更改保單保障申請表

Request for Change of Policy Coverage

請在適當的格內填上「」。Please tick the appropriate boxes where applicable.
保單持有人姓名 Name of Policyholder 受保人姓名 Name of Insured 保單號碼 Policy No.

保險中介人資料 INSURANCE INTERMEDIARY’S INFORMATION

保險中介人姓名 Name of Insurance Intermediary

分行／中介人編號／註冊編號 Branch/ Intermediary Code/ Registration Code 聯絡電話 Contact No.

重要須知 IMPORTANT NOTES

1. 如申請增加附加保障，此表格必須於香港簽署。The form MUST be signed in Hong Kong if addition of rider(s) is applied.
2. 本表格中所用之「本公司」或「貴公司」之表述指中國人壽保險（海外）股份有限公司。The expression “the Company” used in this form refers
to China Life Insurance (Overseas) Company Limited.
3. 只接受正本表格及本表格應以正楷填寫及由保單持有人簽名，簽名式樣須與本公司的記錄相符。保單持有人亦必須於本表格內任何曾
修改的地方簽署作實。Only original form is accepted and this form is to be completed in BLOCK LETTERS and signed by the Policyholder with the signature
correspond with the Company’s record. Any amendments in this form must be countersigned by the Policyholder in full signature.
4. 本公司有權隨時更新本表格，並接受或拒絕未符合本公司要求的申請表。請登入本公司網站 www.chinalife.com.hk 瀏覽及下載最新版本。
The Company has the right to update this form from time to time and to accept or to reject the form if the Company’s requirements are not fulfilled. Please visit
our website www.chinalife.com.hk to view and download the latest version of the form.
5. 如未能及時提交需要的資料，本公司可能無法處理閣下的申請甚或拒絕閣下的申請，亦不會承擔任何可能因此引致的損失。If the
necessary information/form(s) cannot be provided in a timely manner, the Company may not be able to process your application or may even reject your
application and will not bear any loss that may arise.
6. 如申請未能符合本公司的有關規定，本公司有權拒絕有關申請。The Company shall have right to reject the application if the application fails to fulfill
the Company’s requirement(s).
7. 如中英文版本有任何抵觸或不符之處，概以中文本為準。In case of discrepancies between the English and Chinese versions, the Chinese version
shall apply and prevail.
8. 保險中介人或銀行職員收到本表格並不代表本公司亦已收妥。Receipt of this form by Insurance Intermediary or Bank Staff does not constitute receipt
by the Company.
9. 請將已填妥及簽署的表格正本連同所需證明文件寄往香港灣仔軒尼詩道 313 號中國人壽大廈 24 樓中國人壽保險(海外)股份有限公司。
Please send the original duly completed and signed form(s) and document(s) required to China Life Insurance (Overseas) Co. Ltd., 24/F, CLI Building, 313
Hennessy Road, Wan Chai, Hong Kong.

第一部份 更改保單保障 Part 1 Change of Policy Benefit

1.1 □ 更改基本計劃／附加保障 Change of Basic Plan/Riders
冷靜期內申請 Application Within Cooling-off Period □是 Yes □否 No
基本計劃／附加保障 計劃編號 增加附加 刪除 4
減低保額／基本金 新保額／基本金額 生效時間 Effective time
Basic Plan / Riders Plan Code 保障 1, 3 Deletion 4 額 4, 5 （保單貨幣）2，6 即時 7 週年日 On
Addition of Reduction of Sum New Sum Assured / Immediate 7 Anniversary
Riders 1, 3 Assured/Basic Amount Basic Amount Date
4, 5 (Policy /Currency) 2，6
□ □ □ ______________ □ □
□ □ □ ______________
__ □ □
□ □ □ __
______________ □ □
□ □ □ __
______________ □ □
□ □ □ __
______________ □ □
□ □ □ __
______________ □ □
□ □ □ __
______________ □ □
__

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第一部份 更改保單保障（續） Part 1 Change of Policy Benefit (Continued)

更改基本計劃/附加保障注意事項 Notes for Change of Basic Plan/Riders：
1. 申請增加附加保障必須同時填寫第三至七部分。Must complete Part 3 to Part 7 for addition of riders.
2. 如申請刪除附加保障及/或減低保額/基本金額獲批後有任何退款，將按閣下於本申請表第八部份提供的付款指示進行給付；如閣下沒有
填寫付款指示，將支付至閣下已登記的「預設收款賬戶」或以劃線支票形式給付。請參閱第 11 頁所需文件指引以便處理閣下的申請。
After approval of the application to deletion of riders and/or the reduction of the sum assured/basic amount, any refund will be paid according to the payment
instruction provided by you in Part 8 of this application form. If you have not filled in the payment instruction, it will be paid to your registered "Default Payment
Account" or by crossed cheque. Please refer to the Documents Checklist on P.11 for documents required to process your request.
3. 如新增附加保障為醫療或危疾保障，必須同時提交「醫療保險產品合適性評估問卷（適用於醫療及危疾保障 – FNA 豁免產品） 」 ，請聯
絡閣下的保險中介人協助填寫所需表格。Must submit “Suitability Assessment Questionnaire for Medical Insurance Product (Applicable to Medical and
Critical Illness Coverage – FNA Exempted Product)” if apply for addition of medical or critical illness riders. Please contact your Insurance Intermediary to assist
you to complete the required documents.
4. 在申請獲批核後，閣下將會減少／失去相關保障及在任何情況下均不可以還原，閣下於將來或未能以相同條款獲得相若的保障。You
will reduce/lose the relevant coverage of the benefit concerned and cannot revert under any circumstances after approval of the request, you may not be able to
reapply for the same benefit on the same terms/conditions in future.
5. 如在冷靜期後申請減少保單基本計劃保額／基本金額，必須同時填寫第九部份「轉保聲明」。Must complete Part 9 “Policy Replacement
Declaration” if apply for Reduction of Sum Assured/Basic Amount of basic plan after the cooling-off period.
6. 新保額／基本金額不可少於本公司要求的最低保額／基本金額。The new sum assured/basic amount should not be less than the minimum sum
assured/basic amount required by the Company.
7. 如申請增加附加保障並選擇「即時生效」 ，必須連同銀行入數紙一併遞交。Must submit bank-in payment receipt if you apply for rider addition
1.2 □
“With Immediate Effect”.
減額繳清保險 Reduced Paid Up Insurance
（僅適用於保單合約有減額繳清保險選項及內附有減額繳清保險利益說明的保單 Only applicable to those policies with Reduced Paid Up
Insurance Option and Reduced Paid Up Insurance Illustration has been affixed in the Policy Contract）

減額繳清保險注意事項 Notes for Reduced Paid Up Insurance：

1. 必須同時填寫第九部份「轉保聲明」及退回保單合約。Please complete Part 9 “Policy Replacement Declaration” and return the policy contract.
2. 必須先清還所有保單貸款（如有）及自動保費貸款（如有）方能完成此申請。All policy loan (if any) and automatic premium loan (if any) must be
fully settled before the request can be completed.
3. 保單內所有附加保障（如有）在本公司接受本申請的生效日當日將被終止且往後不得有任何附加保障附加於本保單。All riders (if any)
under the Policy will be terminated on the effective date of the Company accepted the application and no riders can be added afterwards.
4. 申請將於下一個保單週年日起生效。The application will be effective from the next policy anniversary date.
5. 在申請獲批核後，閣下將會減少相關保障及閣下於將來或未能以相同條款獲得相若的保障。You will reduce the relevant coverage of the benefit
concerned after approval of the request and you may not be able to reapply for the same benefit on the same terms/conditions in future.

1.3 □ 指定轉換醫療計劃 Designated Medical Benefit Conversion Program

舊醫療險種代號及名稱
Old Rider Code and Name

新醫療險種代號及名稱
New Rider Code and Name

指定轉換醫療計劃注意事項 Notes for Designated Medical Benefit Conversion Program：

1. 必須於保單週年日前一個月內提出及遞交申請，更新保障將於下一個保單週年日生效。Must be applied within 1 month before Policy Anniversary.
The revised protection will be effective from the next Policy Anniversary Date.
2. 指定醫療計劃同級轉換或計劃降級必須同時填寫第三部分。Must complete Part 3 for Designated Medical Benefit Conversion or downgrade.
3. 申請醫療計劃升級必須同時填寫第三至七部分以便重新核保，詳細要求可參考保單合約條款。Must complete Part 3 to Part 7 for upgrade
medical benefit application for re-underwriting. Please refer to the policy contract for the detailed requirements.
1.4 □ 刪除或減免職業額外保費/除外責任 Deletion / Reduction of Occupation Rating / Exclusions
<必須同時填寫及提交《更改持有人及受保人資料/職業/簽名申請表》有關更新職業的部份及遞交受僱證明。Must complete &
submit “Request for Change of Owner & Insured Information/Occupation/Signature” the part relates to occupation updates and provide employment
proof.>

1.5 □ 刪除或減免健康額外保費/除外責任 Deletion / Reduction of Medical Rating / Exclusions

<必須填寫第七部分「健康聲明」。Must complete Part 7 “Health Declaration”>

1.6 □ 重新申報健康狀況 Re-declaration of health information（適用於在保單／附加保障／恢復保單效力前的遺漏申報的健康狀況）

Applicable to report pre-existing health condition which was missed to declare before effective of the policy/rider(s)/policy reinstatement）
<必須在第七部份「健康聲明」的「詳情補充」中註明有關情況。Must provide the details in the “Supplementary Details” of Part 7
“Health Declaration”.>

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第二部份 其他指示 Part 2 Other Instructions

第三部份 每月淨收入及教育程度 Part 3 Monthly Net Income and Education

保單持有人每月淨收入
Monthly Net Income of Policyholder HK$

保單持有人教育程度 □ 小學或以下 Primary or below □ 中學 Secondary

Education Level of Policyholder □ 大學或以上 University or above □ 其他 Others

第四部份 職業詳情 Part 4 Occupation Details

如增加附加保障供款者免繳保費利益，必須在此部份提供受保人及保單持有人的有關資料。Must provide the information on Insured and Policyholder
in this part if Payor Benefit Rider is applied.
受保人 Insured 保單持有人 Policyholder
職業
Occupation

業務性質
Nature of Business

高空工作 □ 否 No □ 否 No
Work at Height □ 是 Yes 最高 maximum height 米M □ 是 Yes 最高 maximum height 米M
□ 否 No □ 否 No
重型機械操作
Heavy Machine Operation
□ 是 Yes □ 是 Yes
請註明(Please specify) 請註明(Please specify)
第五部份 投保履歷 Part 5 Insurance History
如僅增加附加保障供款者免繳保費利益或免繳保費利益，無需填寫此部份問題。This part is not required to complete if only Payor Benefit Rider or
Waiver of Premium Benefit is applied.
受保人是否持有或正在申請任何保險公司的人壽、危疾、醫療或意外保障？若是，請填妥下表。Does the Insured
□
have in force or currently applying for life, critical illness, medical or accident insurance with any insurance company? If Yes, please □
是 Yes 否 No
complete the table below.
簽發年份 保障額 Sum Assured (港元HKD)
承保公司名稱
Year 人壽保障 危疾保障 住院入息保障 意外保障
Name of Insurance Company
Issued Life Insurance Critical Illness Hospital Income Accident Coverage

總保障額 Total Sum Assured

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第六部份 家庭狀況 Part 6 Family Details

