美亚旅行美亚旅行团体意外伤害保.docxVIP

第 PAGE 1 第 PAGE 1 页（共 9 页） 投保单编号：TMCH150541-1 投保单生成日期：2016-6-22 BCGLTA 美亚旅行团体意外伤害保障计划投保单暨报价书(以下简称 “投保单”) GROUP TRAVEL INSURANCE APPLICATION FORM & QUOTATION (hereinafter “Application Form”) Producer Code(Internal Use Only): 业务人员: Jacky Wang 报价书编号： TMCH150541-1 现有保单号码.: WBSZ500406 A．投保人的风险告知 Risk Disclosure by the Policyholder 身故保险金受益人 Beneficiary : 详见名册 As per the Attached List 既往事项告知 Past Experience: 1. 过去 3 年是否有员工/成员死亡或伤残？ Have any employees/members suffered injury or death during the past 3 years? □是 Yes □否 No 是否曾经在本公司或其他保险公司投保，并且 Has any Insurance Company: 曾被保险公司拒绝投保申请？declined your proposal? 曾被保险公司拒绝保险合同续保？refused to renew your insurance policy? 曾被保险公司解除保险合同？cancelled your insurance policy? 曾被保险公司要求加费或附加特别约定方可承保? Increased the premium and/or imposed special terms? □是 Yes □否 No □是 Yes □否 No □是 Yes □否 No □是 Yes □否 No 以上部分如有任何答案为“是”者，请提供详细资料。If the answer is “Yes” to any of the questions above, please provide details (若本投保单空格不够使用，请另用纸张填写 If there is insufficient space, please continue on a separate sheet.) 风险地区告知 Exposure Location: 投保人（包括子公司和分支机构）是否在下列这些国家中存在风险*：古巴、伊朗、缅甸、苏丹、叙利亚、北韩、白俄罗斯、津巴布韦、乌克兰克里米亚共和国? Does the policyholder (including subsidiaries and branches) have exposure* in any of these countries: Cuba, Iran, Myanmar, Sudan, Syria, North Korea, Belarus, Zimbabwe, Crimea region of Ukraine? “风险”是指下列任一情形 For the purpose of this question, "exposure" means any of the following: 投保人的注册地、住所地或运营地位于上述任何国家 Policyholder is incorporated, domiciled or located in any of the above listed countries 投保人所从事的业务活动涉及古巴、乌克兰克里米亚共和国、伊朗、叙利亚或苏丹（例如：服务、货运、销售、供应渠道、投保财产）。Policyholder conducts business activity involving Cuba, Crimea region of Ukraine, Iran, Syria or Sudan (e.g. services, shipments, sales, supply channels, covered property). 投保人的董事会成员或高级管理人员住所地在古巴、乌克兰克里米亚共和国、伊朗、叙利亚或苏丹，或者投保人的大股东（包括个人或者实体）的注册 地、住所地或居住地在古巴、伊朗、叙利亚或苏丹。Information obtained shows that policyholder’s board members or officers are domiciled in Cuba, Crimea region of Ukraine, Iran, Syria or Sudan, o