檢查 1 於續訂保單時, 蘇黎世保險有限公司保留權利增加任何條款或不承保事項於保單上 2 如在保險期內受保人沒有提出任何索償, 則於續訂保單時, 可享有 95 折無索償折扣優惠, 最高可累積享有 85 折靈活組合您的保障計劃兩個簡易步驟即享自由組合的醫療保障步驟 1 選擇基本保障項目先選擇以下任何一節或多節保障 : 第一節房租費用第二節手術費用保障第三節手術後保障醒目提示 : 若同時投保第一節至第三節綜合保障, 可享特別保費優惠及額外保障步驟 2 選擇附加保障項目若選擇綜合保障, 可考慮加入以下其中一個附加保障項目, 以享更大之保障額或保費折扣第四節附加醫療保障此附加保障可助您應付如當遇上嚴重疾病或意外時需要支付的龐大醫療開支第五節自願性自負額您可考慮以自願性質負擔部份住院開支, 從而節省基本保障項目之保費高達 50% 保障範圍一覽表保障項目每名受保人每宗傷疾之最高保障額 ( 港幣 / 元 ) 銅計劃銀計劃金計劃基本保障任選第一節至第三節之任何一節或多節第一節房租費用 1. 房租及一般護理費用最高日數 150 日 150 日 150 日每日最高限額 600 1,000 2, 深切治療部之房租及一般護理費用最高日數 31 日 31 日 31 日每日最高限額 1,200 2,000 4, 陪伴床位費用保障最高日數 31 日 31 日 31 日每日最高限額第二節手術費用保障每名受保人每保單年度於第二節之最高總保障額 150, , , 醫生巡房費最高日數 150 日 150 日 150 日每日最高限額 600 1,000 1, 醫院雜費 8,000 10,000 17, 手術費用 45,000 65,000 85, 麻醉師費用 15,750 22,750 29, 手術室費用 15,750 22,750 29, 住院專科醫生費 6,000 8,000 10, 醫療失誤保障 40,000 80, ,000

3 保障項目每名受保人每宗傷疾之最高保障額 ( 港幣 / 元 ) ( 續 ) 銅計劃銀計劃金計劃第三節手術後保障 1. 手術後門診保障 1,000 1,500 2, 家居看護費用最高日數 31 日 31 日 31 日每日最高限額危疾手術後專科醫生之治療費用每次診症最高限額 1,500 2,000 3,000 每年最高限額 20,000 30,000 50, 人造義肢及輪椅租用 10,000 20,000 30, 心理科或精神科治療費用 10,000 15,000 20, 復康及職業治療費用 10,000 15,000 20,000 附加保障 ( 只適用於選擇綜合保障 ) 任選以下其中一節 # 第四節附加醫療保障每名受保人每宗傷疾之最高保障額 60, , ,000 # 第五節自願性自負額自負額 ( 港幣 / 元 ) 保費折扣 30,000 25% 20% 20% 50,000 35% 30% 25% 80,000 50% 45% 35% 免費額外保障 ( 只適用於綜合保障 ) 意外身故恩恤保障 10,000 20,000 30,000 緊急門診保障每保單年度 3,000 1 只適用於以下 6 種指定危疾 : 良性腦部腫痛癌症慢性肝病心臟病主要器官移植及腎衰竭, 並必須經註冊醫生診斷証實 2 必須由主診醫生推薦或轉介及出院起計 180 天內 # 客戶不可同時選擇附加第四節附加醫療保障及第五節自願性自負額注意事項投保年齡由 15 天至 64 歲若在 65 歲前投保, 可續保至 100 歲保費調整根據保費表所示, 每進入一個年齡界限, 保費便會作出調整附加項目之附加醫療保障 (i) 倘索償總額超逾第二節的保障額, 則可獲賠償索償餘額之 80%, 惟醫生巡房費除外 ;(ii) 如住院超過 150 日, 第一節之房租及一般護理費用及第二節之醫生巡房費則可獲 100% 的賠償, 惟每日最高限額為基本保障之所示金額本計劃乃由蘇黎世保險有限公司承保保費表每保單每年最低保費為港幣 600 元現時年齡每名受保人每月保費 *( 港幣 / 元 ) 銅計劃銀計劃金計劃男女男女男女基本保障第一節房租費用 15 日 - 5 歲歲 - 17 歲歲 - 24 歲歲 - 29 歲歲 - 34 歲歲 - 39 歲歲 - 44 歲歲 - 49 歲歲 - 54 歲歲 - 59 歲歲 - 64 歲第二節手術費用保障 15 日 - 5 歲歲 - 17 歲歲 - 24 歲歲 - 29 歲歲 - 34 歲

4 現時年齡每名受保人每月保費 *( 港幣 / 元 ) ( 續 ) 銅計劃銀計劃金計劃男女男女男女 35 歲 - 39 歲歲 - 44 歲歲 - 49 歲歲 - 54 歲歲 - 59 歲歲 - 64 歲第三節手術後保障 15 日 - 5 歲歲 - 17 歲歲 - 24 歲歲 - 29 歲歲 - 34 歲歲 - 39 歲歲 - 44 歲歲 - 49 歲歲 - 54 歲歲 - 59 歲歲 - 64 歲綜合保障 ( 包括第一節至第三節 ) 可享有九折保費優惠 15 日 - 5 歲歲 - 17 歲歲 - 24 歲歲 - 29 歲歲 - 34 歲歲 - 39 歲歲 - 44 歲歲 - 49 歲歲 - 54 歲歲 - 59 歲歲 - 64 歲 ,131 附加保障第四節附加醫療保障 15 日 - 5 歲歲 - 17 歲歲 - 24 歲歲 - 29 歲歲 - 34 歲歲 - 39 歲歲 - 44 歲歲 - 49 歲歲 - 54 歲歲 - 59 歲歲 - 64 歲 * 保費及年齡組別可不時更改於每年續保時, 蘇黎世保險有限公司有權釐定每年續保時應繳付的保費及其他續保的條款主要不承保事項 1. 保單生效後首 30 天內所患的疾病 2. 投保前已存在之傷疾精神病先天性缺陷癲癇斜視腦積水懷孕整容手術 ( 意外引致除外 ) 酗酒戒毒治療普通體格檢查牙科護理 ( 意外引致除外 ) 愛滋病及其併發症 3. 因肛門瘻膽囊炎腎石尿道或膀胱結石膽石糖尿病胃或十二指腸潰瘍姆趾外翻高血壓或心臟血管疾病肺結核骨瘤血及骨髓的惡性病變接受治療, 其有關保障, 須待保單生效連續 180 天後方可提供 4. 因白內障子宮內膜異位扁桃腺病痔瘡甲狀腺機能亢進聲帶瘜肉 / 皮膚囊腫或腫瘤 / 皮脂腺或肌組織鼻中膈或鼻甲的病理性不正常竇體內器官之腫瘤接受的醫療及手術治療或包皮環切除術, 其有關保障, 則需於保單生效連續 365 天後方可提供 5. 受保人年齡至 8 歲或以前因疝氣而接受的醫療及手術治療

