Application Form for Buying Insurance.doc

Application Form for Buying Insurance 1. Insurance Fee Year of Birth Fee After 1986 130,000won Before 1986 160,000won 2. Payment Account: Kwangju Bank(????) Account holder: Seo Jinhyuk(???) 3. Coverage Coverage Limits Personal Charge Accident Death, Disable 50,000,000 won No charge Wounded Hospitalization 10,000,000 won 10% of Total Charge Wounded Outpatient treatment 250,000 won Private Clinic 10,000won General hospitals 20,000won Wounded Medicine 50,000 won 8,000won Sickness Hospitalization 10,000,000 won 10% of Total Charge Sickness Outpatient treatment 250,000 won Private Clinic 10,000won General hospitals 20,000won Sickness Medicine 50,000 won 8,000won Compensating Others for Causing Damages Unintentionally 100,000,000 won 20,000won Special Charge 20,000,000 won * Insurance does not cover dental treatment, birth, pregnancy, chronic disease and oriental medical clinic. 4. Personal Information ?Passport Name: ?Gender: Male( ) Female( ) ?Date of birth: ?Student ID: ?Alien Number: ?Course: Korean Language( ) Undergraduate( ) Graduate( ) etc( ) ?Address: ?Contact: ?ype: new member( ) rejoin( ) Expiration date: a I totally agree with buying insurance after taking detailed explanation about insurance policy and coverage. 2014. . . Name: Signature: 保险申请书 1. 保险费 出生 保险费 1986年 以后出生 130,000韩币 ~1986年出生 160,000韩币 2. 汇款账号 : 光州银行 收款人 : ??? 3. 担保内容 保障项目 金额 个人分摊额 伤害 死亡·残疾 50,000,000韩币 无 住院 10,000,000韩币 医疗费用的10% 门诊 250,000 韩币 私人医院 10,000韩币 综合医院 20,000 韩币 药品处方调剂 50,000 韩币 8,000 韩币 治疗 住院 10,000,00韩币 医疗费用的 10% 门诊 250,000 韩币 个人医院 10,000 韩币 综合医院 20,000 韩币 药品处方调剂 50,000 韩币 8,000 韩币 日常生活赔偿责任 100,000,000韩币 20,000 韩币 特別費用 20,000,000 韩币 - 投保前有病者，即使购买保险也得不到保险赔偿。 - 牙科妊娠出生韩医院治疗者保险赔偿申请无效 4. 个人信息(用韩语填写) : * 性别 : 男 ( ) 女 ( ) * 出生: * 学号 : 外国人登录 : - * 课程 : 韩国语研修( ) 本科生( ) 研究生( ) 其他 ( ) * 住址 : 联系方式 : “外国人留学生保险” 2014. . . 姓名 : 签名 :