1、 Page 1 of 3 卓越 商务行标准 保险 计划 投保单 ( 2 0 1 7 版 ) S m a r t B I Z T r i p I n s u r a n c e S t a n d a r d P l a n P r o p o s a l Fo r m （ 2017） 投保 人资料 Proposer Details *投保人姓名 /投保单位 Name of Proposer: 联系 人 Contact Person: *联系电话 Tel. No.: 通讯地址 Correspondence Address: 邮政编码 Post Code: *组织机构代码 Company Regi
2、stration Code: 传真 Fax No.: 被保险人资料 Details of the Insured Person *姓名 Name 性别 Gender *出生日期 Date of Birth *身份证 /护照号码 ID/Passport No. 国籍 Nationality 职业 Occupation 保险费 (人民币 :元 ) Premium(RMB: Yuan) 身故保险金受益人 (Death Beneficiary)（若身故受益人资料为空白，身故保险金将作为被保险人之遗产；若未填写受益份额，身故保险金受益人将按照相等份额享有身故保险金 。 The death benef i
3、ts shall be paid to the estate of the Insured if Name of the Benef iciary leav es blank. If the benef its shares are not stated, the benef iciaries shall be entitled to equal share of the death benef its） 被保险人姓名 Name of the Insured Person 身故保险金受益人姓名 Name of Beneficiary 身故保险金受益人 证件号码 D/Passport No. o
4、f Beneficiary 受益份额 (%) Share of Benefits (%) 与被保险人关系 Relationship to the Insured Person (1) (2) (3) (4) 投保计划 Type of Plan 单次旅程 Single Journey *旅游目的地 Travel Destination: *保险期间 Insurance Period: 天 days 每次商务旅行最长承保期间最长为 90 天 The maximum duration of each insured trip is 90 days. *旅行开始日期 Insurance Period
5、From: 年 (yyyy) 月 (mm) 日 (dd) （北京时间 Beijing Time） *旅行结束日期 Insurance Period To: 年 (yyyy) 月 (mm) 日 (dd) （北京时间 Beijing Time） 全年旅程 Annual Journey *保单生效 日期 Insurance Period From: 年 (yyyy) 月 (mm) 日 (dd) （北京时间 Beijing Time） *保单满期日 Insurance Period To: 年 (yyyy) 月 (mm) 日 (dd) （北京时间 Beijing Time） 保险费率表 Premium
6、 Table（币种 Currency：人民币 RMB） 保险期间 Insurance Period 保费 Premium 典雅计划 Classic 保费 Premium 尊贵计划 VIP 全年保障 Annual Premium 1,230 2,150 1 4 天 days 90 195 5 8 天 days 140 275 9 12 天 days 190 365 13 16 天 days 240 450 17 20 天 days 285 535 21 24 天 days 335 625 25 28 天 390 715 每增加一周（不满一周按一周计算） Each additional week
7、(less than 1 week shall be deemed as 1 week) x 100 元 /周 weeks x 145 元 /周 weeks 保障利益明细 Schedule of Benefits 承保项目 Cov erage 各被保险人保险金额（人民币 RMB） Maximum Limit per Insured (RMB: Yuan) 典雅计划 Classic 尊贵计划 VIP 1. 人身意外伤害 Personal Accident - 意外事故身故、烧伤及残疾保险金 Accidental Death, Burns The Company shall reimburse t
8、he Insured Person up to RMB1,000 under Sickness Medical Reimbursement for Domestic Travel on the condition that the insured person has no social medical insurance or other expenses reimbursement medical insurance or cannot get reimbursement from the above mentioned insurance; 若被保险人拥有且已从公 费医疗、社会基本医疗保
9、险、其他费用补偿型医疗保险取得医药费用补偿，则本保险公司在 境内旅行的疾病医药补偿 项下承担保险责任的最高限额为人民币 2,000 元，但需扣除被保险人任何已取得之医药费用补偿 ;If the insured person obtains reimbursement from social medical insurance or other expenses reimbursement medical insurance the above mentioned insurance, the Company shall be liable for the balance only, up to
10、 RMB2,000 under Sickness Medical Reimbursement for Domestic Travel; 3. 本计划的 投保年龄为 18 周岁至 80 周岁。 71 周岁至 80 周岁的被保险人，可经保险公司特别审核同意后，予以承保。其 “意外事故身故、烧伤、残疾保险金 ”和 “医药费用补偿 ”的保险金额为上表所载金额的一半，保险费维持不变 ； The Insured Persons must be from 18 to 80 years of age inclusive upon application. For any Insured Person aged