5 門診保門診醫療保障計劃保障特點 1 單一保費可享用無限次門診醫療服務, 包括普通科醫生診治及專科醫生診治龐大醫療網絡, 逾 500 位遍佈港九新界的醫生可供選擇 2 普通科及專科醫生診症, 毋須繳付自負費用 3 計劃亦包括物理治療中醫診症基本中藥及跌打治療費用 2 每年免費身體檢查免費意外住院現金保障高達港幣 10,000 元 1 無限次專科醫生診治只適用於兒童銀金計劃及成人金計劃 2 只適用於金計劃 3 只適用於成人金計劃保障範圍一覽表保障範圍 ( 以每個保單年度計算 ) 每名受保人最高保障額 ( 港幣 / 元 ) 兒童計劃成人計劃計劃銅銀金銀金承保年齡 15 天至 12 歲 15 天至 12 歲 15 天至 12 歲 13 歲至 69 歲 13 歲至 69 歲普通科醫生診症及基本藥物最高次數不限次數不限次數不限次數不限次數不限次數每次自負費用不適用 35 不適用專科醫生診症及基本藥物最高次數不適用不限次數不限次數不適用不限次數每次自負費用不適用 70 不適用不適用不適用 X 光及化驗測試 ,000 物理治療最高次數不適用不適用不適用不適用 10 次 ( 每保單年度 ) 中醫診症基本中藥及跌打治療最高次數不適用不適用不適用不適用 10 次 ( 每保單年度 ) 每次自負費用不適用不適用不適用不適用 25( 中醫 )45( 跌打 ) 意外住院現金保障 ( 每日港幣 500 元, 最長 20 日 ) 10,000 10,000 10,000 10,000 10,000 免費身體檢查不適用不適用每年一次尿液常規檢查總膽固醇血壓及脈搏高度體重及體重指數驗身報告不適用每年一次血糖 ( 空腹 ) 總膽固醇血壓及脈搏高度體重及體重指數驗身報告保費表兒童計劃成人計劃計劃銅銀金銀金每月保費 ( 港幣 / 元 ) 注意事項兒童計劃之投保年齡為 15 天至 12 歲 ; 成人計劃之投保年齡為 13 歲至 69 歲, 續保最高至 75 歲普通科醫生診症及基本藥物中醫診症及基本中藥及中醫跌打治療 : 每天只限上述其中一項診症服務一次普通科醫生診症包括不多於 3 天基本藥物 ; 中醫診症包括不多於 2 天基本中藥 ; 中醫跌打治療包括外敷一劑專科醫生診症物理治療及 X 光及化驗測試 : 每天只限接受上述其中一項診症服務一次專科醫生診症需由網絡醫生轉介, 轉介信有效期為發信日期起計 6 個月內上述提供之門診醫療服務由蘇黎世保險有限公司 ( 本公司 ) 指定的醫療機構所安排及提供本公司保留更改指定網絡醫生的權利網絡醫生並非由本公司僱用, 本公司對此等服務概不負責本計劃乃由蘇黎世保險有限公司承保主要不承保事項 1. 例行身體檢查及調查測試 2. 慢性疾病或受保前已存在的傷疾 3. 生育絕育人工流產或妊娠包括驗孕有關妊娠的併發症不育測試避孕藥物或避孕裝置 4. 女性荷爾蒙測試分析及荷爾蒙補充治療 ( 因病症所引致者除外 ); 所有有關更年期前, 更年期及更年期後的治療均不包括在內 5. 任何現時並不適用但日後合約可能適用的治療, 而其費用可能極之高昂 6. 由性而傳染的病症的治療費用 7. 性障礙治療費用包括但不限於因任何原因引致的性無能勃起障礙或早洩 8. 治療先天性缺陷的治療費用 9. 任何由老年人病老年精神病及精神病而導致的治療包括精神病神經失常情緒低落驚恐厭食症精神分裂及行為失常等 10. 美容手術費用, 純粹為美容的治療 11. 特別要求的藥物 12. 專科 X 光檢驗 13. 慢性酗酒濫用藥物或療養費用 14. 牙科及眼折射功能或糾正視力的治療費用 15. 各類價格高昂之補品及營養藥材 16. 各類市面上預先包裝好出售之健康輔助食品 17. 戰爭侵略外敵行動敵對局面 ( 不論曾正式宣戰與否 ) 內戰叛亂革命反叛軍事或篡權行動或直接參與罷工暴動或內亂事件

6 醫療快線中國保證卡計劃保障特點在中國內地超過 100 間指定醫院廣被接納一旦遇到意外或患病, 受保人只需出示醫療快線中國保證卡, 便保證可即時入院接受治理, 醫療費用以所選計劃的最高賠償額為上限, 毋須受保人付款如入住非指定醫院, 此計劃可代付保證金高達港幣 39,000 元保障範圍尚包括緊急醫療運送子女護送親屬探望接載出院個人意外及個人法律責任提供 24 小時緊急支援服務成功投保可額外尊享 9 折保費優惠保障範圍一覽表保障範圍 ( 只限於中國境內 ) 每宗傷疾最高保障額 ( 港幣 / 元 ) 標準計劃優選計劃醫療保障因疾病或意外受傷所需的醫療費用, 包括門診及醫療費住院病房手術醫生等費用 300, ,000 返回香港後 90 天內繼續接受治療的費用 ( 已包括在上列最高保障額內 ) 75, ,000 緊急醫療運送如受保人遇到意外而嚴重受傷或病重, 可致電蘇黎世 24 小時緊急支援熱線, 即可獲得以下支援 : 安排交通工具運送醫療人員及藥物前往現場救援不設上限接載受保傷者或病人到鄰近的合適地點或返回香港醫治如遇事身故, 將骨灰或遺體運返香港子女護送如受保人在國內遇到意外而嚴重受傷病重或死亡, 其 17 歲以下的同行子女可獲護送返港, 而回港之單程交通費用可獲賠償 10,000 15,000 親屬探望如受保人在國內因嚴重受傷或病重而住院超過 7 天, 可安排一名直系親屬前往照料, 保障包括來回交通及住宿費用, 而住宿費用最高賠償額為每天港幣 1,000 元 10,000 15,000 接載出院當受保人離開指定醫院時, 可獲救護車由醫院接載往火車站碼頭或機場法律責任賠償因意外而導致他人身體損傷或財物損失而需負上法律責任 1,000,000 2,000,000 額外支援服務只需致電蘇黎世 24 小時全球支援熱線, 便可免費為您安排或轉介以下服務 : 預訂前往國內的任何飛機火車或船票適用安排緊急現金匯款, 以應付急時之需 24 小時免費醫療傳譯員及律師轉介附加人身意外保障 ( 可選中國境內或全球保障 ) 因意外而導致死亡 300, ,000 因意外而導致永久傷殘喪失肢體肢體失去功用或單目失去視力 300, ,000 保費表 ( 港幣 / 元 ) 標準計劃優選計劃一年保障兩年保障一年保障兩年保障附中國人身意外保障文職人員 ,118 # 其他 ,420 附全球人身意外保障文職人員 638 1, ,598 # 其他 968 1,549 1,388 2,220 # 本保單不承保正當受保人於任何國家或國際權力機構的任何武裝部隊執行其職務在碼頭倉庫工作在船泊上起卸貨物雜技員航空服務員船員空中工作人員速度競賽駕駛員貨櫃車司機拆卸工人特技人員娛樂事業工作者騎師於地下或水底工作人員爆炸品操作員建築工人高空工作者如搭棚工人馬戲班訓練員偵探戰地記者馴獸師及消防員注意事項投保年齡為 18 歲至 70 歲投保人及受保人須持有有效之香港居民身份證每次旅程最長 100 日, 全年旅程次數不限額外支援服務只屬轉介服務, 受保人需承擔有關費用本計劃乃由蘇黎世保險有限公司承保主要不承保事項因戰爭引發的意外或啟程前已患之傷病或因分娩酗酒或濫用藥物導致的傷病或有違醫生勸喻以及純粹以治療為目的之行程

