Employees' (Domestic Helper) Insurance Proposal - 藍十字(亞太 ...

EMPLOYEES' (DOMESTIC HELPER) INSURANCE PROPOSAL
Particulars of Employer
Name of Applicant (Employer)
a. Has your Domestic Helper suffered from any physical defect, infirmity or ill
health of any description? If yes, please give details.
?
Occupation
Correspondence Address
b. Does your Domestic Helper engage in any hazardous activities? If yes, please give
details.
?
Contact Telephone No.
Policy Effective Date (dd/mm/yy)
- For 1 year
(Policy effective date subject to Company's underwriting acceptance
(I) Particulars of Domestic Helper
Name of Domestic Helper
Sex
Nationality
Annual Salary
Date of Birth (dd/mm/yy)
(//)
H.K.I.D.Card No.
Passport No.
Place of Employment (if different from the above)
(2) Particulars of Domestic Helper
Name of Domestic Helper
Sex
Nationality
Annual Salary
Date of Birth (dd/mm/yy)
I/We warrant that the particulars given above are true and agree that the statements
made in this proposal shall be the basis of any contract made between myself/ourselves
and Blue Cross (Asia-Pacific) Insurance Limited.
Signature of Applicant (Employer)
Date (dd/mm/yy)
(//)
Name of Intermediary
Intermediary's Code
Please Tick the Payment Mode
Cash
Cheque - payable to "Blue Cross (Asia-Pacific) Insurance Limited"
Credit Card(s) VISA Master Card
VISA
I hereby authorize Blue Cross (Asia-Pacific) Insurance Limited to debit the annual
premium from my credit card account for the insurance policy.
Credit Card Account No.
Expiry Date
Cardholder's Name
Cardholder's Signature
H.K.I.D.Card No.
Passport No.
Place of Employment (if different from the above)