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Hospital Income Plan “Plus” Application Form !"#$%&'()%*29/F, BEA Tower, Millennium City 5, 418 Kwun Tong Road,Kwun Tong, Kowloon, Hong Kong !"#$ QNU !" R !"#$ OVqÉä= =W=PSMU=OVUU c~ñ =W=PSMU=OVPUwww.bluecross.com.hkPlease complete this form in BLOCK letters and if applicable, return together with a crossed cheque payable to: Blue Cross (Asia-Pacific) Insurance Limitedor complete the Credit Card Payment Instruction and Authorisation in section (IV). !"#$%&'()*+,-./012345 !E F !"#$ !"#=E F !"#$%&'()*+,-./01EfF aÉí~áäë=çÑ=^ééäáÅ~åí== !"Name of Applicant Mr Miss HKID Card/Passport No. !"E L F =jêë= =jë= !"L !Date of Birth (dd/mm/yy) Contact Telephone No Mobile Office Home !E =L= =L= F ! ! Correspondence Address !Flat Floor Block Building Estate Phase Street No. !Street/Lot L District HK = KLN = NT Place of Residence of the Insured Person !"#$ Hong Kong líÜÉêë =Average stay of the Insured Person in HK per year !"#$%&'(monthsPersonal E-mail Address !"#Medical Claim Autopay A/C No.* Name of Bank Account Holder Bank Name Branch Name !"#$%&'()G !"# ! !Bank Code Branch Code Account No. ! ! !*The autopay A/C No. shall apply to all family members. Only bank account with 15 digits or below is acceptable. G !"#$%&'()*+,-./01234567 89:2;EffF aÉí~áäë=çÑ=fåëìêÉÇ=mÉêëçå== !"InsuredPersonName of Insured (Sumame / First Name)(Same as Bank Account - for claim purpose) !"E L F !"#$%&'()*+,-HKID Card/Passport No. !"=L !SexDate of Birth(dd/mm/yy) !E L L FHeight(cm) !"#Weight(kg) !"#Relationship withApplicant !" #$%lÅÅìé~íáçå=LgçÄaìíáÉëL 1. L LEfffF mä~å=aÉí~áäë== !Plan Daily Income Benefit Total Premium* !"# !GHospital Income Plan “Plus” HK$ HK$ !"#$%&'()* Payment Mode W Annual Monthly= * If your next birthday falls within the coming six months from the application date, the premium rate will be basedon your next age attained. Otherwise, it will be based on your current age. Policy effective date will be used todetermine the age attained if it is different from the application date.Note: If monthly payment mode is chosen, the monthly premium is equal to annual premium times 0.0875.G !"#$%&'($)*+,"-./0(123 !"#$45+607839:45+6; ( !"#$%!"&'()*% !"+,-./01 !"#$%&'()$%'(*+,%'(-MKMUTREfsF `êÉÇáí=`~êÇ=m~óãÉåí=fåëíêìÅíáçå=~åÇ=^ìíÜçêáë~íáçå= !"#$%&'((Payment by the Applicant’s Credit Card is recommended. !"#$%&!'( Accept credit card in HK currency only. !"#$%&'(FVISA MasterCard Credit Card Account No. !"#$Name of Cardholder (Surname/First Name) Expiry Date (mm/yy) Relationship with the Applicant (must be direct family member) !"= L !"#E =L= F !"#$=E !"