必須在此部份提供受保人的有關資料，如申請增加附加保障供款者免繳保費利益，則必須同
受保人 保單持有人
時提供保單持有人的有關資料。Must provide the information on Insured in this part. If Payor Benefit
Insured Policyholder
Rider is applied, the information on Policyholder is also required.
1 閣下的親生父母、兄弟姊妹中曾否有死於或患有心臟病、中風、高血壓、糖尿病、腎
病、多發性硬化症、精神病、肝炎（或肝炎帶菌）、癌症或任何遺傳疾病？如有，請
在下表註明患病或死亡年齡、關係及原因。Have any of your natural parents, brother(s) or
sister(s) died or suffered from heart disease, stroke, high blood pressure, diabetes mellitus, kidney □是 Yes □否 No □是 Yes □否 No
disease, multiple sclerosis, mental disease, hepatitis (or is a hepatitis carrier), cancer or any other
hereditary diseases? If Yes, please provide details of onset/death age(s), relationship and cause of
death or condition(s) in the table below.
受保人 Insured 保單持有人 Policyholder
關係 Relationship 疾病 病發／死亡年齡 疾病 病發／死亡年齡
Disease Onset/Death Age Disease Onset/Death Age
父親 Father

母親 Mother

兄弟姊妹 Sibling(s)

2 (a) 受保人的父母是否擁有人壽或危疾保險（適用於17歲或以下）？如是，請在下表註明。 Does the Insured’s

parent(s) have in force life or critical illness insurance (for age 17 or below)? If Yes, please complete the table below.
□是 Yes □否 No
(b) 受保人的配偶是否擁有人壽或危疾保險（適用於家庭主婦）？如是，請在下表註明。 Does the Insured’s
spouse have in force life or critical illness insurance (for homemaker)? If Yes, please complete the table below.
□是 Yes □否 No
2(a) 父 Father 2(b) 母 Mother 2(c) 配偶 Spouse
人壽保險金額
Life Insurance Amount (HK$)
危疾保險金額(HK$)
Critical Illness Insurance Amount (HK$)
3 閣下曾否於過去十二個月內或打算在未來十二個月內在香港以外居留超過六個月（旅 受保人 保單持有人
遊除外）？如是，請在下表註明國家、城市、原因及時間。Have you resided or intended Insured Policyholder
to reside outside Hong Kong for more than 6 months during the last 12 months or in the coming 12
months (except for Holiday)? If Yes, please state the country, city, reason(s) and duration in the table □ 是 Yes □ 否 No □
是 Yes 否 No □
below.
受保人 Insured 保單持有人 Policyholder
□中國城市City in China □中國城市City in China
國家及城市 （不包西藏自治區／新彊維吾爾自治區／青海 （不包西藏自治區／新彊維吾爾自治區／青海
Name of Country and City 省excluding Tibet Autonomous Region/Xinjiang Uygur 省excluding Tibet Autonomous Region/Xinjiang Uygur
（請列出所有 Please state Autonomous Region/Qinghai） Autonomous Region/Qinghai）
all） □ 澳門 Macau □ 澳門 Macau
□其他 Others □其他 Others
逗留原因 Reason of Stay
時間(月數) Duration Month(s))

第七部份 健康聲明 Part 7 Health Declaration

必須在此部份提供受保人的有關資料，如申請增加附加保障供款者免繳保費利益，則必須
受保人 保單持有人
同時提供保單持有人的有關資料。Must provide the information on Insured in this part. If Payor
Insured Policyholder
Benefit Rider is applied, the information on Policyholder is also required.
1 公分 公分
(a) 閣下的身高? Your height?
cm cm
公斤 公斤
(b) 閣下的體重? Your weight?
kg kg
(c) 過去一年內，閣下的體重曾否有 5 公斤或 11 磅以上的增減？若有，請說明原
因。Has your weight changed more than 5kgs/11 lbs in the past year? If Yes, please state the □ 是 Yes □ 否 No □ 是 Yes □ 否 No
reason.
(d) 閣下曾否在過去三個月的任何時間內持續超過一星期有下列病徴：疲倦、體重
下降、腹瀉、淋巴核腫大或不尋常的皮膚潰瘍? Have you at anytime in the past 3
months had any of the following symptoms for more than 1 week continuously: fatigue, weight
loss, diarrhea, enlarged lymph nodes or unusual skin lesions?
□ 是 Yes □ 否 No □ 是 Yes □ 否 No

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第七部份 健康聲明（續）Part 7 Health Declaration (Continued)