7 聰明之選保障計劃保障特點一個計劃三重保障, 給您周全保護, 計劃涵蓋 37 種嚴重疾病及兩款附加保障住院現金及意外保障申請手續簡單, 只需回答幾條健康問題並毋須接受體格檢驗 5 款保障級別, 可按人生不同階段之需要而作出選擇無論您或家人 ( 包括配偶子女父母及配偶之父母 ) 皆可投保, 並可享固定保費 1, 讓您理財更有預算危疾保障計劃計劃緊隨醫學發展步伐, 覆蓋 37 種常見危疾包括四大嚴重疾病 ( 癌病心臟病腎病及中風 ) 2 兼具人壽保障 : 倘受保人身故, 可獲 100% 保障額扣除已賠償金額之人壽保障危疾保障一覽表成功投保可額外尊享首兩個月保費豁免亞爾茲默氏病冠狀動脈成形手術障礙性貧血細菌性腦膜炎腦部良性腫瘤失明腦部受損腦外科手術癌症心肌病慢性 / 末期肺病慢性肝病昏迷冠狀動脈手術失聰腦炎突發過濾性病毒肝炎心臟病心瓣手術腎衰竭喪失獨立能力喪失語言能力嚴重燒傷主要器官移植髓質囊性病運動神經元疾病多發性硬化肌肉萎縮症職業性感染愛滋病毒癱瘓中風脊髓灰質炎肺動脈高血壓嚴重類風濕關節炎主動脈手術末期危疾柏金遜症非典型額外症候群危疾保障等級 5 款危疾保障等級 2 款自選附加保障計劃 1 港幣 100,000 元計劃 2 港幣 200,000 元計劃 3 港幣 300,000 元計劃 4 港幣 400,000 元計劃 5 港幣 500,000 元聰明之選住院現金附加保障聰明之選意外附加保障住院現金附加保障不論身處何地, 每日住院現金最高可獲港幣 1,500 元及保障期長達 1,000 日只要住院超過兩個星期, 住院期間可獲部份賠償以解燃眉之急住院現金保障範圍一覽表保障項目保障額 ( 港幣 / 元 ) 計劃 1 計劃 2 計劃 3 計劃 4 計劃 5 住院現金保障 ( 每日 ) ( 每宗病症最長保障期 :1,000 日 ) ,200 1,500 深切治療額外現金保障 ( 每日 ) ( 每宗病症最長保障期 :1,000 日 ) ,200 1,500 長期住院額外保障 ( 每日 ) ( 連續住院 30 日以上及以 970 日為每宗病症最長保障期 ) ,200 1,500 最高賠償總額 891,000 1,782,000 2,673,000 3,564,000 4,455,000 意外附加保障保障因意外而引起之住院或門診治療身體永久傷殘三級燒傷甚或不幸身故保障額最高可達港幣 1,500,000 元以配合您所需意外保障級別保障項目最高保障額 ( 港幣 / 元 ) 計劃 1 計劃 2 計劃 3 計劃 4 計劃 5 意外死亡及永久傷殘保障 300, , ,000 1,200,000 1,500,000 意外醫療費用保障 ( 每宗意外 ) 10,000 15,000 20,000 25,000 30,000 三級燒傷保障 100, , , , ,000 1 蘇黎世人壽保留日後調整保費之權利 2 冠狀動脈成形手術的賠償額為保障額的 10%, 剩餘的保障將會因應有關賠償後而相應扣減注意事項投保年齡為 19 歲至 60 歲 ( 翌年歲 ), 續保最高至 86 歲 ( 翌年歲 ) 有關本計劃詳情及主要不承保事項, 請參閱獨立之聰明之選保障計劃的產品冊子本計劃乃由蘇黎世人壽承保

8 投保熱線本宣傳資料只供參考之用, 並不構成保險合約的一部分, 有關以上保障計劃的內容及細則及不承保事項將詳列於保單之內, 蘇黎世保險集團 ( 香港 ) 保留最終批核權保險顧問 / 經紀 CSB/001C/09/2009 蘇黎世保險集團 ( 香港 ) 香港港島東華蘭路 18 號港島東中心樓電話 : (852) 傳真 : (852) 網址 :

9 Voluntary Medical Insurance Scheme for Civil Servants and Non-Civil Service Staff Enrolment Form Enquiry no. (852) Fax (852) Please complete in BLOCK LETTERS. Applicant s personal details (Please tick as appropriate You are a civil servant non-civil service staff English name: HKID card no. : Chinese name: Sex: Male Female Date of birth: Home address: Flat/Room Floor Block / Building Estate name / Street no. & name / Lot no. // Correspondence address: (if different from Home address) Flat/Room Floor Block / Building Estate name / Street no. & name / Lot no. // District HK/ KLN/ NT / / District HK/ KLN/ NT / / Telephone no. (Home): Mobile phone no.: address (Personal): Staff no.: Telephone no. (Office): Fax no.: address (Business): Position: Name of