of Incorporation X = Others. 3. Please the appropriate box and complete in BLOCK LETTERS. 4. Any changes should be initialed by the Policyholder.

Transcription

1 *HASEFTX* HASEFTX PICS (06/2014) Policy Number* * IIII Request for Policy Change Financial Related Items (Only applicable to RewardYou Life Insurance Plan, SavourLife Annuity Life Insurance Plan and SavourLife II Annuity Life Insurance Plan and SavourLife II (RMB) Annuity Life Insurance Plan) Name of Policyholder in English (Surname first) # # ID Type &. Name of Life Insured in English (Surname first) # # ID Type &. NOTES: 1. *X Please mark X the appropriate boxes to indicate the policy number. 2. # ID Type I = HKIDP = PassportB = Business RegistrationC = Certificate of IncorporationX = Others. 3. Please the appropriate box and complete in BLOCK LETTERS. 4. Any changes should be initialed by the Policyholder. : To : Hang Seng Insurance Company Limited A. Request for Policy Change/Policy Reinstatement 1. Change of Guaranteed Cash Bonus/Total Guaranteed Income/Sum Insured/Optional Benefit (a) Change of Guaranteed Cash Bonus Only applicable to RewardYou Life Insurance Plan New Guaranteed Cash Bonus Change of Total Guaranteed Income IIII Only applicable to SavourLife Annuity Life Insurance Plan, SavourLife II Annuity Life Insurance Plan and SavourLife II (RMB) Annuity Life Insurance Plan New Total Guaranteed Income (b) * Optional Benefit* Only applicable to RewardYou Life Insurance Plan * Add Delete Reduce New Sum Insured (i) Renewable Term Life Benefit (ii) Waiver of Premium on Disability Benefit (iii) Payor s Benefit * BD If the above optional benefit(s) is/are added, please complete Parts B and D below 2. * Policy Reinstatement* Only applicable to RewardYou Life Insurance Plan * B C Please complete Part B Personal Details. If the optional benefit Renewable Term Life Benefit, Waive of Premium on Disability Benefit or Payor s Benefit is chosen, please also complete Part C Health Declaration for Policy Reinstatement. IL12a-R13 (YX) /17 H

2 B. Personal Details 1. Life Insured and Policyholder s employment details (only applicable for age 18 or above) i) Position (a) Life Insured i) (b) Policyholder i) ii) Industry ii) ii) iii) Job Activities iii) iii) iv) Job Location iv) Indoor Work Outdoor Work Indoor & Outdoor Work iv) Indoor Work Outdoor Work Indoor & Outdoor Work v) Country of Work v) Hong Kong Other v) Hong Kong Other vi) Employer s Name & Address vi) vi) vii) Date of Employment viii) Main source of income/ Funding Source vii) Year Month viii) Business Income Inheritance Return on Investment Salary Saving Others, please state: vii) Year Month viii) Business Income Inheritance Return on Investment Salary Saving Others, please state: 2. Life insured and Policyholder s salary details (Please the appropriate box) i) Life insured s salary details (only applicable for age 18 or above) 20,000 20,000-39,999 40,000 Is your total monthly income (include salary and other cash allowance/bonus) below HKD20,000, HKD20,000 - HKD39,999 or not less than HKD40,000? ii) Policyholder s salary details (only applicable for age 18 or above) 20,000 20,000-39,999 40,000 Is your total monthly income (include salary and other cash allowance/bonus) below HKD20,000, HKD20,000 - HKD39,999 or not less than HKD40,000? IL12a-R13 (YX) /17 H