必須在此部份提供受保人的有關資料，如申請增加附加保障供款者免繳保費利益，則必須
受保人 保單持有人
同時提供保單持有人的有關資料。Must provide the information on Insured in this part. If Payor Benefit
Insured Policyholder
Rider is applied, the information on Policyholder is also required.
在過去 12 個月內閣下曾否吸煙? 若有，請填寫下列問題。
2
In the past 12 months, have you ever smoked? If Yes, please complete below questions. □ 是 Yes □ 否 No □ 是 Yes □ 否 No
支 支
(a) 每日平均吸煙多少支? Average number of pieces daily?
Piece(s) Piece(s)
年 年
(b) 吸煙已有多少年? For how many years have you smoked? Year(s) Year(s)
3 閣下曾否服用成癮藥物，或慣常飲啤酒、餐酒、烈酒或曾接受與服用藥物或飲酒相
關的治療或輔導？如有，請註明種類及用量。Have you ever taken any habit forming drugs
or used beer, wine or spirits regularly or been treated or advised in connection with your alcohol □ 是 Yes □ 否 No □ 是 Yes □ 否 No
consumption or taking of drugs? If Yes, please state the type and quantity.
4 閣下曾否患有，或獲告知患有，或曾接受下列疾病之治療？
Have you ever had or been told you had, or been treated for the following diseases?
(a) 肺結核病、哮喘、吐血、呼吸困難、或任何呼吸系統或肺部疾病？Tuberculosis,
asthma, blood-spitting, shortness of breath, or any respiratory or lung disease? □ 是 Yes □ 否 No □ 是 Yes □ 否 No
(b) 心悸、胸痛、高血壓病、貧血、任何心臟、血液或血管疾病？ Palpitation, chest
pain, high blood pressure, anaemia, any disease of the heart, blood or blood vessels? □ 是 Yes □ 否 No □ 是 Yes □ 否 No
(c) 腸胃潰瘍、經常消化不良、疝氣、瘺管、痔瘡、胃、胰、腸、黃疸、或任何肝
病 （包括肝炎帶菌）、膽嚢、消化系統之疾病？Gastro-intestinal ulcer, recurrent
indigestion, hernia, fistula, piles, stomach, pancreas, intestine, jaundice or any disease of liver □ 是 Yes □ 否 No □ 是 Yes □ 否 No
(including hepatitis carrier), gall-bladder or digestive system?
(d) 尿糖、尿蛋白、泌尿系統結石、性病、腎臟或前列腺疾病、或其他生殖泌尿系
統之病症？Urinary sugar/albumin/stones, venereal disease, or diseases of the kidney, □ 是 Yes □ 否 No □ 是 Yes □ 否 No
prostate, reproductive or urinary system?
(e) 腦癎症、抽搐、昏暈、嚴重頭痛、精神病或精神不安、任何腦部或神經系統不
正 常 或 疾 病 ？ Epilepsy, seizure, fainting spells, severe headache, mental or nervous □ 是 Yes □ 否 No □ 是 Yes □ 否 No
condition, any disease or abnormality of the brain or nervous system?
(f) 癌症、腫瘤／不正常的生長物、囊腫、任何透過性接觸傳染的疾病、糖尿病、
甲狀腺腫大、其他內分泌疾病或嚴重受傷？Cancer, tumor/abnormal growth, cyst, any □ 是 Yes □ 否 No □ 是 Yes □ 否 No
sexually transmitted disease, diabetes, goitre, any endocrine disease or severe injury?
(g) 感官疾病或功能失常（如眼、鼻、喉、耳或口腔之疾病）？Disease or disorder of
the sense organ(s) (e.g. disorder of the eyes, nose, throat, ears or oral cavity)? □ 是 Yes □ 否 No □ 是 Yes □ 否 No
(h) 風濕性發熱、關節炎、痛風或肌肉及骨骼疾病 （如關節或骨骼疾病） 、結締組
織或皮膚疾病或任何未在上述各項提及之疾病？Rheumatic fever, arthritis, gout or
disorder of musculoskeletal system (e.g. joint or bone), connective tissues or skin disorder, or □ 是 Yes □ 否 No □ 是 Yes □ 否 No
any other disorder not mentioned?
5 在過去五年內，閣下曾否 In the past five years, have you ever
(a) 接受過或被建議進行診斷檢驗，如 X 光、心電圖、電腦掃瞄、超聲波、尿液、
特殊血液檢驗及健康檢查？Had or had been advised to take any diagnostic test(s), such □ 是 Yes □ 否 No □ 是 Yes □ 否 No
as X-Ray, ECG, CT scan, ultrasound, urine, special blood test or physical check-up?
(b) 患有疾病、接受過手術、就診／治療或留醫等而未在上述各項提及者？
Had any illness, operation, medical consultation/treatment or hospitalization not mentioned □ 是 Yes □ 否 No □ 是 Yes □ 否 No
above?
(c) 其他健康狀況或病徵及症狀（例如腫塊、頭痛、持續咳嗽、胸痛或上腹痛）
而正在或打算尋求醫療意見
Other medical conditions or sign and symptom (such as lump, headache, persistent □ 是 Yes □ 否 No □ 是 Yes □ 否 No
coughing, chest pain or epigastric pain) that you are seeking or intend to seek medical
advice
6 閣下目前是否正接受藥物治療或醫療護理或是否有可預見或打算進行之醫生囑
咐、診症或治療？或閣下是否有慣常求診的醫生／家庭醫生？若是，請註明醫生
姓名及地址。Are you currently receiving medical treatment or under medical care of any kind
or do you have any expected need or intention of receiving medical advice, consultation or □ 是 Yes □ 否 No □ 是 Yes □ 否 No
treatment? Or do you have regular doctor or family doctor? If Yes, please state the name and
address of the doctor and reason(s) of medical consultation(s).
7 閣下曾否接受或打算接受任何有關愛滋病或愛滋病綜合病徵之醫生囑咐、輔導或
治療，或曾被通知患有上述提及之疾病？或閣下的配偶是否曾患有愛滋病或其綜
合病徵？Have you ever received or do you intend to receive any medical advice, counseling or □ 是 Yes □ 否 No □ 是 Yes □ 否 No
treatment in connection with AIDS, or any AIDS-related conditions, or been told you had the
above-mentioned disease? Or has your spouse suffered from any AIDS related condition?

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 保單號碼 Policy No.

第七部份 健康聲明（續）Part 7 Health Declaration (Continued)

必須在此部份提供受保人的有關資料，如申請增加附加保障供款者免繳保費利益，則必須
受保人 保單持有人
同時提供保單持有人的有關資料。Must provide the information on Insured in this part. If Payor Benefit
Insured Policyholder
Rider is applied, the information on Policyholder is also required.
8 閣下是否曾或有此意圖參與任何攀山、跳傘、潛水、危險性運動、賽事或並非以乘
客身份乘搭固定班次的民航客機？如有，請填寫有關之問卷。
Have you ever engaged in any mountaineering, sky diving, scuba diving, hazardous sports, racing □ 是 Yes □ 否 No □ 是 Yes □ 否 No
or flying other than as a fare-paying passenger on a regularly scheduled airline or do you have any
intention to do so? If Yes, please complete the appropriate questionnaire.
9 閣下在過去投保或申請復效人壽、危疾、意外或醫療保險時，曾否被拒絕、延期、
加費或被修改？如有，請填寫原因、投保公司名稱、投保日期及保單號碼。
Has any application for or reinstatement of life, critical illness, accident or medical insurance on □ 是 Yes □ 否 No □ 是 Yes □ 否 No
you been declined, postponed, rated-up or accepted with modified terms? If Yes, please provide
the reason, name of insurance company, application date and policy number.
10 只適用於十二歲或以上之女性 For Female aged 12 or above only
(a) 閣下現在是否懷孕? 如是，請告知懷孕週數。Are you pregnant now? If Yes, please
state pregnancy duration. □ 是 Yes □ 否 No □ 是 Yes □ 否 No
(b) 閣下曾否有乳房或生殖器官疾病或產前產後之併發症、月經失調或柏氏宮頸
抹片不正常？ Have you had any disorder of the breast or reproductive organs, or □ 是 Yes □ 否 No □ 是 Yes □ 否 No
prenatal or postnatal complication, menstrual disorders or abnormal pap smears?
11 只適用於十七歲或以下之未成年人士 For Juvenile aged 17or below only
(a) 閣下是否早產（37 週或以下）或過期出生? 出生後有否接受特別護理？Was your
birth premature (37 weeks or below) or post-mature? Any special care needed after birth? □ 是 Yes □ 否 No 不適用
(b) 閣下是否有身體缺陷、生理上或心智發育緩慢的跡象？Have you had any
physical defects or shown any sign of slow physical or mental development? □ 是 Yes □ 否 No Not Applicable

詳情補充 Supplementary Details

若「健康聲明」問題答案為「是」或有任何補充，請在此欄提供詳細資料並註明所屬部份及題號。如下列空位不夠使用，請填寫「要保補
充陳述書」。如閣下曾進行身體檢查、化驗或入院接受治療，請提供相關之覆診預約紙、身體檢查及化驗報告之副本作參考。
If any answer to “Health Declaration” is Yes or any supplementary information, please give full particulars below and quote the relevant section and question number.
If space given is insufficient, please complete a “Supplementary Information Form”. Please provide copies of appointment slip and investigation reports for review if
there are any physical check-up, laboratory test or hospitalization history.
題號 詳情 Details 康復程度 主診醫生／醫院名稱及地址
Question 包括患病／受傷日期、患病／受傷持續時間、發病次數及病情、診斷結果、 （如適用） （如適用）
No. 曾接受的治療、檢查種類及其結果、最後覆診日期等 Including dates of Degree of Recovery Name & Address of Attending
illness/injury, duration, number of attacks, severity of illness/injury, diagnosis, type of (If applicable) Doctor/Hospital (If applicable)
treatment or investigation received and their results, last follow-up date etc

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 保單號碼 Policy No.

第八部份 付款指示 Part 8 Payment Instruction

付款貨幣選擇 (如無註明，款項將以保單貨幣發放) Payment Currency Option (If not specified, payment will be issued in policy currency)
 保單貨幣 Policy Currency  港元 HKD
A. 資金調配 Fund Transfer to Policy
1. 用途 Purpose  抵繳保費及保費徵費 Offset Premium and Levy
 償還貸款金額及/或全數貸款利息 Repay Loan Amount and/or FULL Loan Interest
 償還自動保單貸款及利息 Repay Automatic Premium Loan and Interest
2. 保單號碼/要保書編號 Policy No./ Application No.
3. 付款分配 Payment Allocation

 全數金額^ Full Amount^  指定金額* Specified Amount* $

B. 抵押保單專用 For Policy that has been assigned to the Assignee only
 以指定付款方式全數金額支付予保單持有人* Payable to the Policyholder in full amount by specified payment method*
 以劃線支票支付予受讓人# Payable to the Assignee by a crossed cheque#
1. 受讓人姓名/名稱 Name of Assignee
2. 支 票 送 遞 方 式 及 聯 絡 人 電 話 號 碼
Cheque Delivery Method and Phone No. of
Contact Person
3. 付款分配 Payment Allocation
 全數金額^ Full Amount^  指定金額* Specified Amount* $
^ 如選擇「全數金額」，無須填寫「C. 付款方式」部份。If select “Full Amount”, you are not required to fill in section “C. Payment Method”.
* 如有餘額/金額支付予保單持有人，請填寫「C. 付款方式」部份。If there is remaining balance / an amount to be paid to the Policyholder, please complete
section “C. Payment Method”.
# 如欲以劃線支票以外的付費方式支付予受讓人，請於「C. 付款方式」部份的「4. 其他指示」提供有關詳情。
If the payment needs to be paid by another payment method other than a crossed cheque, please provide relevant details in “4. Other Instruction” under section “C.
Payment Method”.
C. 付款方式 Payment Method
1. 轉賬至本地銀行戶口 Transfer to Local Bank Account
 A. 轉賬至預設收款銀行賬戶 Transfer to Default Payment Account
 B. 轉賬至非預設收款銀行賬戶(請同時填寫以下銀行賬戶資料) Transfer to Non-Default Payment Account (Please fill in the below bank information.)
銀行名稱 Name of Bank 銀行編號 Bank code 分行編號 Branch code 銀行賬戶號碼 Account No.

2. 電匯至海外銀行戶口 Telegraphic Transfer to Overseas Bank Account

銀行及分行名稱 Name of Bank and Branch

銀行賬戶號碼 Account No.