11、 from 71 to 80 years old, can be cov ered only after a special approval by the Company, and the Maximum Limits under “Accidental Death, Burns 6. 每 次旅行的保障期限最长为 90 天； The maximum duration of each insured trip is 90 days； 7. 本保单只适用于以商务旅行为目的的出行计划 ,不包括被保险人往来其日常居住 /工作地或个人旅游 ;This policy is for business tr
12、avel only; 8. 在您填写本投保单时，您可以要求业务人员向您提供保险条款；请您仔细阅读保险条款，尤其是责任免除、免责条款、赔偿限额、免赔额、基本条款等黑体字 /彩色标题标注的条款内容，并听取保险公司业务人员的说明，如对保险公司业务人员的说明不明白或有异议的，请在填写本投保单之前向保险公司业务人员进行询问，如未询问，视同已经对条款内容完全理解并无异议； Please kindly ask for the Policy Wording via Company Representatives before sign the application form. Please read it
13、carefully, especially on exclusion, indemnity limit, deductible, general condition in Bold/ Color heading, and make sure all coverage of the wording is fully understood. Any unclear or unacceptable part, please inquire to the Company Representatives before your sign off. It is assumed that the conte
14、nts have been fully understood and accepted if there is no enquiry 9. 任何在下列期间发生的或由下列原因造成的保险事故，本公司不负任何赔偿责任：战争、军事行动、暴动或武装叛乱期间；侵略、外敌行为、敌对 (不论是否宣战 )、内战、叛乱、革命、起义、军事行动或篡权、受任何政府或国家 权力机构的指挥对财产的没收或国有化或征用或毁坏或破坏的、暴乱骚乱 ； This Policy does not cov er claims: directly or indirectly occasioned by, happening through
15、 or in consequence of: During war, military operations, insurrection or military rising; war or relevant operations (whether war be declared or not), act of terrorism, invasion, hostilities, act of foreign enemy, civil war, strike, insurrection, civ il commotion, rebellion, revolution, civil rising,
16、 military or usurped power； 10. 投保人可于保险合同成立后，保险责任开始前书面申请撤销本合同，本公司 进行审查后符合条件的将退还已缴保费 ，保险合同关系自本 公司同意退费之日解除。除保险期间为一年期的保单， 一旦保险责任开始，保险合同将不予解除 ,并不予退还保险费 ； The insured person may cancel the Policy before the inception date subject to the cancellation terms 13. 若英文译本 与中文有异，以中文版本为准。 Should there be any inco
17、nsistencies between Chinese and English version, the Chinese version shall prevail. 投保人 /被保险人声明 Proposer and Insured Persons Declaration 投保人 /被保险人 谨此声明 1. 本人身体、精神状况良好并无任何不适宜旅行的精神状态或身体状况，旅行并未违反医生的劝告，旅行目的不在于治疗疾病，且对任何可能导致旅行取消 或缩短的Page 3 of 3 状况并不知晓。 The Insured Persons are not traveling contrary to the
18、 advice of medical practitioner, for the purpose of obtaining medical treatment; do not know of any condition, cause or circumstance existing that may necessitate the cancellation or curtailment of the journey. 2. 本人从未遭受任何保险公司拒绝受理投保、续保或取消保险合同或要求提高保费及附加特别约定。 I/We have never been cancelled, declined,
19、refused to renew or imposed special terms & conditions on any policy held by me/ us. 3. 本人已经如实填报一切重要的有关资料，绝无隐瞒或保留任何重大事实以影响贵公司评估风险或接受本投保申请，并同意将本投保单和声明作为 安盛 天平财产保险股份有限公司 和本人所定合约的根据，并以保险条款为准。 I/We declare that the statements and information given in this proposal are, to the best of our knowledge and b
20、elief, true and complete and accept that this proposal and declaration shall be the basis of, and be incorporated in, the contract between AXA Tianping Property & Casualty Insurance Company Limited and myself/ourselves. 4. 本人已经仔细阅读保险条款，尤其是责任免除、免责条款、赔偿限额、免赔额、基本条款等黑体字 /彩色标题标注的条款内容，并对保险公司就保险条款内容的说明和提示完
21、全理解，没有异议，申请投保。 I/We have read the wording carefully, especially on exclusion, indemnity limit, deductible, general condition in Bold/ Color heading, and make sure all cov erage of the wording is well known. 5. 本人 理解并同意保险公司对本投保书有拒绝或者接受的权利。如果保险公司对本投保单没有提出异议，投保人同意保险公司直接安排出具正式保险单。保险合同生效日期以保险单所载生效日期为准，贵公