department & department code: Insured person s details (Please tick as appropriate Insured person 1 Insured person 2 Insured person 3 Insured person 4 Surname Given name Sex HKID card no. Date of birth Relationship with the applicant Self Spouse Children Parents/ Parents-in-laws / Spouse Children Parents/ Parents-in-laws / Children Parents/ Parents-in-laws / Children Parents/ Parents-in-laws / Height (cm) Weight (kg) Occupation & position 1

10 Choice of plan and cover (Please tick as appropriate CareMultiple Medical Insurance Plan Insured person 1 Insured person 2 Insured person 3 Insured person 4 Plan level Basic cover Package Cover (Include Section 1 to Section 3) Package Cover (Include Section 1 to Section 3) Package Cover (Include Section 1 to Section 3) Package Cover (Include Section 1 to Section 3) Section 1 Room & board Section 1 Section 1 Section 1 Section 1 Section 2 Surgical cover Section 2 Section 2 Section 2 Section 2 Section 3 Post-surgery cover Section 3 Section 3 Section 3 Section 3 Additional cover (Only applicable to selection of Package Cover Section 4 Supplementary major medical cover # # Section 4 Section 4 Section 4 Section 4 Section 5 Voluntary deductible # Please choose the deductible amount (HK$) # / Section 5 30,000 50,000 80,000 Section 5 30,000 50,000 80,000 Section 5 30,000 50,000 80,000 Section 5 30,000 50,000 80,000 # # Supplementary major medical cover and Voluntary deductible cannot be chosen at the same time Deductible amount (HK$) / 30,000 50,000 80,000 25% 35% 50% Discount on premium 20% 30% 45% 20% 25% 35% Total premium (HK$) / Monthly premium = Basic cover premium x (1 - Deductible discount (if applicable)) or Basic cover premium + Supplementary major medical cover premium (if applicable) = x (1 - + Annual premium = Monthly premium x 12 = x 12 Annual / Monthly Annual / Monthly Annual / Monthly Annual / Monthly Less 5% premium discount 95 Total premium payable (HK$) / (Minimum annual premium per policy is HK$ Annual / Monthly Annual / Monthly Annual / Monthly Annual / Monthly Effective date of insurance ClinicCare Outpatient Medical Plan Plan type Kid plan Adult plan Kid plan Adult plan Kid plan Adult plan Kid plan Adult plan Plan level (Not applicable to Adult plan (Not applicable to Adult plan (Not applicable to Adult plan (Not applicable to Adult plan Total premium payable (HK$) / Annual premium = Monthly premium x 12 = x 12 Annual / Monthly Annual / Monthly Annual / Monthly Annual / Monthly Effective date of insurance* * * If the enrolment form is received by the company on or before the 15th day of the month, the insurance will be effective on the 1st day of the following month. If the enrolment form is received on or after the 16th day of the month, the insurance will be effective on the 15th day of the following month. *