收款銀行地址 Bank Address

國際匯款代碼 SWIFT Code 賬戶持有人的海外聯絡電話 Overseas Contact No. of Bank Account Holder

賬戶持有人的海外通訊地址 Overseas Correspondence Address of Bank Account Holder

3. 支票支付 (以劃線支票支付予保單持有人) Cheque Payment (Payable to the Policyholder by a crossed cheque)

 以平郵寄至通訊地址 By surface mail to correspondence address
 經保險中介人轉交 Deliver via Insurance Intermediary
 親身到分行領取(只適用於經銀行投保的保單) To be collected at Branch in person (Applicable to policy applied via by bank only)
分行名稱/編號 Branch Name/Code

 親身到客戶服務中心領取 To be collected at Customer Service Centre in person

 保單持有人領取 To be collected by the Policyholder

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 保單號碼 Policy No.

第八部份 付款指示（續） Part 8 Payment Instruction (Continued)

 授權人領取 To be collected by the Authorized Person

授權人姓名 授權人聯絡電話 授權人身份證明文件號碼
Name of Authorized Person Contact No. of Authorized Person I.D. No. of Authorized Person

 灣仔 Wan Chai  其他地點# Other Location#

#請於 www.chinalife.com.hk 查閱香港境內其他地點的客戶服務中心(如有)。*Please visit our website www.chinalife.com.hk to
obtain information of other Customer Service Centre location(s) in Hong Kong (if any).
4. 其他指示 Other Instruction

注意 Note：
1. 銀行賬戶持有人必須為保單持有人，不接受聯名戶口。The bank account holder must be the same as the policyholder. Joint account is not accepted.
2. 轉賬或電匯至銀行賬戶須遞交銀行賬戶證明文件，而銀行賬戶證明文件必須顯示賬戶持有人姓名及賬戶號碼，並可以於文件上遮蓋其
他非必要的資料。Transfer or Telegraphic Transfer to bank account requires the submission of bank account proof, which must clearly display the account
holder's name, and account number; unrelated content can be masked.
3. 如選擇保單貨幣以外的貨幣領取保單價值或利益，款項將於付款處理當時按本公司的匯率進行兌換。保單持有人須自行承擔因匯率變
動衍生之風險及貨幣兌換時所產生的匯兑損益(如有)。If choosing a currency other than the policy currency to receive policy values or benefits, the fund
will be processed and exchanged according to the company's exchange rate at the time of the transaction.The policyholder has to bear for any potential exchange
rate risks and associated gain or loss (if any) due to the currency exchange.
4. 實際到賬時間會因應個別銀行而有差異，可向有關銀行查詢。The actual time for receiving the funds may vary depending on the bank, please contact
the bank for details.
5. 如未有足夠資料顯示銀行賬戶持有人為保單持有人或因故未能成功入賬，有關款項將以劃線支票形式給付。發出支票的處理時間會較
銀行轉賬為長。If there is insufficient information to confirm that the bank account holder is the policyholder, or the payment cannot be credited for any reason,
the relevant payment will be paid by a crossed cheque instead. The processing time for cheque issuance will be longer compared to bank transfer.
6. 如保單持有人選擇的支付貨幣是港元或人民幣以外貨幣，即使付款失敗，相關的銀行手續費(如適用)及匯率損差(如適用) 須由客戶自行
承擔，並將於給付款項中自動扣除。If the policyholder chooses a currency other than HKD or RMB as the payment currency, even if the payment fails, the
related bank charge (if applicable) and any associated gain or loss (if applicable) have to be borne by the policyholder, and will be automatically deducted from
the payment amount.

第九部份 轉保聲明 Part 9 Policy Replacement Declaration

注意事項 Notes：
如在冷靜期後申請減少保單基本計劃保額／基本金額或將保單轉換為減額繳清保險，請填寫此部分。Please complete this part if you apply
for reducing the sum assured/basic amount of basic plan after the cooling-off period or converting the policy to a reduced paid-up insurance.
閣下是否使用或打算使用此人壽保險保單的部分或全部資金，或使用或打算使用通過減少此人壽保險保單的應付保費而節省的金額，以
資助閣下於過去12個月內新申請的人壽保險保單（如有）？例如，該等資金或金額可能來自從閣下將此人壽保險保單轉換為減額繳清保
險或在冷靜期後通過減低此人壽保險保單基本計劃的保額／基本金額而節省的保費。如是，該等情況將被視為「轉保」 。Are you using or do
you intend to use some or all of the funds arising from the above-mentioned policy, or any savings made by reducing the premium payable under the above-
mentioned policy, in order to fund the new life insurance policy (if any) which is purchased within 12 months prior to the date of this application? For example, such
funds or savings may arise from reducing the premium payable of the above-mentioned policy by converting the policy to a reduced paid-up insurance or reducing
the basic plan sum assured/basic amount of the policy after the cooling-off period. If yes, such conditions will be considered as Policy Replacement.
□ 是 Yes
□ 否 No
□ 尚未決定 Not Yet Decided
□ 不適用（適用於過去12個月內並沒有購買新的人壽保險保單） Not applicable (Applicable to those who have not purchased a new life insurance
policy in the past 12 months) policy in the past 12 months)
註 Notes：
「轉保」可能令閣下帶來實質及潛在損失。為保障閣下的權益，請仔細比較現有保單與新保單的條款，衡量轉保是否符合本身的最佳利
益，閣下應尋求專業意見以了解相關風險及轉保的不利後果，並細閱本公司的網站 www.chinalife.com.hk 的壽險轉保須知。You may suffer loss
in case of Policy Replacement. To protect your interest, you should carefully consider your existing and the new insurance policies and assess whether the Policy
Replacement is in your best interests before making a decision. You should seek professional advice to understand the associated risks and potential disadvantages
of Policy Replacement. For details, please visit our website at www.chinalife.com.hk to view the useful tips on Life Insurance Policy Replacement.

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 保單號碼 Policy No.