3 C. Health Declaration for Policy Reinstatement 1. If optional Benefit Renewable Term Life Benefit is chosen, please complete the declaration below: 214? Have you ever had or been told that you have, or are you under current investigation or intending to have investigation for, any heart, lung, kidney, liver or circulatory diseases, high blood pressure, stroke, diabetes, HIV infection or AIDS, liver diseases (include Hepatitis B/C carrier), cancer, or lump or other growths of any kind, or are you suffering from or receiving treatment for, any of the above diseases or conditions, or have you ever been hospitalized for more than 14 consecutive days during the past 2 years? 2. If optional Benefit Waiver of Premium on Disability Benefit is chosen, please complete the declaration of Life Insured as below: If optional Benefit Payor s Benefit is chosen, please complete the declaration of Policyholder as below: (a) 2 Has any proposal or application for life or accident or health insurance (e.g. major illness insurance, out-patient/in-patient insurance or hospital cash insurance, etc) on you or reinstatement of such insurance ever been declined/postponed during the past 2 years? (b) Have you ever suffered from any significant medical condition (e.g. cancer, diabetes, HIV/AIDS, liver diseases (include Hepatitis B/C carrier); heart, kidney, blood, respiratory or digestive system disorder, etc), and/or requires regular follow up and treatment with doctors? (c) Are you engaged or intended to engage in any hazardous sports or activities (e.g. motor sports, mountaineering, scuba diving) or any form of aviation other than as a fare paying passenger on a licensed air service within recognised scheduled routes? (d) (i) Are you engaged in a part-time job or unemployed? (If you are full-time student, housewife or retiree, please answer.) (ii) 25 Does your job nature involve working at heights (over 25 feet), working underground, handling explosives, scuba diving, armed with weapons (exclude Hong Kong or Macau Police), working with or maintaining high voltage power lines and cables? (e) (i) Are you not a Hong Kong or Macau resident holding in Hong Kong or Macau Identity Card? (ii) 12 6If you are Hong Kong or Macau resident holding a Hong Kong or Macau Identity Card, do you intend to stay outside Hong Kong or Macau for more than 6 months consecutively in the next 12 months coming year? D. Personal Details and Health Declaration for Policy If adding Benefit Waiver of Premium on Disability Benefit and/or Renewable Term Life Benefit, please complete the declaration of Life Insured as below: If adding optional Benefit Payor s Benefit, please complete the declaration of Policyholder as below: Personal Details 1. Please provide current country of residence (a) Life Insured (b) Policyholder/Payor/Joint Life Insured 2. Are you covered by any life/medical/hospital cash/critical illness insurance policy (excluding group insurance)? If the answer is, please give information below. Name of Insurance Company Year Issued Amount of Life Insurance (HKD) Amount of Accidental Death (HKD) Amount of Hospital Cash/ Medical Insurance/Critical Illness (HKD) (a) Life Insured (a) Life Insured (b) Policyholder (b) Policyholder 3. Is there any other application of insurance on your life now pending? If the answer is, please give details on name of the company and proposed amount. 4. i. Has any proposal or application for life/accident/ medical/hospital cash insurance on you or reinstatement of such insurance ever been declined/postponed/ accepted at other than normal terms? If the answer is, please give reason and name of the company. ii. Have you ever filed an insurance claim due to hospitalization? If, please provide details. Date Amount of Claims Claim Reason Claim Result IL12a-R13 (YX) /17 H

4 Health Declaration (a) Life Insured (b) Policyholder 1. (a) Life Insured Height: Weight: ft in cm Ib/ kg (b) Policyholder Height: Weight: ft in cm Ib/ kg 2. (a) Life Insured 12Smoking Habit (in the past 12 months) n-smoker Smoker cigarettes per day (b) Policyholder Joint Life Insured 12Smoking Habit (in the past 12 months) n-smoker Smoker cigarettes per day Have you ever taken or used any habit addictive drugs? Have you, in the past 12 months, frequently taken alcoholic drink(s)? If the answer is please state average consumption (such as quantity per day or week) and type Question 4 is for female only i. Are you now pregnant? If the answer is, please state for how many months. ii. Have you ever had complications of pregnancy during gestation in the past 10 years including current pregnancy, if applicable (eg. ectopic pregnancy, abortion, disseminated intravascular coagulation, gestational diabetes, hypertension, protein in urine etc.)? 5. (a)(b)(c)(d)(e)(f) (g)(h) (i)(j)(k)(l) Have any of your parents, brothers, or sisters whether dead or living EVER SUFFERED from (a) heart disease, (b) stroke, (c) cancer, (d) kidney disease, (e) diabetes, (f) high blood pressure, (g) mental disorder, (h) coronary artery disease, (i) liver diseasesinclude Hepatitis B/C carrier, (j) tuberculosis, (k) any hereditary disease or (l) liver disease? If the answer is, please state details of which relative(s), the diagnosis, the onset age and current health condition. 6. Have you ever had, been told by a physician that you had or been treated for cancer, tumour, diabetes, asthma, stroke, heart trouble (including murmur), high blood pressure, lupus erythematosus, rheumatic fever, lung disease, liver diseases (include Hepatitis B/C carrier), kidney disease, mental disorder, blood disease, blood spitting, passing blood per rectum, epilepsy, or any disease, abnormality or discomfort of the brain, eyes, ears (including hearing impairment), genito-urinary system, musculo-skeletal system, digestive system, respiratory system or nervous system? 7. Have you ever consulted any medical adviser about, or been tested for, or been recommended to undergo a test (including self-initiated oral fluid test) for Human Immunodeficiency Virus, AIDS-related Complex or AIDS, or is there anything about your life-style which could expose you to the risk of AIDS? If the answer is, please state details of test, dates and results/life-style below: 8. 5(a)(b) XX-ray? Have you, in the last 5 years, (a) consulted your physician or medical adviser, or (b) had any operations, hospital care, medical tests (including mammogram, pap smear, ultrasound or biopsies), X-ray, or other treatment or examination not mentioned above (exclude consultations for minor complaints, such as flu, cold, as well as pre-employment medical examination which did not lead to any further investigation or treatment? 9. Do you have any other acquired or congenital deformity, bodily injury or disorder not mentioned above? 49If the answer to questions 4-9 is, please complete the following: Question. Date and Onset Age Type of Treatment Received Reason Diagnosis Duration of Illness or Injury Last Follow Up Date Results Physician & Hospital Name Address 10. Any Additional Information IL12a-R13 (YX) /17 H

