个人人身保险契约变更申请书(保益变更)

个人人身保险契约变更申请书（保益变更）

Application for Alteration of Individual Insurance Policy

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 select items marked with a “*” below, please fill out the relevant personal information and health declaration according to the applicable requirements. 新增被保险人姓名/Name of new Insured:____________________________________ 与投保人关系 Relationship with Insured □/本人Self □配偶/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/V alid ID number

性别/Gender □男/Male □女/Female

生日/Date of birth

_________年/Year _________月/Month _________日/Day *□增加被保险人 Addition of Insured

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 an Insured 被保险人姓名/Name of Insured to be removed:

1、________________________________

2、_________________________________

3、________________________________

4、_________________________________ 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

*□保障计划变更 Alteration of policy selection

被保险人姓名 Name of Insured 险种简称及代码 Name and code of rider

新保额、档次、份数

New selection

保单号/Policy number 投保人/Policyholder

被保险人/Insured

B ．变更项目/Items to be altered

*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 "Life Insurance Application Notice " when applying for additional riders.

□保单挂失补发 Report loss of policy

□挂失 □挂失解除 □补发 Report loss Cancel loss reported Reissue

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 previously reported loss will also be void.

□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

□犹豫期退保 Cancellation during cooling-off period

申请对象（被保险人） Name of applicant (the Insured)

附加险名称及代码 Name and code of rider

□整单退保/Full policy cancellation □附加险退保/Rider cancellation

□退保 Cancellation

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:________________________

申请对象（被保险人） Name of applicant (the Insured) 附加险名称及代码 Name and code of rider

*□续保选择权变更Alteration of renewal choice 自动续保选择/Auto-renewal: □是/Yes □否/No 变更对象 Applicable to □投保人/ Policyholder □被保险人/ Insured □其他被保险人/ Other Insured

*□职业变更 Alteration of occupation

变更后的职业及代码 New occupation and Code

职业/Occupation:_________________________________ 代码/Code:______________________________________

□特别约定 Special arrangement 约定详情/Details of arrangement:

________________________________________________________________________________________________________________________________________________ 告知对象/ Applicable to

□投保人/Applicant □被保险人/Insured □其他被保险人/Other Insured:_____________________

*□补充告知 Supplemental disclosure

告知事项起始时间/Disclosed item valid since:__________________________________