11 MediExpress China Medical Card Plan Insured person 1 Insured person 2 Insured person 3 Insured person 4 Plan type Standard plan Premier plan Standard plan Premier plan Standard plan Premier plan Standard plan Premier plan Supplementary cover Worldwide personal accident cover China personal accident cover Worldwide personal accident cover China personal accident cover Worldwide personal accident cover China personal accident cover Worldwide personal accident cover China personal accident cover Insurance period 1-year 2-year 1-year 2-year 1-year 2-year 1-year 2-year Total premium payable (HK$) / Annual / Biennial Annual / Biennial Annual / Biennial Annual / Biennial Effective date of insurance Medical Questionnaire Applicable to application for CareMultiple Medical Insurance Plan and MediExpress China Medical Card Plan All questions must be answered in full by all insured person(s). Yes No 1. Have the insured person(s) planned to attend or are currently attending or have attended in the past 5 years any hospital or sanitarium for surgery, observation and treatment or require medication due to any illness or effects of an accident?? 2. Have the insured person(s) ever had any physical disability or suffered from any congenital abnormalities and/or disease, chronic disease or hereditary disease or any disorder on physical conditions? /? 3. Have the insured person(s) ever had an application, reinstatement or renewal for the same kind of insurance policy or life insurance or medical benefit insurance been refused or subject to special terms and conditions?? 4. Have the insured person(s) ever pursued any claim/loss history in the past 3 years? /? 5. Do the insured person(s) currently have any individual medical insurance or hospital cash insurance (excluding group medical insurance provided by your employer)?? If the answer to any of the above question is Yes, please give full details below. (If the space provided is insufficient, please use a separate sheet to give details.) Name of insured person Question 1 Reason(s) of being subject to special terms and conditions or additional premium or being refused for enrolment or renewal of life or medical insurance Question 2 Details of physical impairment, diagnosis & treatment received (including any kind of medication treatment) Question 3 Present health condition Question 4 Period of medical treatment Question 5 Name & address of attending doctor Question 6 State the name of insurer and number of individual medical insurance the insured person currently has 3