22、司承担保险责任须以投保人缴付约定保险费并经贵公司同意承保为前提。 I/We understand and agree the insurer has the rights to decline or accept the proposal and agrees to issue the policy directly if the insurer has no doubt of the proposal form. I/We understand and agree that the effective date of the insurance is subject to the appro
23、val of the Company and collection of premium. The Company will issue a formal Policy validated with an authorized signature of the Company. 6. 投保人理解并同意在保险合同订立后，保险公司可因处理与保险合同有关的事项如理赔调查、损失查勘等事务授权第三方公司或者人员基于继续履行保险合同义务的需要查阅与投保人有关的资料或者基于监管部门 /人员的调查要求，在要求 范围内披露投保人的有关信息。 I/We also agree that in case of any
24、 claims, AXA Tianping Property & Casualty Insurance Company Limited could assign any third party for relevant investigation affairs or disclose my/our relevant information based on government department/employees investigation requirement. 7. 本人同意保险公司及 /或安盛集团成员公司、关联公司，可以在安盛集团内部或者外部使用我所提交的以及后续提交的信息，并
25、且为进行保险业务或 /和为了其他相关目的，可以转让或者披露上述信息给那些公司。 I/We agree that the information and any subsequent information submitted by and collected from us may be used by the insurer and/or any company within the AXA Group of companies and/or any of its associated companies, within or outside AXA entity, for the purp
26、ose of carrying on i nsurance business and/or for other related purpose and in this connection, You may transfer or disclose that information to any of those other companies. 8. 本人理解并同意若因提供该保单项下的保障或赔付，致使保险公司或服务提供方违反 (包括但不限于由欧盟、英国、美国制定或根据联合国决议规定的 )国际经济制裁条款、法律或法规，则保险公司以及其他服务提供方将不会提供该项保障或给于赔付。如若发现潜在的违规
27、行为，保险公司将尽快以书面形式通知我 /我们。 I/We understand and agree the Insurer and other service providers will not prov ide cover or pay claims under this policy if doing so would expose us the insurer or the service prov ider to a breach of international economic sanctions, laws or regulations, including but not l
28、 imited to those provided for by the European Union, United Kingdom, United States of America or under a United Nations resolution. If a potential breach is discovered, where possible the insurer will adv ise Proposer and Insured Person in writing as soon as possible. 9. 本人理解并知晓：若本人投保的是安盛天平财产保险股份有限公
29、司北京分公 司的产品，在中国法律允许或要求的范围内，本人同意授权安盛天平财产保险股份有限公司将本人个人信息及保单信息提供给北京意外保险信息平台以作合理利用，如果填写手机号码安盛天平财产保险股份有限公司将为本人提供免费的投保短信提示。 10. I/We understand and agree that the information and any subsequent information submitted by and collected from me/us may be used by AXA Tianping Property & Casualty Insurance Compa
30、ny and Beijing Insurance Information Services Platform, if the insurance was purchased from AXA Tianping Property & Casualty Insurance Company Beijing Branch. I/We understand SMS notice will be sent by AXA Tianping Proper ty & Casualty Insurance Company if my mobile phone number is prov ided. 被保险人签名
31、 Signature of the Insured 被保险人（ 1） Insured Person (1) 被保险人（ 2） Insured Person (2) 被保险人（ 3） Insured Person (3) 被保险人（ 4） Insured Person (4) 日期 Date： 日期 Date： 日期 Date： 日期 Date： _ 投保人签章 Signature of the Proposer _ 日期 Date 业务经办人专用 CONTACT PERSON USE ONLY 业务经办人所在单位 Contact Persons Company： 业务经办人姓名 Contact Person： 经办日期 Date： 保险公司专用 COMPANY USE ONLY 业务员姓名 Producer Name: 渠道 Channel: 联系方式 Contact Information:
