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Application/Policy No. 投保書/保單編號：
Supplement Form (Hong Kong) –
⃞ New Application 新生意
Consents to Data Processing
⃞ Policy Service 保單服務
Pursuant to AXA’s Privacy Policy ⃞ Claims 索償
補充表格 ( 香港 ) - 同意根據 “The Company” or “AXA”
AXA 安盛的私隱政策進行資料處理 “本公司”、“貴公司”或“AXA安盛”：
AXA China Region Insurance Company (Bermuda)
Limited (Incorporated in Bermuda with limited liability)
Important Notes: 安盛保險（ 百慕達）有限公司
1. This form is supplemental to the Main Form (New Application/Police Service/Claims) (於百慕達註冊成立的有限公司) /
submitted by Personal Data Subject. AXA China Region Insurance Company Limited
2. This form is to be filled in BLOCK LETTERS and signed by Personal Data Subject. 安盛金融有限公司 /
3. Please put a “✓” in the appropriate box (if applicable). AXA Wealth Management (HK) Limited
4. Please do not sign on blank form. 安盛財富管理（香港）有限公司
重要事項：
1. 此表格是對個人資料當事人提交的主表格（新生意/保單服務/索償）之補充。
2. 此表格應由個人資料當事人以正楷填寫及簽署。
3. 請在適當方格內加上「✓」號（如適用）。
4. 請勿在空白表格上簽署。
1. Name of Personal Data Subject 個人資料當事人姓名
Name of Personal Data Subject 1:
個人資料當事人 1 姓名 :
Name of Personal Data Subject 2:
個人資料當事人 2 姓名 :
2. Declaration and Authorisation 聲明及授權
I/We HEREBY DECLARE AND AGREE on behalf of myself/ourselves and other persons referred to in the application form/service form/request
form and/or other forms submitted in relation to the application and/or policy referred hereinabove (hereinafter referred to as the “Main
Form(s)”) that where I/We have provided the personal data of other persons (including but not limited to the beneficiary) (“Such Other
Persons”) to the Company in the Main Form(s) or in any ways provided to the Company for or relating to the application/request under the Main
Form(s), or for or relating to the future services in connection with the application/request under the Main Form(s), (a) I/We have obtained the
personal data from Such Other Persons lawfully; (b) I/we have notified Such Other Persons of the Company’s Privacy Policy# and the relevant
data collection document (being the Main Form(s), this form or any other documents provided to the Company) and obtained all necessary
consent from Such Other Persons for the data processing (including provision of personal data to the Company) as set out in the Company’s
Privacy Policy#; (c) I/We will assist the Company to obtain all necessary consent from Such Other Persons if the processing of personal data
of Such Other Persons goes beyond the original scope of consent provided by them; (d) I/We acknowledge and understand that a minor is a
person under 14 (in Mainland China) or 18 years old (in Hong Kong) under applicable data protection law, and I/We am/are (or I/We have been
authorised by) the guardian of Such Other Person who is a minor, or I/We have been authorised by Such Other Person who is not a minor
(e.g. individuals aged 14-17 years old located in Mainland China) to give necessary consent on his/her behalf; and (e) I/We have taken reasonably
practicable measures to ensure that the personal data I/We provide to the Company is accurate and complete.
