You are on page 1of 2

$,$,QWHUQDWLRQDO/LPLWHG

,QFRUSRUDWHGLQ%HUPXGD
ZLWKOLPLWHGOLDELOLW\

2017 年 10 月新版本
Oct 2017 New Version
DIRECT DEBIT AUTHORISATION FOR CREDIT CARD ACCOUNT
۬΢͚̘ʿ‫ڢ‬૥̿ೡ૲ᜌप
Policy Number ؓ௤㲕⻲$,$9LWDOLW\0HPEHUVKLS Agent /Broker Code
1XPEHUˬ$,$9LWDOLW\‫ڛ‬ᓭぁᕅ˭ᴹ㊃㐞㲕 Area Code
⠕ᾣଗ㏉㌶㐞㲕
ॶต㐞㲕
% 

%         
Agency / Broker Name
$     
⠕ᾣଗ㏉㌶㍺࡛
         %     
(

         &     
3

         '     
Agent / Financial Advisor's Name
$
⠕ᾣଗ⨼䋗亝அဉ੃
         (     

0
             

*
             

Agent / Financial Advisor's Tel. No. For Office Use


9              
⠕ᾣଗ⨼䋗亝அ䴱䂧㲕⻲
&6
             

             

Name of Insured$,$9LWDOLW\0HPEHU HKID Card / Passport Number


਍ؓӰλˬ$,$9LWDOLW\‫ڛ‬ᓭぁᕅ˭ᴹଗဉ੃ 俏⑥䓡࠼䅿䆭➝㲕⻲

'LUHFW'HELW$XWKRULVDWLRQ6HWXS5HTXHVW!!⴪᧛Ԏⅴᦾ⅀ᴮ䁣㄁㾷≸!! 2SWLRQZLOOEHDVVXPHGLIWKLVER[LVOHIWEODQNྸ↚℺⮏グθሽ㻡㿌⛰䚮᫽䚮主*

 $ERYHVWDWHG1XPEHU  $ERYHVWDWHG3ROLF\1XPEHU ,QVXUHG¶V$,$9LWDOLW\0HPEHUVKLS


р䘦㲕⻲ р䘦ؓ௤㲕⻲਀ެ਍ؓӰҁˬ$,$9LWDOLW\‫ڛ‬ᓭぁᕅ˭ᴹ㊃
8QWLO IXUWKHU QRWLFH SOHDVH FKDUJH P\ IROORZLQJ FUHGLW FDUG DFFRXQW XSRQ SUHVHQWDWLRQ RI WKLV VOLS LQ DFFRUGDQFH ZLWK WKH SD\PHQW PRGH RI WKH
DERYHPHQWLRQHGSROLF\IRUSUHPLXPSD\PHQWDQ\SUHVFULEHGOHY\ ZKHUHDSSOLFDEOH DQGPHPEHUVKLSIHHRI$,$9LWDOLW\PHPEHUVKLS,XQGHUVWDQGWKDWWKH
DPRXQW LV VXEMHFW WR FKDQJH LQ DFFRUGDQFH ZLWK WKH SURYLVLRQV RI WKH DERYHPHQWLRQHG SROLF\  PHPEHUVKLS DQGRU WKH VWDWXWRU\ UHTXLUHPHQWV RQ OHY\ ,
XQGHUVWDQGWKDWWUDQVDFWLRQZLOOEHGHELWHGLQ+.'
⴪㠩ਜ㺂䙐⸛⛰↘⮬䋪‫ޢ‬ਮ᭬ࡦ↚䙐⸛ᴮᱸθ䄁᤿р䘦ؓ௤λɇ$,$9LWDOLW\‫ڛ‬ᓭぁᕅɈᴹ㊃ҁ㒩䋱ᯯᕅ൞ᡇсࡍⲺ‫⭞ؗ‬গᡬਙ‫ޝ‬ᨆ਌ⅴ主θ֒⛰㒩Ԏр䘦ؓ௤
ؓ䋱Ա֋ؓ䋱ᗫ䋱 ྸ䚟⭞ ਀ެᴹ䋱ҁ⭞Ⱦᡇ᱄ⲳᴿ䰒䠇亃ᴹṯᬐؓ௤λᴹ㊃Ⲻồⅴ਀ᡌؓ䋱ᗫ䋱ҁ⌋ׁ㾷≸㙂ᴿᡶ䇀ᴪȾᡇ᱄ⲳӚ᱉ֵ⭞⑥‫ݹ‬ᢙ䌢Ⱦ

&DUG1XPEHU
‫⭞ؗ‬গ㲕⻲
&DUG([SLU\'DWH
‫⭞ؗ‬গࡦᵕᰛ

                00ᴾ! <<<<ᒪ
               

               

