美亚“小探险家”旅行保障计划投保单（E）-Producer Code.docVIP

Producer Code (Internal Use Only) — Producer Name (Internal Use Only) Name of Policyholder: (Note: For Insured Person under 18 years of age, the policyholder must be parent or guardian) Passport / ID No: Contact Tel/Mobile Phone No: Fax: Correspondence Address: Postcode: Insured Person Name of Insured Person(s) Passport / ID No. Date of Birth （DD/ MM/ YY） Relationship between Policyholder and Insured Person Premium (RMB:Yuan) // Parent Guardian // Parent Guardian // Parent Guardian // Parent Guardian Death Benefit Beneficiary （If death benefit beneficiary is not named in the application form, the death benefit will be treated as heritage of Insured Person. If the proportion is not determined in the application form, the beneficiaries shall be entitled to equal shares of the death benefits.） Name of Insured Person(s) Beneficiary Passport / ID No. Proportion（%） Relationship to Policyholder % % % Type of Plan: （Single journey or each journey cannot exceed 182 days） Single Trip Protection Plan Travel Destination: Departure Place: Expected Inception Date: (DD/MM/YY) // Expected Expiry Date: (DD/MM/YY) // Expected Policy Period: Total:__Days (Inception date and expiry date inclusive) Annual Travel Protection Plan Note:  1. This policy will not cover any loss, injury, damage or legal liability arising directly or indirectly from: Travel in, to, or through Afghanistan, Burma, Cuba, Democratic Republic of Congo, Iran, Iraq, Liberia, Sudan, or Syria. 2. This policy will not cover any terrorist or member of a terrorist organization, narcotics trafficker, or illegal purveyor of nuclear, chemical or biological weapons defined by any country or international organization. 3. Any cancellation or change of the insured travel need to inform the insurance company in writing before policy becomes effective. Or the insurance company will not handle the change request. 4. The Insured Person shall