12 Premium payment (Please tick as appropriate By cheque ( Only applicable to annual payment mode Cheque no. Bank name Cheque made payable to Zurich Insurance Company Limited If the cheque issuer is not the applicant, please fill in the following information. Relationship with the applicant By credit card Annual payment Monthly payment (The first two months premium will be debited in the first billing Credit card type Cardholder s name Cardholder s HKID card no. Credit card no. Credit card expiry date M Y By bank account Annual payment Monthly payment (Please fill in the direct debit authorization form and pay the first three months premium by cheque Account holder s name Account no. I hereby authorize Zurich Insurance Company Limited to debit automatically the premium due from my credit card / bank account above on a monthly / yearly basis, including payment for the subsequent years / instalments upon my acceptance on renewal of the insurance plan(s) applied above until further written notice from me. I accept full responsibility for any overdraft on my credit card / bank account which may arise as a result of such transfer. I agree that should there be insufficient funds in my account to meet any transfer authorized here, the Bank has the right not to effect such transfer in which event the Bank may make the usual service charge. / / / / If credit cardholder / bank account holder is not the applicant, please fill in the following information. / Relationship with the applicant Signature of credit cardholder / bank account holder: Date D M Y Declaration 1. I/We hereby apply for Zurich s Voluntary Medical Insurance Scheme for Civil Servants and Non-Civil Service Staff ( this Plan ). I declare that to the best of my/our knowledge and belief the information given on this enrolment form is true and complete in every respect and all information disclosed have been verified by me as true and correct. I declare that I have full and complete authority from the insured person to sign this application and disclose any personal information in relation to me/us being requested to assess this application and I agree that this enrolment form and declaration shall form the basis of the contract between me/us and Zurich Insurance Company Limited ( the Company ). 2. I authorize the Company to obtain medical information from my/our medical practitioner(s) and I agree to supply additional information relevant to this Plan at my own expense. 