5 E. Financial and Business Information Only applicable to Corporate Policyholder 1. Region of operation/trade Funding source Business Income Donation From Business Owner Fee and Commission Income Return on Investment Sales Proceed Others, please state: Business relationship with Hang Seng Insurance Company Limited, please state: 2. Financial Information (past 3 years) Turnover (HKD) Gross Profit (HKD) Net Profit (HKD) Tangible Net Worth (Total Assets minus Total Liabilities) (HKD) 20 /20 20 /20 20 /20 3. Business Key Person Information Name of Key Person Why vital? Is he/she a major shareholder of the Company? If yes, how many % of shares does he/she hold currently? Annual remuneration package Key Person service years with the Company & service years in the industry 12 If Key Person is lost, financial impact on business income in next 12 month? What is the justification of the proposed sum assured for an insurance? 1) 2) 3) 4. Business Loan Information Total Loan Exposure (Including application in process) Total Limit Total Outstanding Amount Guarantor Is the loan protected with insurance? Fully/Partial/ IL12a-R13 (YX) /17 H

6 F. Personal Information Collection Statement 1. (i)(ii)(iii) (a) (b) * (c) * (d) * (a) (b) (c) 4.3 (a) (b) (c) (d) (852) IL12a-R13 (YX) /17 H

7 F. Personal Information Collection Statement (cont d) tice to Customers and Other Individuals relating to the Personal Data (Privacy) Ordinance (the Ordinance ) 1 From time to time, it is necessary for individuals to supply Hang Seng Insurance Company Limited ( the Company ) with data in connection with the provision, maintenance and administration of insurance or other financial products and services by the Company or compliance with any laws, guidelines or request issued by regulatory or other authorities. Failure to supply such data promptly may result in the Company being unable to provide or continue to provide products and services. It is also the case that data are collected from (i) data subjects in the ordinary course of the continuation of the relationship, (ii) a person acting on behalf of the data subjects whose data are provided, and (iii) other sources available to the Company. Data may also be generated or combined with other information available to the Company or any member of the HSBC Group ( HSBC Group means HSBC Holdings plc, its affiliates, subsidiaries, associated entities and any of their branches and offices (together or individually) and member of the HSBC Group has the same meaning). The purposes for which data may be used are as follows: 1.1. processing, assessing and/or approving applications for and any alterations, variations, cancellation, renewals and reinstatements of any insurance, or other financial products and services, provident fund scheme or related products or services; 1.2. verifying and conducting any eligibility, identity, medical and/or underwriting in connection with provision of products and/or services; 1.3. offering, providing, maintaining, reviewing, administering and evaluating products and/or services including processing any claims or investigation or analysis of such claims; 1.4. sales or marketing of products, services and other subjects (subject to further details in paragraph 4 below); 1.5. exercising any right of subrogation, if applicable; 1.6. enabling an actual or proposed assignee or transferee of the Company, or participant or sub-participant of the Company s rights to evaluate and/or undertake due diligence in relation to the transaction intended to be the subject of the assignment, transfer, participation or sub-participation; 1.7. meeting the obligations, requirements and arrangements, whether compulsory or voluntary, of the Company or any member of the HSBC Group to comply with or in connection with: (a) any law, regulation, judgment, court order, voluntary code, sanctions regime, within or outside the Hong Kong Special Administrative Region ( Hong Kong ) existing currently or in the future ( Laws ) (e.g. the Inland Revenue Ordinance and its provisions including those concerning automatic exchange of financial account information); or (b) any guidelines, guidance or requests given or issued by any legal, regulatory, governmental, tax, law enforcement or other authorities, or selfregulatory or industry bodies* or associations of financial services providers within or outside Hong Kong existing currently or in the future and any international guidance, internal policies or procedures (e.g. guidelines or guidance given or issued by the Inland Revenue Department including those concerning automatic exchange of financial account information); or (c) any present or future contractual or other commitment with local or foreign legal, regulatory, judicial, administrative, public or law enforcement body, or governmental, tax, revenue, monetary, securities or futures exchange, court, central bank or other authorities, or self-regulatory or industry bodies* or associations of financial service providers or any of their agents with jurisdiction over all or any part of the HSBC Group (together the Authorities and each an Authority ) that is assumed by, imposed on, or applicable to the Company or any member of the HSBC Group; or (d) any agreement or treaty between Authorities; * including any association, federation or similar organisation of insurance companies ( Federation ) 1.8. complying with any obligations, requirements, policies, procedures, measures or arrangements for sharing data and information within the HSBC Group and/or any other use of data and information in accordance with any programmes for compliance with sanctions or prevention or detection of money laundering, terrorist financing or other