第十部份 聲明及授權 Part 10 Declaration and Authorization

本人／我們現申請辦理上述之更改事項，謹此聲明並確認所有提供之資料及細節是準確無誤，真實及為事實之全部，並且
是盡本人／我們所知及所信而作答的，本人／我們並同意此等更改事項或服務必須符合下列所有條件及經 貴公司批准，方
能生效 I/We hereby request the above change(s) be effected and declare that all statement, information and particulars given herein are accurate,
true and complete and are given to the best of my/our knowledge and belief and no material information has been withheld in relation to this request.
I/We agree that such change(s) or service(s) will not take effect unless all of the following conditions are met and approved by the Company：
1. 所有需要之款項及文件已提交予 貴公司並由 貴公司收妥。All required payment and documents have been submitted to the
Company and duly received by the Company.
2. 此項申請在受保人在生並仍然符合受保條件時，經 貴公司接納及批准。The request is accepted and approved by the Company
during the lifetime and continued insurability of the Insured.
3. 在此申請表及 貴公司所須之其他文件上填報之一切資料及申報，將成為此保單之一部份（除非另有其他指示） 。The
information and statement made in this request and in other documents as required by the Company shall form the basis for this policy
alteration request and form a part of the policy(ies) unless otherwise specified.
4. 貴公司將以書面或附註形式通知此申請被接納。Acceptance of the request for change shall be confirmed by the Company in writing
or endorsement.
5. 本人／我們提供符合 貴公司要求之有效証明文件（例如：身分證明及地址證明）予 貴公司，讓 貴公司能按照於「打
擊洗錢及恐怖分子資金籌集（金融機構） 條例」第 615 章所載，對本人／我們、保單之最終實益擁有人（如有）及
本人／我們之授權簽署人士 （如適用）進行客户盡職審查。I/We provide valid documentation proofs (such as identity document
and address proof) to the satisfaction of the Company for the Company to conduct due diligence on myself/ourselves, the ultimate beneficial
owner of the policy (if any) and my/our authorized signatory(ies) (if applicable) pursuant to the Anti-money Laundering and Counter-Terrorist
Financing (Financial Institutions) Ordinance, Cap. 615.
本人／我們謹此代表本人及所有受保人同意及授權：I/We hereby agree and authorize on behalf of myself and/or the Insured that：
1. 任何僱主、註冊西醫、醫院、診所、保險公司、銀行、政府機構，或其他機構、組織或人士、凡知道或持有任何有關本
人及受保人或任何一位受保人之紀錄者，及／或曾診驗或可能將會診驗本人及任何一位受保人者，均可將該等資料提供
給貴 公司 。 Any employer, registered medical practitioner, hospital, clinic, insurance company, bank, government institution, or other
organization, institution or person, that has any records or knowledge of me/the Insured and who has attended or may hereafter attend
myself/the Insured to disclose such information to the Company.
2. 貴公司或任何其指定之醫生或化驗所，可就此保單更改申請替本人及任何受保人進行所需之醫療評估及測試，作為審核
本人及任何受保人之健康狀況。此授權對本人之繼承人及受讓人具有約束力；即使本人死亡或無行為能力時，此授權仍
具效力。本授書影印本與正本均有同等效力。The Company or any of its appointed medical examiners or laboratories may perform
the necessary medical assessment and tests to evaluate the health status of myself/the Insured in relation to this Application. This authorization
shall bind my successors and assignees and remain valid notwithstanding my death or incapacity. A photocopy of this authorization shall be as
valid as the original.

第十一部份 收取個人壽險保費徵費 Part 11 Collection of Premium Levy on Individual Life Insurance Policy
本人／我們謹已收悉I/We hereby notified that：
貴公司就保險業監管局要求並授權向每位保單持有人所持有的有效保單徵收「保費徵費」 （下稱「徵費」 ），及將收取的保費
徵費將會全數轉交予該局。保險業監管局亦可以根據相關條例，將有關的欠付款作為民事債項及向相關的保單持有人追討
欠款並有機會徵收罰款。有關收取徵費的詳情，請瀏覽中國人壽（海外）股份有限公司的網頁 www.chinalife.com.hk/levy。China
Life Insurance (Overseas) Company Limited, as an authorized insurer, is statutorily required to collect Premium Levy (“Levy”) from policyholder on
behalf of the Insurance Authority (“IA”) and report to IA. IA may take legal proceedings against policyholder in respect of any outstanding Levy as
civil debt and may impose pecuniary penalty. For details of the collection of Levy, please refer to the website at www.chinalife.com.hk/levy.

第十二部份 個人資料收集聲明 Part 12 Personal Information Collection Statement

本人／我們確認已閱讀及明白「中國人壽保險（海外）股份有限公司」的收集個人資料聲明。有關最新版本的收集個人資
料聲明，可於 www.chinalife.com.hk 下載或向本公司索取。I/We confirm that I/we have read and understood the Personal Information
Collection Statement (“PICS”) of China Life Insurance (Overseas) Company Limited. For the latest version of the PICS, it can be downloaded from
www.chinalife.com.hk or available upon request.

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 保單號碼 Policy No.

