ApplicationFormB.docVIP

丘博保险（中国）有限公司 Chubb insurance (china) company LIMITED 中国上海市浦东新区芳甸路1155号浦东嘉里城901-905室，907－908室 邮编：201204 电话：(86 21)传真:(86 21)Unit 901-905 and 907-908,Kerry Parkside Office Buliding,No.1155,Fangdian Road,Pudong New District,Shanghai 201204, China Tel: (86 21)Fax: (86 21) 服务热线 Service Hotline: 400-889-2120 若英文译本与中文有异，以中文版本为准。Should there be any inconsistencies between Chinese and English versions, the Chinese version shall prevail. 爱商旅商务旅行综合保障计划投保单 iBusiness Business Travel Package Insurance Plan Application Form Producer Code　Producer Name(Internal Use Only)(Internal Use Only) _______________________投保单位资料Information of Applicant 投保人 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.保障计划内容 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 Travel1,000,000 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Privilege1.意外身故、烧伤及残疾保障 Accidental Death, Burns and Dismemberment100,000250,000500,0001,000,0002.双倍给付意外伤害(仅适用境外) Double Indemnity (only for outbound )100,000250,000500,0001,000,0003. 紧急医疗费用 Emergency Medical Expenses - Accident Sickness300,000500,000750,0001,000,000*其中境内旅行的疾病医药赔偿限额每次或全年