&DUG,VVXLQJ3ODFH +RQJ.RQJ俏⑥
               
‫⭞ؗ‬গⲲগ൦
               
QRQ+RQJ.RQJ䶔俏⑥
               

               

               

               

               

&DUGKROGHU
V1DPH
‫⭞ؗ‬গᤷᴿӰဉ੃

'DWH
&DUGKROGHU
V6LJQDWXUH ᰛᵕ
‫⭞ؗ‬গᤷᴿӰ㉳੃ 00ᴾ ''ᰛ <<<<ᒪ
3OHDVHUHDGWKHWHUPVFDUHIXOO\DVVWDWHGRQWKHEDFNSDJHEHIRUHVLJQLQJWKHIRUP
䄁᯲㉳㖨ࢃ㍦䯧㜂丷ҁồⅴ

5HODWLRQVKLSZLWK 3URSRVHG ,QVXUHG$SSOLFDQW$,$9LWDOLW\0HPEHU


㠽 Ⓦ ਍ؓӰ⭩䄁Ӱ0ˬ$,$9LWDOLW\‫ڛ‬ᓭぁᕅ˭ᴹଗҁ䰒‫;׸‬
6LJQDWXUHRI 3URSRVHG ,QVXUHG
$SSOLFDQW 3URSRVHG ,QVXUHG$,$9LWDOLW\0HPEHU %HQHILFLDU\
Ⓦ ਍ؓӰɇ$,$9LWDOLW\‫ڛ‬ᓭぁᕅɈᴹଗ
$SSOLFDQW$,$9LWDOLW\0HPEHU
⭩䄁Ӱ ਍ⴀӰ
Ⓦ ਍ؓӰ⭩䄁Ӱˬ$,$!9LWDOLW\
2WKHU 3OHDVH6SHFLI\ ‫ڛ‬ᓭぁᕅɈᴹଗҁ㉳੃
ެԌ 䄁䁱᱄ BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
3URSRVHG ,QVXUHG$SSOLFDQW$,$9LWDOLW\0HPEHUVLJQRQWKHULJKWFROXPQ
Ⓦ਍ؓӰ⭩䄁Ӱɇ$,$9LWDOLW\‫ڛ‬ᓭぁᕅɈᴹଗ举᯲਩ᯯṲ‫ޝ‬㉳㖨

37$3&$7)
3(5621$/'$7$&2//(&7,21$1'86( $33/,&$%/(72$,$32/,&<
,:HFRQILUPWKDW,:HKDYHUHDGDQGXQGHUVWRRGWKH$,$3HUVRQDO,QIRUPDWLRQ&ROOHFWLRQ6WDWHPHQW ³$,$3,&´ ,:H
GHFODUHDQGDJUHHWKDWDQ\SHUVRQDOGDWDDQGRWKHULQIRUPDWLRQUHODWLQJWRPHXVRUP\RXUSROLF\ LHV RULQYHVWPHQWV
FRQWDLQHGLQWKLVDSSOLFDWLRQRUFROOHFWHGREWDLQHGFRPSLOHGRUKHOGE\WKH&RPSDQ\E\DQ\PHDQVIURPWLPHWRWLPHPD\EH
FROOHFWHGDQGXWLOL]HGLQDFFRUGDQFHZLWKWKH$,$3,&,:HDFNQRZOHGJHDQGFRQVHQWWRWKHWUDQVIHURIP\RXUSHUVRQDOGDWD
RXWVLGHRI+RQJ.RQJIRUWKHSXUSRVHVDQGWRWKHW\SHVRIWUDQVIHUHHDVVHWRXWLQWKH$,$3,&
7KHXSGDWHGYHUVLRQRI$,$3,&LVDYDLODEOHIRUGRZQORDGIURPLWVZHEVLWHZZZDLDFRPKNDQGLVPDGHDYDLODEOHXSRQUHTXHVW

ᾳṢ屯㕁㓞普⍲ἧ䓐炷怑䓐㕤⍳恎ᾅ╖炸
㛔Ṣ0ㆹᾹ䡢娵㛔Ṣ0ㆹᾹ⶚教嬨⍲㖶䘥BJBᾳṢ屯㕁㓞普倚㖶ˤ㛔Ṣ0ㆹᾹ倚㖶⍲⎴シ⛐㛔䓛婳㇨庱ㆾ屜℔⎠ᶵ㗪ẍả
ỽ㕡㱽㓞普㇨⼿ˣ䶐墥ㆾ㊩㚱䘬ảỽᾳṢ屯㕁⍲斄㕤㛔Ṣ炾ㆹᾹㆾ㛔Ṣ炾ㆹᾹ䘬ᾅ╖ㆾ㈽屯䘬℞Ṿ屯㕁炻⎗㟡㒂BJB
ᾳṢ屯㕁㓞普倚㖶㓞普⍲ἧ䓐ˤ㛔Ṣ0ㆹᾹ䞍〱⍲⎴シ⯙BJBᾳṢ屯㕁㓞普倚㖶㇨徘䚖䘬廱嬻㛔Ṣ0ㆹᾹ䘬ᾳṢ屯㕁军
楁㷗⠫⢾ḰBJB!ᾳṢ屯㕁㓞普倚㖶㇨庱䘬屯㕁㈧嬻Ṣˤ
BJBᾳṢ屯㕁㓞普倚㖶䘬㚨㕘䇰㛔⎗㕤ẍᶳ䵚⛨ᶳ庱;!xxx/bjb/dpn/il炻⍲⎗⎹屜℔⎠䳊⍾ˤ

