永诚个人高端医疗保险计划臻享版投保单.PDF

` Application for Alltrust Individual High-End Medical Insurance 永诚个人高端医疗保险计划（臻享版）投保单 Instructions 投保指南 1. Please read clauses and application requirements in the proposal carefully before you fill out the application form. Should you have any questions concerning the insurance benefits, please feel free to consult the sales representative. 在填写投保单前，请仔细阅读保险计划书中相关条款和投保条件。若对您的保险福利有疑问，请与您的销售代表进行确认。 2. The complete application documents should include: Proposal, Application Form, ID Card/Passport (soft copy). 您的完整投保材料包括：保险计划书、投保单、有效证件复印件。 3. Please completely fill out the application form and submit all required application documents, in case the enrollment process would be delayed. We would proceed with underwriting upon receipt of complete application documents. 请完整填写本投保单并递交以上材料，否则可能会延长投保流程。我们会在收到完整投保材料后进行审核。 4. The application form is valid for 30 days from the date signed. 本投保单自签署之日起，有效期为30 天。 Section 1-A: Enrollment Type 1-A 区：保全类型 New Enrollment 新加保 Renewal 续保 Add Child 增加附属被保险子女 Other 其他 __________________ Add Spouse 增加附属被保险配偶 Date of Marriage 结婚日期 _____/______/_______(MM/DD/YYYY) (月/ 日/年) Section 1-B: Coverage Type 1-B 区：保障类型 Diamond Plan 钻石计划 Platinum Plan 白金计划 Annual Maximum 年度最高保额: ¥ 8,000,000 Annual Maximum 年度最高保额: ¥ 1,000,000 Greater China Coverage 大中华保障 Greater China Plus Coverage 大中华增强保障 Mainland China Coverage 中国大陆保障 Only for Diamond Plan Individual Annual Deductible 个人年免赔额 ¥0 ¥800 ¥2,000 Other 其他 ¥___________ 仅适用于钻石计划 Policy Co-payment 保单自付比例 0% 10% 20% 30% Provider Co-payment 通常惯例自付比例 Greater China Coverage and Greater China 0% 100%