#$%Declaration:1. I hereby authorise Blue Cross (Asia-Pacific) Insurance Limited “the Company” to debit the premium and charge back ineligible claimamounts from my credit card account specified herewith for the insurance policy, until further written notice is given.2. I understand that I have the right to cancel this authorisation at any time and agree that any notice of cancellation or variation of thisauthorisation shall be given to the Company and Credit Card Centre at least 1 month prior to the effective date of such cancellation/variation.3. I understand that all the personal information collected or held by the Company may be used by or disclosed to any individual ororganisation within or outside Hong Kong for the purposes of assessing and servicing this application and authorising direct debitpayment or credit card payment. Any request(s) for access to and correction of my personal information heid by the Company can bemade in writing to the Company’s Corporate Data Protection Officer at 29/F, BEA Tower, Millennium City 5, 418 Kwun Tong Road,Kwun Tong, Kowloon, Hong Kong !"#$%E F !"#$%&"#'()*+,-./01234567 !" #$%&'()*+,-./012345678 ! "#$%&'()*+,-./0123*+456 -.78%&/ !L !"#$%&'()*+,-./012345 !"#$%&'()*+,-./0"#$12'345678'79:;< !"#$%&'()*+,-./01234567%8239:; !"#$%&'())*+,-.,/0123456%&'-.,/078 !"#$%&'()*+,QNU !"R !"#$OV Signature of CardholderDate (dd/mm/yy) !" =E =L= =L= F_äìÉ=`êçëë=E^ëá~Jm~ÅáÑáÅF=fåëìê~åÅÉ=iáãáíÉÇ !"#$%&'()MD070/10.2008

EsF ^ää=áåëìêÉÇ=éÉêëçåë=áåÅäìÇÉÇ=áå=íÜáë=~ééäáÅ~íáçå=ãìëí=~åëïÉê=íÜÉ=ÑçääçïáåÖ=èìÉëíáçåëW !"#$%&'()*+1. During the last five years, have you suffered from or been treated for any of the following disorders/diseases ? If "Yes", please tick the appropriate items below. Yes No !"#$%&'()*+,-./012345678&9$:;+,?#@A8 √ = =Stone or kidney diseasesHemorrhoidsSpinal or muscular skeletalcçê=cÉã~äÉ=låäó=== !"# !conditions/diseasesUlcer of any kindVaricose Veins !"#$%&Gynecological conditions !"# !oÜÉìã~íáÅ=cÉîÉê !Cancer or tumour of any kindeÉêåá~ !"#$%Asthma or respiratory diseasesaÉîá~íÉÇ=å~ë~ä=ëÉéíìã=Eçê=íìêÄáå~íÉëFbéáäÉéëóDiseases/complications or conditionsassociated with pregnancy !"#$ ! "#$%Infection by Human !"#$%&'()*Immunodeficiency Virus (HIV)Mental disorder or psychiatrice~ääìñ=s~äÖìë !"#$%&'()problems/ diseases !dçìíaá~ÄÉíÉëVenereal diseasesAnal FistulaeHypertensionPlease attach complete details for anyArthritisAlcoholism or drug addictionCardio Vascular or circulatory diseasesother disorders/diseases not listed !"Malaria !"#$%&'(Hepatitis Bhere.Thyroid Diseases ! !"#$%&'()* !Others !"#$%OK e~îÉ=óçì=ÉîÉê=ÄÉÉå=áå=~=Üçëéáí~ä=çê=ë~åáíçêáìã=Ñçê=ëìêÖÉêóI=çÄëÉêî~íáçå=çê=íêÉ~íãÉåí=ïáíÜáå=íÜÉ=ä~ëí=ÑáîÉ=óÉ~êë\ vÉë kç !"#$%&'( )*+,-*#./01234+5,6PK ^êÉ=óçì=ÅìêêÉåíäó=ìåÇÉê=çÄëÉêî~íáçå=çê=í~âáåÖ=~åó=íêÉ~íãÉåí=çê=ãÉÇáÅ~íáçå\ vÉë kç !"#$%&'()*+,-./QK e~îÉ=óçì=ÉîÉê=Ü~Ç=~åó=ãÉÇáÅ~äI=Üçëéáí~äáò~íáçåI=~ÅÅáÇÉåí=çê=äáÑÉ=áåëìê~åÅÉ=~ééäáÅ~íáçå=êÉàÉÅíÉÇ=çê=éçäáÅó=Å~åÅÉääÉÇI=ê~íÉÇ=çê=êÉëíêáÅíÉÇ\ vÉë kçfÑ=?vÉë?=I=éäÉ~ëÉ=éêçîáÇÉ=íÜÉ=êÉ~ëçåEëF=K !"#$%&'()'*+,-.$/01234,56$7!189':;$?@= !"#$%&'()*+,RK e~îÉ=óçì=ÉîÉê=ÄÉÉå=ÅçîÉêÉÇ=Äó=áåÇáîáÇì~ä=L=Öêçìé=ãÉÇáÅ~ä=áåëìê~åÅÉ=éä~å\=EfÑ=?vÉë?=I=éäÉ~ëÉ=ëí~íÉ=íÜÉ=å~ãÉ=çÑ=áåëìê~åÅÉ vÉë kçÅçãé~åóI=éçäáÅó=åçK=~åÇ=íÜÉ=éçäáÅó=Éñéáêó=Ç~íÉKF !"#$L !"#$%&'()*+,-./01"234567"89:;"8?