Application Form - B.docVIP

Producer Code 　 Producer Name Internal Use Only Internal Use Only 投保单位资料Information Name of Applicant: 办公地址 Business Address: 邮政编码 Postcode: 营业范围 Business Scope: 联络人 Contact Person: 手机MP: 联系电话 Contact Tel. No: 传真号码 Fax No: 电子邮箱: E-Mail Address: 保险单资料Policy Information 详细的保障计划以投保人最后确认的报价单为准Benefits details shall refer to the quotation accepted by the Applicant. 保险期间Proposed Policy Period 由From: 00:00 时hrs. 年/月/日YYYY/MM/DD 至To: 24:00时 hrs. 年/月/日YYY/MM/DD 说明：保险期间最早开始于投保人签署本投保单的次日零时零分。 Remark: The Policy Period shall start not earlier than the time of 00:00 on the next day of the date this Application Form is signed by the Applicant. 保计划内容 Insurance Coverage of the Package: 保障项目 Coverage 保险责任 Limit of Liability RMB：yuan 一、商务旅行公众责任保险 Public Liability During Business Travel 1,000,000 每次事故及年度累计 二、监管行动及诉讼保障保险 Regulatory Action Protector 每人50,000 / 累计100,000 三、团体旅行意外综合保险 Group Travel Accident 保险金额 / 人 人民币：元 Sum Insured/Limit RMB：yuan 每次差旅/Per Trip 黄金计划Gold 铂金计划Platinum 钻石计划Diamond 至尊计划Privilege 1.意外身故、烧伤及残疾保障 Accidental Death, Burns and Dismemberment 100,000 250,000 500,000 1,000,000 2.双倍给付意外伤害 仅适用境外 Double Indemnity only for outbound 100,000 250,000 500,000 1,000,000 3. 紧急医疗费用 Emergency Medical Expenses - Accident Sickness 300,000 500,000 750,000 1,000,000 *其中境内旅行的疾病医药赔偿限额 Limit of Sickness Medical Reimbursement for Domestic Travel 1,000 1,000 1,000 1,000 4. 每日住院津贴 境内仅包含意外住院 Hospital Cash （domestic for accident only） / 100/天 150/天 200/天 5. 紧急医疗运送及医疗遣返 Medical Evacuation Repatriation 300,000 500,000 750,000 Actual cost 6. 遗体遣返和丧葬费用 Body Repatriation （funeral fee） 80,000 100,000 150,000 Actual cost 7. 家属紧急旅行费用 Emergency Travel Expenses for Family Member 8,000 8,000 8,000 8,000 8. 个人钱财 Loss of Money 1,000 2,000 3,000 5,000 9. 随身财产及旅行证件遗失 Loss of Baggage Personal Documents 3,000 6,000 8,000 10,000 *每件手提电脑赔偿限额 Limit per laptop computer 3,000 3,000 3,000 3,000 *每件或每套物品赔偿限额 Limit per item or set of items 1,5