业主或住户公众责任保险计划HouseownersorHouseholdersPublic.PDFVIP

Houseowner’s or Householder’s Public Liability Insurance Plan Enrollment Form Enquiry no. +852 2903 9391 Fax +852 2968 0639 Agent Name Please tick the appropriate box and * delete where inappropriate. ________________________ * Agent No Please complete in BLOCK LETTERS. ________________________ All fields are mandatory, except the fields marked with #. # 1 Proposer’s information Mr Mrs Ms Surname First Name Other Name HKID card no./ Passport no.* Date of birth# # D M Y Sex# # Male Female Occupation# # Marital Status# # Risk address Flat/ Rm.* / * Floor Block Building Estate name/ street no. name/ lot no.*/ / * District HK/ KLN/ NT* / / * Correspondence address Flat/ Rm.* / * Floor Block Building ( if different Estate name/ street no. name/ lot no.*/ / * from above) District HK/ KLN/ NT* / / * Contact Number (Please fill in at least one) Email address# Mobile phone no. Day time telephone no. # Building age Gross floor area (sq.ft.) ( ) Owner Tenant 1 2 Insurance details Coverage and premium table (Please  whichever is appropriate) 保障項目及保費表（請適用方格） Plan type Maximum limit of liability (any one event/any one period) Annual premium (HKD) /