@fÑ=íÜÉ=~åëïÉê=íç=~åó=çÑ=íÜÉ=~ÄçîÉ=èìÉëíáçåë=N=íç=P=áë=?vÉë?I=éäÉ~ëÉ=éêçîáÇÉ=Ñìää=ÇÉí~áäë=áå=íÜÉ=ÑçääçïáåÖ=í~ÄäÉK=EfÑ=íÜÉ=ëé~ÅÉ=éêçîáÇÉÇ=áë=áåëìÑÑáÅáÉåíI=éäÉ~ëÉ=ìëÉ=~=ëÉé~ê~íÉ=ëÜÉÉíKF !"#$%&'()*+,-./01 23456789 5:;?1@AB8CnìÉëíáçåk~ãÉ=çÑ=fåëìêÉÇ !"jÉÇáÅ~ä=eáëíçêóLa~íÉ=çÑ=lÅÅìêêÉåÅÉ !"#$L !aá~Öåçëáë !`~êÉ=C=qêÉ~íãÉåí=oÉÅÉáîÉÇ !"#$%&mêÉëÉåí=`çåÇáíáçåë !"a~íÉ=çÑ=i~ëí=`çåëìäí~íáçå !"#$%oÉã~êâëW=mäÉ~ëÉ=ÉåÅäçëÉ=êÉä~íÉÇ=ãÉÇáÅ~ä=êÉéçêíëK !"#$%&'()*+EsfF aÉÅä~ê~íáçå==I/WE HEREBY DECLARE AND AGREE:1. That the answers to all the above questions including all information and particulars given herein are accurate, true and complete and are given to the best of my/our knowledge and belief. I/We have not withheld any materialinformation and accept that this application and declaration shall form the basis of the contract between Blue Cross (Asia-Pacific) Insurance Limited (“the Company”) and me/us. I/We hereby acknowledge that failure to supplytrue and accurate answers to this application or inform the Company of all material information about my/our application may render the Company unable to accept or process this application or the insurance policy void.2. That the insurance coverage applied for shall only take effect when this application has been accepted by and the first premium has been paid to the Company.3. That the Applicant shall have the authority to deal with, receive or request for information from the Company concerning the Insured(s) in relation to any claims or matters arising from the policy issued pursuant to this application.I/We further agree that payment of any benefits hereunder to the Policyholder or Insured(s) by the Company in relation to all medical claims shall be credited to the bank account as specified in part (I) of this application or madeby cheque in the absence of such an account, which shall constitute a full discharge on the part of the Company in relation to such claims. L !"#$%&'(NK !"#$%&'( !)*+,-./0123456+7869:;4?@L !" #$%&'()*L !"#$%&'()*+,-./01234+56789.:;2?;@ABCDL !"#$%&'()*+,-"./0123456789:;?@0AB12$CD'EF678G'HI3JK!=>?@3LM=NOPQOK !"#$%&'()*+,-./01234 56789:;-?@PK !"#$%&"'() *+,-./0123456*7'89:;?@AB:CDEFG-+H;) "'5IJK/ L !"#$%&'()*+,-$./0+.123456789:;/3*(),IJ*KL MNOENF !"L !"# !"#$%&!'#(!)*%&!'#$+,-./-01-23-.4!567EOF !"#$%&'()*+,-)./)01234567EPF !"#$%&!"'()*+,- !EQF L L !"#$%&'()*+,- L !"#$ERF !" #$%&'()*+,-"./01"23456789:&;:)*?@A L !"#$% !"#$%%&'( L !"#$%&" L !"#$%&'()*+,-./EPF !"# L !"#$%&'()E F !"#$%&'()*+,-./0123456 !"#$%&' QNU !" R !"#$ OV Date at Hong Kong (dd/mm/yy) Signature of Applicant Signature of Insured Person(s)E L L F !" !"GqÜÉ=`ÜáåÉëÉ=Åçéó=çÑ=íÜáë=~ééäáÅ~íáçå=Ñçêã=áë=Ñçê=êÉÑÉêÉåÅÉ=çåäóK=få=Å~ëÉ=çÑ=~åó=ÇáëÅêÉé~åÅó=ÄÉíïÉÉå=íÜÉ=`ÜáåÉëÉ=~åÇ=båÖäáëÜ=îÉêëáçåëI=íÜÉ=båÖäáëÜ=îÉêëáçå=ëÜ~ää=éêÉî~áäK !"#$% &'()*+,-./0,123$45678EsffF cçê=^ÖÉåíëL_êçâÉê=rëÉ=låäó== !L !"Agent/Broker Name Agent/Broker code Agent/Broker Tel Agent/Broker FaxL !" L !" L !" L !"EsfffF cçê=lÑÑáÅÉ=rëÉ=låäó== !"Policy No. !