个人人身保险契约变更申请书(保益变更)

1、中国平女PINGAN舷银行股帝平支显肓眼公司PING AN HEALTH INSURANCE COMPANY OF CHINA.LTD. 个人人身保险契约变更申请书（保益变更） Applicati on for Alterati on of In dividual In sura nee PolicyA .基本申请信息 /General information保单号 /Policy number投保人 /Policyholder被保险人/InsuredB .变更项目 /Items to be altered申请下述标记有* ”的项目时，请根据本公司要求填写相关人员信息及健康告知It you s

2、elect items marked with a * ” below, please fill out the relevant personal information and health declaration according to the applicable requirements.Name of InsuredName and code of riderNew selection*增加被保险人Addition ofInsured新增被保险人姓名/Name of new Insured:与投保人关系Relationship withInsured / 本人 Self 配偶 /

3、Spouse / 子女 Child 其他 / Other:证件类型Type of ID身份证 /Identity card护照 /Passport其他 /Other证件号 /Valid ID number性别 /Gender男 /Male 女 /Female生日 /Date of birth年 /Year月 /Month日 /Day其他新增被保险人信息 /Information of any additional new Insureds 新增被保险人姓名 /Name of additional new Insured:详情 /Details:减少被保险人Removal of anInsure

4、d被保险人姓名 /Name of Insured to be removed:1、2、3、4、*保障计划变更Alteration ofpolicy selection申请项目 /Policy selection to be altered保额 /Insured amount档次计划 /Plan份数 /Number of units新增附险 /Additional rider终止附险 /Cancellation of rider被保险人姓名险种简称及代码新保额、档次、份数*若申请新增附险，请投保人同时阅读并确认人身保险投保提示书。Please read and confirm the "

5、;Life Insurance Application Notice" when applying for additional riders.保单挂失补发Report loss ofpolicy挂失挂失解除补发Report lossCancel loss reportedReissue若申请补发保单，则自补发之日起，原保单自动作废，且挂失状态自动取消。When a new insurance policy is issued, the original insurance policy will be automatically cancelled and the previous

6、ly reported loss will also be void.犹豫期退保Cancellationduring cooling-offperiod整单犹豫期退 保/Full policy cancellation during cooling-off period 附加险 犹豫期退 保/Rider cancellation during cooling-off period申请对象(被保险人)附加险名称及代码Name of applicant (the Insured)Name and code of rider退保Cancellation整单退保/Full policy cancell

7、ation附加险 退保/Rider cancellation申请对象(被保险人)附加险名称及代码Name of applicant (the Insured)Name and code of rider退保原因 /Reasons for cancellation经济原因 /Financial problem出国移居 /Migration保障 不理想 /Coverage problem服务不理想 /Service problem理赔不满意 /Claim problem其它/Other reason:*续保选择权变更Alteration ofrenewal choice自动续 保选择/Auto-r

8、enewal:是/Yes否/No* 职业变更Alteration ofoccupation变更对象Applicable to投保人 / Policyholder被保险人 / Insured其他被保险人/ Other Insured变更后的职业及代码New occupation and Code职业 /Occupation:代码/Code:特别约定Specialarrangement约定 详情 /Details of arrangement:*补充告知Supplementaldisclosure告知对象 / Applicable to投保人/Applicant被保险人/Insured其他被保险人

9、/Other Insured:告知事项起始时间/Disclosed item valid since:告知 事项/Details of disclosure:C.申请注意事项/Notes of即plication1、请用黑色钢笔或签字笔在 变更项目前内打V,并用正楷填写变更内容；Please tick “V” ” in the front of the applicable item(s) using a black pen or a signature pen, and fill in the details in clear handwriting.2、 若您申请的变更项目 中，存在部分或

10、全部 申请项目不符合法律规定或者 保险合同约定的，该申请项目无效。The application will not take effect if any or all of the alteration applied for conflicts with relevant laws, regulations, or the insurance contract.3、请保持申请书签名与留存于本公司的签名样本一致。为维护您的权益，请勿在空白申请书上签名。The signature on the application form has to be the same as the signatur

11、e sample left with the Insurer. To protect your rights and interest, please do not sign a blank application form.4、 本人同意提供给平安集团(指中国平安保险(集团)股份有限公司及其直接或间接控股的公司)的信息， 及本人享受平安集团金融 服务产生的信息(包括本单证签署之前提供和产生的)，可用于平安集团及因 服务必要而委托的第三方为本人提供服务及推荐产品，法律禁止的除外。平安集团及其委托的第三方对 上述信息负有保密义务。本条款自本单证签署时生效，具有独立法律效力，不受合同成立与否及效力

12、状 态变化的影响。I hereby agree that all information provided by me to the Ping An Group (Ping An Insurance (Group) Company of China, Ltd. and its direct or indirect holding companies), and all information arising from the financial services I receive from Ping An Group (including information provided or ge

13、nerated prior to the signing of this application) may be used by the Ping An Group and its appointed third party(ies) (necessitated by service-related reasons) for the purpose of providing client services and product recommendations, excluding those prohibited by law. Ping An Group and its appointed

14、 third party(ies) have the obligation to keep the aforementioned information confidential. This authorization clause shall take effect upon the signing of this application and carry legal effect on its own regardless of whether or not the contract is signed or any change(s) to its legal effect.5、如果本

15、申请书的中英文表述不一致，以中文表述为准。Should there be any discrepancies between the Chinese and English versions, the Chinese version shall prevail.D. 委托授权及申请确认/ Authorizati on and applicati on confirm收付款方式Method of payment现金/Cash其他账户转账/Bank transfer续期交费账户转账/Direct debit其他方式 /Other method:账户信息Account details开户银行/Ban

16、k:银行账号 /Account number:户主 /Name of account holder:第三方转账付费授权声明/The account holder 'declaration:本人(账户所有人)已确认并同意投保人使用本人账户支付上述申请中涉及的保单保费。I (the account holder) have agreed to let the applicant use my account to pay for the premium of the application above.账户所有人签名/Account holder 'signature:退费转账注意

17、事项 /Refund of payment transfer notice:如果授权人（申请资格人）提供的账户为他人所有，本公司视同授权人可以从该账户中取得该笔退费，由此 引起的纠纷，由授权人自行承担；If the applicant provides an account under a name different from that of the applicant, Ping An Health considers that the refund of payment is able to be obtained by the applicant. The applicant shal

18、l be responsible for any potential problems that may arise in this situation.办理人Transactor本人申请/The applicant委托服务人员代办/Service agent委托他人代办/Other授权人（申请资格人）声明 /Declaration of the applicant:本人（申请资格人）已经详细阅读并同意申请书填写相关注意事项，现全权委托（受托人）办理以上指定申请事项，日后如有任何法律纠纷由本人自行负责，特此声明。I （the applicant） have read and agreed the Notes of the Application ”，and authorize the above person to handle my application. I will be responsible for any legal disputes caused by this application.受托人声明 / Declaration of the assignee:受托人保证本申请书填写内容及授权人签