unlawful activities; 1.9. conducting any action to meet obligations of the Company or any member of the HSBC Group to comply with Laws or international guidance or regulatory requests relating to or in connection with the detection, investigation and prevention of money laundering, terrorist financing, bribery, corruption, tax evasion, fraud, evasion of economic or trade sanctions and/or any acts or attempts to circumvent or violate any Laws relating to these matters; meeting obligations of the Company or any member of the HSBC Group to comply with any demand or request from Authorities; exercising any rights the Company or a member of the HSBC Group may have in connection with the products or services provided to a customer; and matching any data held by the Company or a member of the HSBC Group relating to a data subject from time to time for any of the purposes listed in this paragraph Data held by the Company relating to an individual will be kept confidential but may be provided to the following parties (whether within or outside Hong Kong) for the purposes set out in the paragraph 1 above except that any transfer of data to another party for sales and marketing purpose will be subject to paragraph 4 below: 2.1. any member of the HSBC Group; 2.2. any agents, contractors, sub-contractors, service providers, reinsurers or associates of the HSBC Group (including their employees, directors, officers, agents, contractors, service providers and professional advisers); 2.3. any third party service provider who provides administrative, telecommunications, computer, payment or securities clearing or other services to the Company in connection with the operation of its businesses (including their employees, directors and officers); 2.4. hospitals, clinics, medical practitioners, laboratories, technicians, loss adjustors, legal advisers or private investigators that may be engaged by the Company or on behalf of the Company; 2.5. any actual or proposed assignee or transferee of the Company, or participant or sub-participant of the Company s rights; 2.6. any Authorities; 2.7. any person under a duty of confidentiality to the Company including a member of the HSBC Group which has undertaken to keep such information confidential; 2.8. any other person in the context of the sale or transfer by the Company or any member of the HSBC Group of all or part of its business or portfolio of products, policies or other assets or any proposed or confirmed transaction relating to such a sale or transfer; 2.9. third party financial institutions, insurers, banks, credit card companies, securities and investment services providers; third party reward, loyalty, privileges programme providers or merchants; charitable or non-profit making organisations; any external service providers (including but not limited to mailing houses, telecommunication companies, telemarketing and direct sales agents, call centres, data processing companies and information technology companies) that the Company engages for the purposes set out in paragraph 1.4; any Federation that exists or is formed from time to time or any of its members for any of the above or related purposes set out in paragraph 1.4; any person to or with whom the Company or any member of the HSBC Group is under an obligation or required or expected to make disclosure or use data for the purposes set out in paragraph 1.7, 1.8, 1.9 or 1.10 above; any persons acting on behalf of an individual whose data are provided, payment recipients, beneficiaries, account nominees, intermediary, correspondent and agent banks, clearing houses, clearing or settlement systems, market counterparties, upstream withholding agents, swap or trade repositories, stock exchanges, companies in which the customer has an interest in securities (where such securities are held by the Company or any member of the HSBC Group) or persons acting on behalf of the customer or the individual whose data is provided for the purposes of receiving benefits under an insurance policy; and any party to a transaction or potential transaction acquiring interest in, or assuming or bearing risk in, or in connection with an insurance policy including, without limitation, reinsurers. Such information or data may be transferred to a place outside Hong Kong. 3. The Company may obtain access to and/or verify the data with the information collected by the Federation from the insurance industry. 4. The Company intends to use personal data in relation to a data subject in direct marketing and the Company requires the data subject s consent (which includes an indication of no objection) for that purpose. In this connection, please note that: 4.1. the name, contact details, products and services portfolio information, transaction pattern and behaviour, financial background and demographic data held by the Company from time to time may be used by the Company in direct marketing; 4.2. the following classes of products, services and subjects may be marketed: (a) insurance, banking, credit card, financial, provident fund scheme and related products and services; (b) reward, loyalty or privileges programmes and related products and services; and (c) donations and contributions for charitable and/or non-profit making purposes; 4.3. the above products, services and subjects may be provided or (in the case of donations and contributions) solicited by the Company and/or: (a) members of the HSBC Group; (b) third party financial institutions, insurers, banks, credit card companies, securities and investment services providers; (c) third party reward, loyalty, privileges programme providers or merchants; (d) charitable or non-profit making organisations; IL12a-R13 (YX) /17 H

