投保保全申追溯声明书.doc

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1、投保/保全根据实际运用二选一申请追溯声明书DeclarationforBackdatedAddition/Enrolment本次投保/新增人员根据实际运用二选一在追溯期内（自****年**月**日至****年**月**日）未发生以下事项：Itisherebydeclaredthatnoneofthefollowingoccurredduringthebackdatedperiodtotheperson(s)tobeenrolled/added:1.任何的住院或手术治疗；Anyinpatientorsurgicaltreat

2、ment;2.意外身故或残疾；Accidentaldeathordisability;3.累计5000元以上的治疗费用。TreatmentexpensestotalingRMB5,000.00ormore.声明：本声明书是保险合同的重要组成部分，上述各项声明均属实，如有知情不告的情况，贵公司有权依法解除保险合同，并对保险合同解除前的保险事故不承担保险责任。Declaration:ThisDeclarationisanintegralpartoftheInsuranceContract.Allthestatementsabo

3、vearetrueandcomplete.Ifthereisanyconcealment,youcanrescindtheInsuranceContractinaccordancewithlawsandregulations,andwillbeexemptfrominsuranceliabilitiesforinsuredaccidentsthatoccurpriortosuchrescission.投保单位签章/Applicant(Signature/seal):____________________日期/date：_

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