3. I/We hereby agree and undertake to settle any medical expenses that is not payable or not covered by MediExpress China Medical Card Plan or any amount in excess of the insurance limit within 14 days after written notification from the Company. The credit facility will be suspended if I/we fail to reimburse the Company within the above specified time. Upon suspension, I/we have to return all the MediExpress China Medical Card(s) to the Company and will remain liable to the Company for any outstanding payment in arrears. In the event of card loss, I/we should advise the Company within 48 hours and pay HK$100 for each replacement card. I/We understand that the arrangement for emergency cash transfer is subject to the service provider nominated by the Company first securing payment from me/us (N.B. applicable to application for MediExpress China Medical Card Plan only). 4. I/We understand that all the personal information collected or held by the Company, howsoever obtained, may be used by or disclosed to any individual or organization within or outside Hong Kong for the following purposes: (1) to assess and service this application, (2) to process the direct debit authorization or credit card payment, (3) to provide marketing material of the Company or its associated companies and (4) to conduct insurance claims or analysis. 5. I/We understand that I/we may contact the Company s Personal Data Privacy Officer at 24-27/F, One Island East, 18 Westlands Road, Island East, Hong Kong for any request to access to and/or correct my/our personal information held by the Company. 1. /()/ / / 2. / 3. / / / 100 / / 4. / (1) (2) (3) (4) 5. // // This insurance application will not be in force until it has been accepted by the Company and the premium has been paid. Applicant s signature: Date: For internal use only Authorized agent/ Broker / Name of insurance consultant Contact tel. no. of insurance consultant CSB/002/09/2009 Zurich Insurance Group (Hong Kong) 蘇黎世保險集團 ( 香港 ) 24-27/F, One Island East, 18 Westlands Road, Island East, Hong Kong Customer Services Hotline (852) Fax (852)

13 Direct Debit Authorization 直接付款授權書 I/We hereby authorize my/our below-named Bank to effect transfer from my/our account to that of Zurich Insurance Company Limited (name of beneficiary) in accordance with such instructions as my/our Bank may receive from the beneficiary from time to time provided always that the amount of any one such transfer should not exceed the limit indicated below. 本人等現授權本人等的下述銀行, 根據受益人或其往來銀行不時給予本人等銀行的指示自本人等的戶口內轉賬予蘇黎世保險有限公司受益人, 惟每次轉賬金額不得超過以下的限額 I/We agree that my/our Bank shall not be obliged to ascertain whether or not notice of any such transfer has been given to me/us. 