3(5621$/'$7$&2//(&7,21$1'86( $33/,&$%/(72$,$9,7$/,7<0(0%(56+,3
,:HFRQILUPWKDW,:HKDYHUHDGDQGXQGHUVWRRGWKH$,$9LWDOLW\3HUVRQDO,QIRUPDWLRQ&ROOHFWLRQ6WDWHPHQW ³$,$9LWDOLW\
3,&´ ,:HGHFODUHDQGDJUHHWKDWDQ\SHUVRQDOGDWDDQGRWKHULQIRUPDWLRQUHODWLQJWRPHXVDVSURYLGHGLQWKHDSSOLFDWLRQIRU
PHPEHUVKLSLQ$,$9LWDOLW\RUFROOHFWHGREWDLQHGFRPSLOHGRUKHOGE\WKH$,$9LWDOLW\2SHUDWRUE\DQ\PHDQVIURPWLPHWRWLPH
PD\EHFROOHFWHGDQGXWLOL]HGLQDFFRUGDQFHZLWKWKH$,$9LWDOLW\3,&,:HDFNQRZOHGJHDQGFRQVHQWWRWKHFROOHFWLRQRI
P\RXUSHUVRQDOGDWDDQGRWKHULQIRUPDWLRQE\WKH$,$9LWDOLW\2SHUDWRUIURPWKH$,$9LWDOLW\3DUWQHUVDQGWRWKH$,$
9LWDOLW\3DUWQHUV¶SURYLVLRQRIVXFKSHUVRQDOGDWDDQGLQIRUPDWLRQWRWKH$,$9LWDOLW\2SHUDWRULQUHODWLRQWRP\RXU
SDUWLFLSDWLRQDQGXVHRIWKHPHPEHUVKLSJRRGVRUVHUYLFHVSURYLGHGE\VXFK$,$9LWDOLW\3DUWQHUVDQGWRWKH$,$
9LWDOLW\2SHUDWRU¶VXVHDQGSURYLVLRQRIWKHVDPHLQDFFRUGDQFHZLWKWKH$,$9LWDOLW\3,&,:HDOVRDFNQRZOHGJHDQG
FRQVHQWWRWKHWUDQVIHURIP\RXUSHUVRQDOGDWDRXWVLGHRI+RQJ.RQJIRUWKHSXUSRVHVDQGWRWKHW\SHVRIWUDQVIHUHHDVVHWRXW
LQWKH$,$9LWDOLW\3,&
,:HFRQILUPWKDW,:HKDYHUHDGDQGXQGHUVWRRGWKDWWKHH[LVWHQFHRIWKH$,$9LWDOLW\PHPEHUVKLSPD\EHGLVFORVHGE\WKH
$,$+RQJ.RQJDQG$,$9LWDOLW\2SHUDWRUWRRWKHUSDUWLHVZKRLQWHQGWRSXUFKDVHDGGLWLRQDO$,$9LWDOLW\PHPEHUVKLSRU$,$
9LWDOLW\6HULHVLQVXUDQFHSURGXFWIRUPHXV
7KHXSGDWHGYHUVLRQRI$,$9LWDOLW\3,&LVDYDLODEOHIRUGRZQORDGIURPLWVZHEVLWHZZZDLDYLWDOLW\FRPKNDQGLVPDGHDYDLODEOH
XSRQUHTXHVW