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The Privacy policy is available here: https://www.axa.com.hk/en/legal
本人/我們謹此代表本人/我們及其他在有關本表格上提及的投保書及/或保單而提交的投保書/申請書/申請表格及/或其他表格（下稱
「主表格」）提及之人士聲明及同意就本人/我們在主表格中或以任何方式，為主表格的申請或與之相關，或為主表格的申請有關未來
服務或與之相關而向AXA安盛提供其他人士（包括但不限於受益人） （“該等其他人士”）的個人資料，(a) 本人/我們已合法地從該等其他
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人士取得個人資料；(b) 本人/我們已通知該等其他人士AXA安盛的私隱政策 及有關資料收集文件（即主表格、本申請表或向AXA安盛提
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供的任何其他文件），並取得該等其他人士對AXA安盛私隱政策 所述的資料處理（包括向AXA安盛提供個人資料）的一切必要同意；(c) 如
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對該等其他人士的個人資料的處理超出了該等其他人士原先提供的同意範圍，本人/我們將協助AXA安盛取得該等其他人士的一切必要
同意； (d) 本人/我們確認並理解，根據適用的保障資料法律，未成年人是指未滿14歲（在中國大陸）或未滿18歲（在香港）的人士，以
及本人/我們是未成年的該等其他人士的監護人（或本人已獲未成年的該等其他人士的監護人授權），或本人/我們已獲非未成年的該
等其他人士（例如，身處中國大陸的14-17歲的個別人士）的授權，可代表他/她作出必要的同意；及 (e) 本人/我們已採取合理可行的措
施，確保本人/我們向AXA安盛提供的個人資料是準確和完整的。
LFUW265-2410
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在此取得私隱政策：https://www.axa.com.hk/zh/legal
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Supplement Form (Hong Kong) – Consents to Data Processing Pursuant to AXA’s Privacy Policy 補充表格 ( 香港 ) - 同意根據 AXA 安盛的私隱政策進行資料處理
3. Consents to Data Processing Pursuant to AXA Privacy Policy (Applicable to individual signatory(ies)
with any declared address in the Mainland China only)
同意根據 AXA 安盛的私隱政策進行資料處理 ( 只適用於任何申報地址位於中國大陸的個人簽署 )
Please sign below to ACKNOWLEDGE and CONFIRM you agree to the following statements and grant each of the separate consents below. If you
do not agree to grant any one of the consents below, the Company and/or other companies of the AXA Group may not be able to provide the
information, products or services you need or process your request.
• I/We have read and consent to the Privacy Policy#; and
• I/We agree to the processing and/or management of my/Our personal data, sensitive personal data, and that of minors under my/Our
guardianship (if applicable) outside of Mainland China as prescribed in the Privacy Policy.
In the case that the Personal Data Subject is aged below 18, I/We grant each of the above separate consents on behalf of the Personal Data
Subject as his/her guardian or authorised person (as the case may be).
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The Privacy policy is available here: https://www.axa.com.hk/en/legal
請在下方簽署，以確悉及確認您同意以下聲明，並對下列每一項作出單獨同意。如果您不同意對下列任何一項作出同意，AXA安盛及/
或AXA安盛集團的其他公司可能無法提供您所需的資料、產品或服務或處理您的請求。
• 本人/我們已經閱讀並同意私隱政策#；及
• 本人/我們同意本人/我們的個人資料、敏感個人資料及由本人/我們監護的未成年人（如適用）之敏感個人資料依照私隱政策於
中國大陸境外處理及/或管理。
若個人資料當事人未滿18歲，本人/我們以其監護人或獲授權人（視情況而定）的身份，代表個人資料當事人對上述每一項作出單獨同
意。
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在此取得私隱政策：https://www.axa.com.hk/zh/legal
Signature of Personal Data Subject 1
個人資料當事人 1 簽署
Signature of the Personal Data Subject 1 (if aged 18 or above) / Sign Date (YYYY/MM/DD)
the guardian or authorised person of the Personal Data Subject 1 簽署日期（ 年 / 月 / 日）
(if the Personal Data Subject 1 is aged 18 below).
個人資料當事人1簽署（如十八歲或以上）/
個人資料當事人1的監護人或獲授權人簽署
（如個人資料當事人1未滿十八歲）
Signature of Personal Data Subject 2
個人資料當事人 2 簽署
Signature of the Personal Data Subject 2 (if aged 18 or above) / Sign Date (YYYY/MM/DD)
the guardian or authorised person of the Personal Data Subject 2 簽署日期（ 年 / 月 / 日）
(if the Personal Data Subject 2 is aged 18 below).
個人資料當事人2簽署（如十八歲或以上）/
個人資料當事人2的監護人或獲授權人簽署
（如個人資料當事人2未滿十八歲）
* Note: The signature of the Personal Data Subject / authorised person / guardian in this form shall be identical to that in the Main Form (New Application /
Police Service / Claims) submitted to the Company.
* 注：此表格和已向本公司提交的主表格（新生意 / 保單服務 / 索償）的個人資料當事人 / 授權人 / 監護人的簽名必須相同。
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