本人等同意本人等的銀行毋須證實該等轉賬通知是否已交予本人等 I/We jointly and severally accept full responsibility for any overdraft (or increase in existing overdraft) on my/our account which may arise as a result of any such transfer(s). 如因該等轉賬而令本人等的戶口出現透支或令現時的透支增加, 本人等願共同及各別承擔全部責任 I/We confirm that my/our signature(s) on this application form is/are the same as that/those for the operation of my/our Savings/Current Account to be debited for the transfer. 本人等確認本人等在此表格上的簽署與本人等用以轉賬的戶口的簽署相同 I/We agree to notify Zurich Insurance Company Limited (name of beneficiary) of any change of bank account or cancellation of payment method and further agree that should there be insufficient funds in my/our Bank account to meet any transfer hereby authorized, the Bank shall be entitled, at its discretion, not to effect such transfer in which event the Bank may make the usual service charge to be paid by me/us. 本人等同意會通知蘇黎世保險有限公司受益人任何銀行戶口的變更或取消交費方式, 亦同意如本人等的戶口並無足夠款項支付該等授權轉賬, 本人等的銀行有權不予轉賬, 且銀行可收取慣常的收費 This authorization shall have effect until further notice or until the expiry date written below (whichever shall first occur). 本授權書將繼續生效直至另行通知為止或直至下列到期日為止以兩者中最早的日期為準 I/We agree that any notice of cancellation or variation of this authorization which I/we may give to my/our bank shall be given at least two working days prior to the date on which such cancellation/variation is to take effect and at the same time such notice shall be given to the beneficiary. 本人等同意, 本人等取消或更改本授權書的任何通知, 須於取消 / 更改生效日最少兩個工作天之前交予本人等的銀行及受益人 Account number 戶口號碼 : Bank name 銀行名稱 : Name of account-holder(s) 戶口持有人 : (As recorded on statement/passbook Please complete in English) ( 在結單 / 存摺上所有紀錄的名稱請以英文填寫 ) ID no. of account-holder(s) 戶口持有人的身分證件 : ID Type* 身分證件類別 * : Limit for each payment/month# 每次 / 月付款限額 # : HKD 港幣 Debtor s reference 債務人參考 : Expiry date 到期日 : Signature of Account-holder(s) 戶口持有人簽署 : * ID type 身分證件類別 : I = HKID 香港身分證 P= Passport 護照 B = Business Registration 商業登記證 C = Certificate of Incorporation 公司註冊證書 X = Others 其他 # If limit for each payment/month is not specified, the debtor s bank will set the limit as unlimited. 如每次 / 月付款的限額一欄未有填上, 債務銀行會將轉賬限額設定為不設上限 wìêáåü=fåëìê~ååé=`çãé~åó=iáãáíéç=e~=åçãé~åó=áååçêéçê~íéç=áå=pïáíòéêä~åçf= OQJOTLcI=låÉ=fëä~åÇ=b~ëíI=NU=tÉëíä~åÇë=oç~ÇI=fëä~åÇ=b~ëíI=eçåÖ=hçåÖ= qéäééüçåéw=eurof=ovsu=oooo=c~ñw=eurof=ovsu=mvuu==üííéwllïïïkòìêáåükåçãküâ= 蘇黎世保險有限公司 ( 於瑞士註冊成立之公司 ) 香港港島東華蘭路 NU 號港島東中心 OQJOT 樓 = 電話 :EUROF=OVSU=OOOO= 傳真 :EUROF=OVSU=MVUU==ÜííéWLLïïïKòìêáÅÜKÅçãKÜâ=

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ch_code_infoaccess 地產代理監管局公開資料守則 2014 年 5 月目錄引言第 1 部段數適用範圍 1.1-1.2 監管局部門 1.1 紀律研訊 1.2 提供資料 1.3-1.6 按慣例公布或供查閱的資料 1.3-1.4 應要求提供的資料 1.5 法定義務及限制 1.6 程序 1.7-1.19 公開資