8 F. Personal Information Collection Statement (cont d) 4.4. in addition to marketing the above products, services and subjects itself, the Company also intends to provide the data described in paragraph 4.1 above to other Hang Seng Bank Group companies for use by them in marketing those products, services and subjects, and the Company requires the data subject s written consent (which includes an indication of no objection) for that purpose. If a data subject does not wish the Company to use or provide his data to other Hang Seng Bank Group companies for use in direct marketing as described above, the data subject may exercise his opt-out right by notifying the Company. 5. A data subject has the right to request access to and correction of any of his data held by the Company. The Company has the right to charge a reasonable fee for the processing of any data access request in accordance with the terms of the Ordinance. Requests for access to data or correction of data or for information regarding policies and practices or kinds of data held can be made in writing to the Data Protection Officer, Hang Seng Insurance Company Limited, 83 Des Voeux Road Central, Hong Kong. Fax: (852) June 2014 (Updated in December 2016) te: In case of discrepancies between the English and Chinese version, the English version shall apply and prevail. G. Declaration and Authorisation I declare that the statements and answers given in this form are complete and true. I authorise any person or organisation that has records of or information on the Life Insured and the Payor regarding our personal data and health to provide such records or information to Hang Seng Insurance Company Limited or its representative, as required for its consideration of this application or for the purposes of any insurance provide pursuant to this application. By signing below, I/we agree that Hang Seng Insurance Company Limited may use and disclose all personal data about me/us that Hang Seng Insurance Company Limited currently or subsequently holds for the purposes as set out in the tice to Customer and Other Individuals relating to the Personal Data (Privacy) Ordinance which accompanies this form. Signature of Life Insured Signature of Policyholder (if other than Life Insured) Name: Date: Name: Date: Daytime Contact.: Signature of Irrevocable Beneficiary (if any) Signature of Witness Name: Date: Date: Name: Date: Date: Signature of Assignee (if any) Signature of Witness Name: Date: Name: Date: " " To comply with the regulatory requirements, please complete the Financial Needs Analysis in person at any of Hang Seng Branch for increase of Sum Insured or addition of Optional Benefit. For other request, please return the original of this form, duly completed and signed to Hang Seng Insurance Company Limited of 18/F, Tower 1, HSBC Centre, 1 Sham Mong Road, Kowloon, Hong Kong. Please note that we will only process your request upon actual receipt of this original form. For Bank Use Client s ID copy attached Client s original ID sighted Staff Name and ID: Branch Code and Chop: Remarks: DC1 DC2 DC3 DC4 DC5 DC6 DC7 NRI DC9 DC10 DC11 DC12 IL12a-R13 (YX) /17 H