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healthcare
SmartCare Optimumthe full refund insurance
that leaves you with no medical bills to pay
Get Extra Premium Discount! Family discount: enjoy extra 5% off on total
premium for each additional family member that enrolls together
SmartCare Optimum Plus: offers maximum 60% off if a deductible of HK$250,000 is chosen
smart solutions for your medical protection
Guaranteed renewal1
Once you have taken out SmartCare Optimum, you will be entitled to continuous renewable protection, regardless of your health conditions.
Hospitalisation benefits up to HK$5 million(apply to all age groups)Covers a wide range of benefits including Daily Room & Board, Intensive Care Unit, Surgeon’s Fees and Anaesthetist’s Fees, up to a maximum of HK$5,000,000 per policy year.
Full refund with no surgical tableProvides genuine and adequate benefits under Surgeon’s Fees, Anaesthetist’s Fees and Operation Theatre Fees. Surgical benefits are payable within the maximum limit of your selected plan. There is no need to refer to complicated surgical schedules anymore.
No waiting periodOthe r t han p r e - e x i s t i n g cond i t i ons , SmartCare Optimum can provide you with immediate medical protection as soon as your application is accepted.
Deductible options with great savingsIf you choose to pay a fixed deductible towards the total costs of your treatment under Basic Cover - Hospitalisation Benefits, you can enjoy up to 60% premium discount for that benefit section.
Deductible Options (SmartCare Optimum Plus)
Deductible Amount(On annual policy basis
per insured person)
Premium Discount Rate(Applies to the premium table
of SmartCare Optimum)
HK$10,000 10%
HK$50,000 25%
HK$100,000 40%
HK$250,000 60%
Optional cover(1) Outpatient Benefits Clinical Consultation Specialist Consultation Physiotherapy & Chiropractic Treatment Chinese Herbalist, Bonesetter &
Acupuncturist X-Ray & Laboratory Expenses Prescribed Drugs & Medicine
(2) Dental Benefits Dental Treatment Preventive & Oral Examination Dentures
(3) Hospital Cash Benefits (SmartCare Essential) Daily Hospital Cash Choice of HK$1,000, HK$750 or
HK$500 per day during hospitalisation Annual benefits up to a maximum of
HK$500,000
1
Value-added servicesFamily Care Services2,3
In case of hospitalisation due to accidental bodily injury, you will be entitled to the following services: Domestic home helper to deliver home care
service Baby-sitter or child-carer to look after your
unattended dependent child(ren)4
Pet care and accommodation5
Meal delivery assistance
24-Hour Emergency Assistance Service Wherever you need emergency assistance, AXA Emergency Assistance Hotline is at your service on the following: Telephone medical advice Emergency medical evacuation Repatriation after treatment Repatriation of mortal remains/ashes Compassionate visit Return of unattended dependent child(ren) Travel information Legal assistance
China Hospital Deposit Guarantee Worry free as no cash deposit required Cover over 200 network hospitals in China Al low immediate hospital admission
arrangement
In-Hospital Credit Arrangement3 Free arrangement of credit facility when you
need to stay in hospital Contact us and simply get a pre-approval
before admission to the hospital for treatment right away
AXA Medical Card3
When you opt for Outpatient Benefits, you will get our exclusive AXA Medical Card A list of AXA panel doctors for clinical and
specialist consultations services for you to choose from
No need to make medical payments when you present your AXA Medical Card to the listed doctors
Eligibility You must be a Hong Kong resident with Hong
Kong Identity Card, aged 18 to 64 on the first entry.
You may also apply to cover your family members for the same plan. Family members include your legal spouse aged 18 to 64, and any unmarried child(ren)6 aged 15 days to 17 or below aged 23 if in full time education.
Remarks:1. Policy annual renewal is guaranteed. AXA General Insurance
Hong Kong Limited reserves its right to amend premium rates, benefits, terms and conditions upon policy renewal.
2. This service is applicable to the insured person aged 16 or above only. The provision of services is subject to the terms and conditions of the Family Care Services Program. This program is offered by AXA General Insurance Hong Kong Limited and administrated by a third party administrator. AXA General Insurance Hong Kong Limited reserves the right to amend the terms and conditions thereof from time to time without prior notice.
3. This service will be provided in Hong Kong only.4. Up to two children under age of 12.5. Applicable to one dog or cat only, with pet hotel expense up
to HK$500 per day for 5 days.6. Hospital Cash Benefits (SmartCare Essential) is not
applicable to insured child(ren).
The information of this leaflet does not form any part of a contract of insurance. For full terms and conditions, please refer to the policy for complete details. A specimen policy can be made available upon request. In case of discrepancy, the English version shall prevail.
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Schedule of benefits (Effective from 16 June 2014 until further notice)
Basic Cover - Hospitalisation BenefitsMaximum Limits, Per Insured Person
Elite Plan Deluxe Plan
Full Refund Full Refund
▪ Overall Annual Policy Limit $5,000,000 $2,500,000
▪ Daily Room & Board +
Private Room Semi-Private
• Unlimited no. of days per disability Room
▪ In-Hospital Doctor’s Visit +
▪ In-Hospital Specialist’s Consultation +*
▪ Surgeon’s Fee +
▪ Anaesthetist’s Fee +
▪ Operating Theatre Fee +
▪ Hospital Expenses +
▪ Intensive Care Unit +
• Max. 30 days per disability
▪ In-Hospital Physiotherapy +
▪ Prescription Drugs +
▪ Organ Transplantation +#
▪ Parent Accommodation +
• Max. 60 days per disability
▪ Psychiatric Treatment +
• Max. 60 days per year
▪ Pre-Hospitalisation Treatment • Limit to 1 visit per disability
▪ Post-Hospitalisation Treatment • Within 42 days after discharge from hospital • Max. limit per day $500 $500
▪ Home Nursing* • Max. 90 days per disability • Max. limit per day $1,000 $500
▪ Hospital Cash (subject to Hong Kong SAR Government Public Ward only) • Max. 90 days per disability • Max. limit per day $1,000 $700
▪ Outpatient Kidney Dialysis & Outpatient Cancer Treatment • Max. limit per year $500,000 $250,000
▪ Accidental Dental Treatment +
• Max. limit per year $10,000 $10,000
▪ Artificial Prosthesis (include Stent & Pacemaker) +*
• Max. limit per year $30,000 $15,000
▪ Max. limit per year for the above listed hospitalisation benefits $1,000,000 $500,000 (applicable to medical expenses incurred overseas only)
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(1) Outpatient Benefits - Max. limit per year $150,000 $100,000 a) Clinical Consultation
## Full Refund Full Refund b) Specialist Consultation
## Full Refund Full Refund c) Physiotherapy & Chiropractic Treatment
##* 80% Reimbursement 80% Reimbursement Max. 10 visits per year d) Chinese Herbalist, Bonesetter & Acupuncturist
## 100% Reimbursement 100% Reimbursement Max. limit per visit $200 $200 Max. 10 visits per year e) X-Ray & Laboratory Expenses* Full Refund Full Refund f) Prescribed Drugs & Medicine* Max. limit per year $20,000 $10,000
(2) Dental Benefits^ - Max. limit per year $16,000 $16,000 a) Dental Treatment Full Refund Full Refund b) Preventive & Oral Examination Max. limit per visit $500 $500 Max. 2 visits per year c) Dentures Max. limit per tooth $2,400 $2,400 ▪
(3) Hospital Cash Benefits (SmartCare Essential) a) Maximum Annual Limit $500,000 $375,000 $250,000 b) Hospital Cash Benefit - per day $1,000 $750 $500 Unlimited no. of days c) Double Hospital Cash Benefit - per day $2,000 $1,500 $1,000 Unlimited no. of days (i) Confinement Overseas (ii) Intensive Care Unit (iii) Critical Illness d) Accidental Death Benefit $100,000 $75,000 $50,000 e) Accidental Dental Benefit - per year $10,000 $7,500 $5,000
Family Care Services ✔
24-Hour Emergency Assistance Service ✔
China Hospital Deposit Guarantee ✔
In-Hospital Credit Arrangement ✔
Remarks:All expenses must be medical necessary and reasonable and customary.Overseas cover & 24-Hour Emergency Assistance Service will be ceased if stay longer than 90 consecutive days outside Hong Kong.AXA Medical Card and In-Hospital Credit Arrangement can be provided subject to indemnification.All amounts are in Hong Kong dollars.+ If the insured person is confined to a higher level of room type, the amount of benefit payable will be adjusted by multiplying the
adjustment factor.# Include the expenses of Daily Room & Board, Intensive Care Unit, Hospital Expenses, Surgeon’s Fee, Anaesthetist’s Fee, Operating
Theatre Fee, In-Hospital Doctor’s Visit and In-Hospital Specialist’s Consultation relating to the transplantation of heart, kidney, liver or bone marrow.
## Limit to 1 visit per day.* Recommendation or referral by the attending physician is required. ^ To enroll Dental Benefits, a separate Dental Examination Report completed by Registered Dentist is required to be submitted.
