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时间:2020-04-09
《团体被保险人个人告知声明书DECLARATIONOFHE.pdf》由会员上传分享,免费在线阅读,更多相关内容在工程资料-天天文库。
1、单证号:01006团体被保险人个人告知声明书DECLARATIONOFHEALTH由被保险人填写正反面并由其本人签名TobecompletedbytheInsuredandpleasesigntheDeclarationoverleaf被保险人姓名InsuredName.(NameonChinaIDCard)性别□男性Male出生日期(DateofBirth)姓/Surname:名/Givenname:Sex□女性Female年Y月M日D□身份证号码ChinaIDNo.婚姻状况(MaritalStatus)基本月薪(MonthlySalary)□其它证件(Othercertif
2、icate)□未婚SingleRMB元/Yuan请在下面空格处填写对应号码:□已婚MarriedPleasefilltherelatednumberintheblank:□离婚Divorced职位(Position)__________________□丧偶Widowed工种(Occupation)工作范围/Duties:您是否有机动车辆驾驶执照?(如有,请详述驾照类型)DoyouhaveanyDrivingLicense?If“yes”,pleasegivethetypeofthelicense.您是否有驾车肇事记录?Doyouhaveanyrecordofcausingan
3、accident?您是否参加危险性或比赛性运动,请在此详述。Doyouengageinanyhazardousororganizedsports?If“yes”,pleasegivedetails.您现在是否有任何人身保险?如有,请详述险种名称、保额、保险公司。Doyouhaveanylifeorhealthinsurancenow?If“yes”,pleasegivetheplan,suminsuredandinsurer.请清楚回答下列问题过去12个月之体重改变身高体重改变原因PleaseanswertheAnyweightchangeduringtheHeightWeig
4、htReasonforChangefollowingquestionspast12monthscarefully米/m公斤/kg+/-公斤/kg以下问题必须选择“是”或“否”(AllQuestionsmustbeanswered“Yes”or“No”)是/否Y/N1)您是否全职工作及现在是否正常工作?Areyounowonafull-timebasisandactiveinyourjob?2)就您所知,您是否有身体缺陷、畸形、或身体不正常?Tothebestofyourknowledge,doyouhaveanyphysicalimpairmentordeformityorde
5、parturefromgoodhealth?3)在过去五年内,您是否接受或被建议接受X光检查,心电图或血液检验(例如胆固醇、后天免疫缺乏症,肝炎包括乙型肝炎、贫血等)?HaveyouhadorbeenadvisedtohaveanX-ray,ECGorbloodtest(e.g.,Cholesterol,AIDS,HepatitisincludingHepatitisB,anaemiaetc)inthelastfiveyears?4)在过去五年内,您是否进行过外科手术或疗养或接受治疗?Haveyouhadasurgicaloperationorbeenconfinedortre
6、atedinanyhospital,sanatoriumorotherinstitutioninthelastfiveyears?5)您是否接受过下列疾病之治疗或被报告曾患下列疾病:高或低血压,心脏、静脉或动脉问题,风湿热,昏倒病,肺部或呼吸问题,哮喘,气肿,胸膜炎,结肠炎,溃疡,胃、胆囊、肝或直肠问题、疝气,糖尿病,任何结核病,肾胰脏、膀胱或生殖及泌尿系统问题,甲状腺,性病、梅毒,精神或神经的问题,羊癫病,痛风,脑部疾病,关节炎或风湿病,骨骼、神经痛,背部或脊骨问题,癌症,肿瘤,畸形,瘫痪,丧失听觉、视觉或肢体,任何其他以上未提及的健康情况,损伤及病症,后天免疫力缺乏症(艾滋
7、病),与艾滋病有关的并发症或状况?Haveyoueverbeentreatedfororbeentoldtohavehighorlowbloodpressure;heart,veinorarterytrouble;rheumaticfever;faintingspells;lungorotherrespiratorytrouble;asthma;emphysema;pleurisy;colitis;ulcers;stomach,gallbladder,liver,intestinalorre
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