第十三部份 聲明及簽署（請勿在空白表格上簽署）Part 13 Declarations and Signature (Please DO NOT sign on BLANK form)
1. 此表格必須於保單持有人簽署日起計30天內交至本公司。This form must be received by the Company within 30 days from the date of its signing.
2. 保單持有人、受讓人(如適用)及不可撤換受益人(如適用)的簽名式樣必須與本公司的記錄相符。The signatures of the Policyholder, Assignee (if
applicable) and Irrevocable Beneficiary (if applicable) must match with the Company’s record.
3. 若保單持有人以圖章蓋印簽署，必須有一位見證人。見證人之個人資料只會用於處理此申請及確認此表格簽署人的身份之用。If the
Policyholder uses a signature chop, a witness is required. The personal particulars of the witness will only be used for the purpose of verification and confirmation
of the identity of the signatory(ies) of this form.
本人/我們僅此確認已閱讀及明白以上申請的所有條款及條件，並同意受該等條款及條件約束。本人/我們僅此同意作出以上協議及聲明。
I/We hereby confirm that I/we have read and understood all the terms and conditions of the above request, and agree to be bound by the same. I/We hereby agree
to make the above agreements and declarations.
受保人(倘非保單持有人及18
保單持有人簽署及印鑑(如適 受讓人/不可撤換受益人簽署及
歲或上)簽署及印鑑(如適用)
用) 印鑑(如適用) 見證人簽署(如適用)
Signature and Stamp (if applicable)
Signature and Stamp (if applicable) Signature and Stamp (if applicable) of Signature of Witness (if applicable)
of Insured (if different from the
of Policyholder Assignee / Irrevocable Beneficiary
Policyholder & aged 18 or above)

與保單持有人之關係
Relationship to Policyholder

 保險中介人/銀行職員/客戶服務中心
職員
Insurance Intermediary/Bank Staff/CS Centre
Staff
編號
Code.
其他人士(請註明)
Others (Please Specify)
身份證明文件號碼
Identity Document No.

姓名/名稱 Name 姓名/名稱 Name 姓名/名稱 Name 姓名/名稱 Name

日期 (年/月/日) Date (YYYY/MM/DD) 日期 (年/月/日) Date (YYYY/MM/DD) 日期 (年/月/日) Date (YYYY/MM/DD) 日期 (年/月/日) Date (YYYY/MM/DD)

HK-PS-CHG-07/202506-01 P. 10 of 11
 保單號碼 Policy No.

所需文件指引 Documents Checklist

客戶類別 所需文件(請✓閣下已提交的文件)
服務申請類別
Customer Documents Required (Please ✓ against the documents you submitted)
Type of service
Type 保單持有人/不可撤換受益人(如適用)
request 受讓人(如適用) Assignee (if applicable)
Policyholder / Irrevocable Beneficiary(if applicable)
個人客戶 保單價值提取/  身份證明文件的核實副本(如未曾遞交)  《自我證明表格 – 實體 (保單服務適用)》，或
Individual 保單貸款/ Certified True Copy of Identification Proof (If not submitted) 《自我證明表格 – 個人 (保單服務適用)》(如有
Customer 終止保單/  載有銀行賬戶持有人姓名及賬戶號碼的銀行存摺 任何稅務地區變更)
Policy Value ／銀行卡／最近 3 個月內發出的月結單(包括電子 “Self-Certification Form – Entity (For Policy Service Use)”,
Withdrawal/
結單)／其他有效銀行賬戶證明副本 (如選用轉賬 or “Self-Certification Form – Individual (For Policy Service
Policy Loan/Policy 或電匯為付款方式) Use)” (If there is any change of the tax residence)
Termination
Copy of bank book / bank card / bank statement which is
刪除附加保障/
減低保額/ issued within the past 3 months (including e-statement) /
基本金額 other valid account proof showing the bank account
(如有退款) holder's name and account no.. (If select bank transfer or
Deletion of Riders/ telegraphic transfer as payment method)
Reduction of Sum
Assured/
 《自我證明表格 – 個人 (保單服務適用)》 (如有
任何稅務地區變更)
Basic Amount
“Self-Certification Form – Individual (For Policy Service
(Refund,if any)
Use)” (If there is any change of the tax residence)
償還保單貸款  繳款證明
Policy Loan Payment Proof
Repayment
公司客戶 保單價值提取/  公司查冊文件及其他公司文件，詳情請參閱本公  公司查冊文件及其他公司文件，詳情請參閱本公
Corporate 保單貸款/ 司網站 www.chinalife.com.hk (服務 > 網上自助服務 司網站 www.chinalife.com.hk (服務 > 網上自助服務
Customer 終止保單 及表格下載 > 繳付及領取 > 提取保單款項) 之 及表格下載 > 繳付及領取 > 提取保單款項) 之
Policy Value 《保單領款須知(適用於保單持有人為實體/機 《保單領款須知(適用於保單持有人為實體/機
Withdrawal/ 構)》 構)》
Policy Loan/Policy Company search document and other company Company search document and other company
Termination documents, please visit our website www.chinalife.com.hk documents, please visit our website www.chinalife.com.hk
刪除附加保障/ (Service > E Self-Service and Form Library > Payment & (Service > E Self-Service and Form Library > Payment &
減低保額/ Collection > Request For Policy Value Withdrawal) for Collection > Request For Policy Value Withdrawal) for
基本金額 information on “Policy Payment Application Guidance information on “Policy Payment Application Guidance
(如有退款)
Notes (Applicable to Entity Policyholder)” Notes (Applicable to Entity Policyholder)”
Deletion of Riders/
Reduction of Sum  載有銀行賬戶持有人姓名及賬戶號碼的銀行存摺  《自我證明表格 – 實體 (保單服務適用)》 (如有
Assured/ ／銀行卡／最近 3 個月內發出的月結單(包括電子 任何稅務地區變更)
Basic Amount 結單)／其他有效銀行賬戶證明副本 (如選用轉賬 “Self-Certification Form – Entity (For Policy Service Use)”
(Refund,if any) 或電匯為付款方式) (If there is any change of the tax residence)
Copy of bank book / bank card / bank statement which is
issued within the past 3 months (including e-statement) /
other valid account proof showing the bank account
holder's name and account no.. (If select bank transfer or
telegraphic transfer as payment method)
 《自我證明表格 – 實體 (保單服務適用)》(如有
任何稅務地區變更)
“Self-Certification Form – Entity (For Policy Service Use)”
(If there is any change of the tax residence)
償還保單貸款  繳款證明
Policy Loan Payment Proof
Repayment

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