Deluxe Plan
Maximum Limits, Per Insured PersonElite Plan
Bronze PlanGold Plan Silver Plan
Additional Optional Cover
Major ExclusionsSome of the exclusions under SmartCare Optimum are: Pre-existing conditions Drug addiction or alcoholism Suicide or self-inflicted injury Cosmetic or plastic surgery Pregnancy, childbirth, birth control or treatment for
infertility
Congenital anomalies Sexually transmitted diseases, AIDS or HIV-related
conditions Routine health checks or rest cure Professional sports War or warlike operation, strike, riot or civil revolution Other exclusions as per our underwriting decisions
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AXA General Insurance Hong Kong LimitedUnit 2201-2206, 22/F, Manhattan Place, 23 Wang Tai Road, Kowloon Bay, Kowloon, Hong Kong Tel: 2523 3061 Fax: 2810 0706
If you do not wish to receive promotional or direct marketing materials from AXA, please inform Data Privacy Officer, AXA General Insurance Hong Kong Limited, Unit 2201-2206, 22/F, Manhattan Place, 23 Wang Tai Road, Kowloon Bay, Kowloon, Hong Kong. AXA shall, without charge to you, ensure that you are not included in future direct marketing activities.
(Only for use in Hong Kong Special Administrative Region)
June 2014
AXA: a global leader in financial protection
AXA Group in 2013 HK$933 billion1 in consolidated revenues HK$11,390 billion1 in assets under management 157,000 employees2 worldwide working to deliver the right solutions and top quality
service to our customers 102 million customers3 across the globe have placed their trust in AXA to: – Insure their property (vehicles, homes, equipment) – Provide health and personal protection coverage for their families or employees – Manage their personal or corporate assets Standard & Poor’s Rating: A+4
About AXA Hong KongAXA Hong Kong, a member of the AXA Group, prides itself of serving over 1 million customers in Hong Kong and Macau. Besides being one of the largest health protection providers in Hong Kong, it is also the number 1 General Insurance provider5 and a market leader in motor insurance.
AXA Hong Kong is committed to helping its customers achieve stability and prosperity through providing a comprehensive range of life, health, property and casualty protection, as well as wealth management and retirement solutions.
We believe it is our inherent responsibility to support the communities we operate in, hence creating a sustainable business via constant and considerable contribution in the dimensions of health, environment and the community.1 As at 31 December 2013, calculated based on exchange rate of 1 Euro = HK$10.23352 As at 2 April 20143 As at 31 December 20134 As at 15 November 20135 Based on 2013 Office of the Commissioner of Insurance market share statistics
