Blue Cross TravelSafe Plus Insurance Application Form   藍十字旅遊寶投保書  (請以英文填寫)
Applicant Details   投保人資料   註：並非受保人或受益人。
Name of Applicant            H.K.I.D./Passport No.
投保人性名   (投保人必須為十八歲或以上)                                                                                    香港身份証/ 旅遊証件號碼
Correspondence Address in H.K.  香港通信地址

Contact Telephone No. 聯絡電話         Email Address電郵地址
Plan 保險計劃 :  Global Diamond  環球藍鑽石      Global Gold  環球千足金      China Basic  中國基本     
Premium Package 保費類別 :Individual  個人  Individual + Children  個人及其子女  Family 家庭
Commencement Date 起保日期:  Day 日 Month 月 Year 年        For 共Day(s) 日
Details of Insured Person(s)  受保人資料   註：即去旅遊的人。
Surname       Given Name          Age    H.K.I.D./Passport No.       Place of Origin(Please fill if not H.K.)    Premium
姓氏       名字                年齡    香港身份証/旅遊証件號碼    起保地點(如非香港，請填寫)    保費
1. HK$
2. HK$
3. HK$
4. HK$
5. HK$
  Total Premium 總保費 HK$
Declaration   聲明
1. It is hereby declared that the information and answers provided on this form are true and completed to the best of my/ our knowledge and belief. I/ We also accept that this
     application and the declaration therein shall form the basis of and be incorporated in the contract between Blue Cross (Asia-Pacific) Insurance Limited ("the Company")
     and me/ us.
2. I/ We understand that the liability of the Company shall not come into effect until this application has been accepted by the Company and the premium has been paid.
3. I/ We declare that no insured person is travelling contrary to the advice of a medical pratitioner or for the purpose of obtaining medical treatment and that insured person(s)
     understand(s) that treatment of any pre-existing, recurring or congenital medical conditions are not insured. I/ We further declare that insured person(s) is/are not aware of any
     condition, cause or circumstances that may necessitate the cancellation or curtailment of the Journey as planned.
1. 我們特此聲明，於此投保書內提供的資料及答案，根據本人∕我們所知所信均屬真確無訛及事實之全部，並同意此投保書內容及其所載聲明將構成
    藍十字(亞太)保險有限公司(「貴公司」) 與本人∕我們所訂保險合約的依據。
2. 本人∕我們明白此投保書須經貴公司接納，並在保費繳付後，貴公司的承保責任始告生效。
3. 本人∕我們於此聲明，受保人(等)參與旅遊並無違反醫生囑咐或非為獲得醫學治療，而且清楚明白任何先存、現存、復發或先天性的疾病一概不受保
    障；此外，受保人(等)亳不知悉任何可能導致已計劃旅程被取消或縮減的情況、原因或事故。
Personal Information Collection Statement 收集個人資料聲明
I/ We understand and agree that any personal information is collected or held by Blue Cross (Asia-Pacific) Insurance Limited(“the Company”) to enable the Company to carry on insurance business and may be used, stored, disclosed and transferred (within or outside of Hong Kong) to any individuals∕organisations associated with the Company or any selected third party as the Company may consider necessary for the purposes of: (1)any insurance or financial related product or service or any addition, alteration, variations, cancellation or renewal or reinstatement of them; (2) any scope of insurance coverage, claim processing∕investigation, any analysis of it and data matching; (3) promotion of financial products or services by the Company and its affiliated companies; and (4) communicating with me∕us∕the insured or any relevant organisation∕person as the Company may consider necessary. I∕We have the right to obtain the “Privacy Policy Statement” access to and to request correction of any personal information concerning myself/ourselves held by the Company. Such request could be made in writing to the Company’s Corporate Data Protection Officer at 29th Floor, BEA Tower, Millennium City 5, 418 Kwun Tong Road, Kwun Tong, Kowloon, Hong Kong.
本人∕我們明白並同意藍十字(亞太)保險有限公司(「貴公司」)可收集或持有本人∕我們之個人資料用於保險業之用途，並可將此等資料使用、儲存、透露及轉交(於本地或以外)予任何與貴公司有關之人士∕機構或被選定之第三者，作以下用途：(1) 有關保險或財務之產品或服務，或該等產品或服務之增加、更改、轉變、取消、更新或復效；(2) 任何保障範圍，處理理陪∕調查或其有關分析及資料核對；(3) 任何貴公司及其他附屬公司之財務計劃，商品及服務之推廣活動；及(4) 與本人∕我們∕受保人或貴公司認為有關之機構∕人仕聯絡。本人∕我們有權致函香港九龍觀塘418號創紀之城5期東亞銀行中心29樓向貴公司之個人資料保護主任索取「私隱政策聲明」，查明及要求更正貴公司所持有有關之個人資料。
Applicant's Signature    投保人簽署                                         Day 日 Month 月 Year 年
                  
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