ᾳṢ屯㕁㓞普⍲ἧ䓐!炷怑䓐㕤ˬBJB!WJUBMJUZ!‍⹟䦳⺷˭㚫䯵炸
㛔Ṣ0ㆹᾹ䡢娵㛔Ṣ0ㆹᾹ⶚教嬨⍲㖶䘥ˬBJB!Wjubmjuz!‍⹟䦳⺷˭ᾳṢ屯㕁㓞普倚㖶ˤ㛔Ṣ0ㆹᾹ倚㖶⍲⎴シ⛐
ˬBJB!Wjubmjuz!‍⹟䦳⺷˭㚫䯵䓛婳ᷕ㇨㍸ὃㆾˬBJB!Wjubmjuz!‍⹟䦳⺷˭䆇忳侭ᶵ㗪ẍảỽ㕡㱽㓞普ˣ⍾⼿ˣ⋗
䶐ㆾ㊩㚱䘬斄㕤㛔Ṣ0ㆹᾹ䘬ảỽᾳṢ屯㕁⍲℞Ṿ屯㕁炻⎗㟡㒂ˬBJB!Wjubmjuz!‍⹟䦳⺷˭ᾳṢ屯㕁㓞普倚㖶㓞普⍲
ἧ䓐ˤ㛔Ṣ0ㆹᾹ䡢娵⍲⎴シ⯙㛔Ṣ0ㆹᾹ⍫冯ㆾἧ䓐䓙ˬBJB!Wjubmjuz!‍⹟䦳⺷˭⎰ἄ⣍Ờ㇨㍸ὃ䘬㚫䯵䓊⑩ㆾ㚵
⊁炻ˬBJB!Wjubmjuz!‍⹟䦳⺷˭䆇忳侭⮯⽆ˬBJB!Wjubmjuz!‍⹟䦳⺷˭⎰ἄ⣍Ờ㓞普㛔Ṣ0ㆹᾹ䘬ᾳṢ␴℞Ṿ屯
㕁炻⍲ˬBJB!Wjubmjuz!‍⹟䦳⺷˭⎰ἄ⣍Ờ⮯⎹ˬBJB!Wjubmjuz!‍⹟䦳⺷˭䆇忳侭㍸ὃ㚱斄ᾳṢ␴℞Ṿ屯㕁炻᷎䡢
娵⍲⎴シˬBJB!Wjubmjuz!‍⹟䦳⺷˭䆇忳侭⮯㟡㒂ˬBJB!Wjubmjuz!‍⹟䦳⺷˭ᾳṢ屯㕁㓞普倚㖶ἧ䓐⍲㍸ὃ㛔Ṣ0
ㆹᾹ䘬ᾳṢ␴℞Ṿ屯㕁ˤ㛔Ṣ0ㆹᾹ䡢娵⍲⎴シ䁢ˬBJB!Wjubmjuz!‍⹟䦳⺷˭ᾳṢ屯㕁㓞普倚㖶㇨徘䓐徼廱䦣㛔Ṣ0
ㆹᾹ䘬ᾳṢ屯㕁军楁㷗⠫⢾ḰˬBJB!Wjubmjuz!‍⹟䦳⺷˭ᾳṢ屯㕁㓞普倚㖶㇨徘栆⇍䘬㈧嬻Ṣˤ
㛔Ṣ0ㆹᾹ䡢娵㛔Ṣ0ㆹᾹ⶚教嬨⍲㖶䘥⍳恎楁㷗⍲ˬBJB!Wjubmjuz!‍⹟䦳⺷˭䆇忳侭⎗傥㚫⎹㚱シ䁢㛔Ṣ0ㆹᾹ岤屟
柵⢾ˬBJB!Wjubmjuz!‍⹟䦳⺷˭㚫䯵ㆾBJB!‍⹟䲣↿$ᾅ晒䓊⑩䘬℞Ṿ㕡㉓曚㛔ˬBJB!Wjubmjuz!‍⹟䦳⺷˭㚫䯵䘬
⬀⛐ˤ
ˬBJB!Wjubmjuz!‍⹟䦳⺷˭ᾳṢ屯㕁㓞普倚㖶䘬㚨㕘䇰㛔⎗㕤℞䵚䪁ᶳ庱;!xxx/bjbwjubmjuz/dpn/il炻Ṏ⎗⎹⍳恎
楁㷗䳊⍾ˤ

$,$9LWDOLW\6HULHVPHDQVWKRVHGHVLJQDWHGLQVXUDQFHSURGXFWVRIIHUHGDQGLVVXHGE\$,$+RQJ.RQJZKLFKDOORZIOH[LEOHGLVFRXQWLQSUHPLXPVRQWKHEDVLVRIWKH$,$9LWDOLW\6WDWXVRIWKH3URSRVHG,QVXUHG,QVXUHGZKRPXVW
MRLQDVDPHPEHURI$,$9LWDOLW\!BJB!‍⹟䲣↿䁢⍳恎楁㷗㍸ὃ⍲䷽䘤䘬㊯⭂ᾅ晒䓊⑩炻℞ᾅ屣⎗⚈ㅱ⽭枰幓䁢ˬBJB!Wjubmjuz!‍⹟䦳⺷˭㚫⒉䘬㸾⍿ᾅṢ0⍿ᾅṢ䘬ˬBJB!Wjubmjuz!‍⹟䦳⺷˭㚫⒉䳂⇍侴䌚⼿䚠ㅱ⃒よˤ

You might also like