2523 3061www.axa-insurance.com.hk
For application or enquiry, please contact your insurance consultant or you can contact us on
HPO-B-0614
5
安盛保險有限公司 香港九龍九龍灣宏泰道23號22樓2201-2206室電話: 2523 3061 傳真: 2810 0706
如閣下不願意接收AXA安盛的宣傳或直接促銷材料，敬請聯絡香港九龍九龍灣宏泰道23號22樓2201-2206室安盛保險有限公司個人資料保護主任。AXA安盛會在不收取任何費用的情況下確保不會將閣下納入日後的直接促銷活動中。
2014年6月
AXA安盛集團：經濟保障 世界翹楚
AXA安盛集團（2013年）
全年總收入達9,333億港元1
管理資產總值達113,900億港元1
全球聘用157,000名僱員2，竭誠為客戶提供所需的方案及優質服務 獲全球逾 102,000,000位客戶3信賴 － 保障他們的財物（汽車、家居、器材） － 為他們的家人或僱員提供醫療及個人保險 － 為他們管理個人或企業的資產 標準普爾評級：A+4
AXA安盛簡介
AXA安盛為法國AXA安盛集團之成員，憑藉其超卓的產品及服務，現時於香港及澳門的客戶人數已超過100萬。AXA安盛不單是香港其中一家最大的醫療保險供應商，其一般保險業務更在香港巿場擁有最大的佔有率5，而其汽車保險亦是業界的翹楚。
AXA安盛致力為客戶提供涵蓋人壽、健康及財產的全面保障，與及財富管理和退休方案，幫助客戶實踐安定及豐盛的生活。
AXA安盛肩負企業責任，致力透過推廣健康人生、環境保護及社會服務三大範疇回饋社會，推動可持續發展的業務。1 截至2013年12月31日，以1歐羅兌10.2335港元計算2 截至2014年4月2日3 截至2013年12月31日4 截至2013年11月15日5 根據保險業監理處所發表有關2013年巿場佔有率之數據
2523 3061www.axa-insurance.com.hk
有意投保人士或欲進一步了解本保險計劃的內容，歡迎聯絡您的保險顧問或致電本公司查詢。
HPO-B-06145
（只適合於香港特別行政區使用）
註：所有費用必須是醫療必須、合理及慣常。如離港連續超過90日，海外保障及24小時緊急支援服務會即時停止。AXA安盛醫療咭及住院費用代繳服務須簽妥同意書後，方可生效。所有金額均以港元計算。+ 如受保人入住較高的病房類別，可支付之保障金額將乘以調整參數作相應調整。# 包括因處理心臟、腎、肝及骨髓等移植有關之住房費用、深切治療病房、醫院雜項費用、手術費用、麻醉師費用、手術室費
用、主診醫生費用及住院醫生費用。## 每天只限一次。* 須經由主診醫生推薦或配方。^ 如投保牙科保障，需提交由註冊牙醫填寫之牙科檢查報告。
豪華計劃額外自選保障
每名受保人最高賠償額
尊貴計劃
家庭護理服務 ✔
24小時緊急支援服務 ✔
中國住院按金保證 ✔
住院費用代繳服務 ✔
(1) 門診保障-每年最高限額 $150,000 $100,000 a) 普通科門診費用
#
# 全數賠償 全數賠償 b) 專科診症費用
#
# 全數賠償 全數賠償 c) 物理治療及脊骨治療
#
#* 80% 賠償 80% 賠償▪ 每年最多10次
d) 中醫、跌打及針灸治療
#
# 100% 賠償 100% 賠償▪ 每次最高限額 $200 $200▪ 每年最多10次
e) X光檢驗及化驗費用* 全數賠償 全數賠償
f) 處方藥物*
▪ 每年最高限額 $20,000 $10,000
(2) 牙科保障^-每年最高限額 $16,000 $16,000 a) 牙齒治療 全數賠償 全數賠償 b) 洗牙及口腔檢查
▪ 每次最高限額 $500 $500▪ 每年最多2次
c) 鑲牙費用 ▪ 每顆牙齒最高限額 $2,400 $2,400
(3) 住院現金保障（「卓越」健樂錢） a) 全年最高賠償總額 $500,000 $375,000 $250,000 b) 住院現金保障-每日 $1,000 $750 $500
▪ 不設賠償期上限 c) 「雙倍」住院現金保障-每日 $2,000 $1,500 $1,000
▪ 不設賠償期上限 (i) 海外住院 (ii) 深切治療 (iii) 嚴重疾病 d) 意外死亡保障 $100,000 $75,000 $50,000 e) 意外牙科保障-全年 $10,000 $7,500 $5,000
銅計劃銀計劃金計劃
主要不受保項目「卓越」無憂保之部份不受保項目包括： 受保前已存在的疾病 吸毒或酗酒 自殺或蓄意自殘 美容或整容手術 懷孕、分娩、節育或醫治不育
先天性的疾病 性病、愛滋病或其他併發症 例行健康檢查或療養 專業運動 戰爭或任何類似戰爭行動、罷工、暴亂或民事騷亂 其他不受保項目（以本公司的承保決定為準）
4
承保範圍（由2014年6月16日起生效，直至另行通知為止。）
豪華計劃基本保障 - 住院保障
每名受保人最高賠償額
尊貴計劃
▪ 全年最高賠償總額 $5,000,000 $2,500,000
▪ 住房費用
+私家病房 半私家病房
• 每症不設賠償期上限
▪ 主診醫生費用
+
▪ 住院專科醫生費用
+*
▪ 手術費用
+
▪ 麻醉師費用
+
▪ 手術室費用
+
▪ 醫院雜項費用
+
▪ 深切治療病房
+
• 每症最高賠償期為30天
▪ 住院物理治療
+
▪ 處方藥物
+
▪ 器官移植
+#
▪ 父母陪房費用
+ • 每症最高賠償期為60天
▪ 精神病治療+
• 每年最高賠償期為60天
▪ 入院前治療 • 每症只限一次
▪ 離院後治療
• 離院後42天內 • 每天最高限額 $500 $500
▪ 家庭看護*
• 每症最高賠償期為90天 • 每天最高限額 $1,000 $500
▪ 住院現金津貼（只限入住香港特別行政區政府醫院公眾病房）
• 每症最高賠償期為90天 • 每天最高限額 $1,000 $700
▪ 非住院洗腎及非住院癌病治療
• 每年最高限額 $500,000 $250,000
▪ 意外牙科治療
+
• 每年最高限額 $10,000 $10,000
▪ 義肢/人造假體（包括血管支架及心臟起搏器）+*
• 每年最高限額 $30,000 $15,000
▪ 適用於以上各項住院保障的每年總額（只適用於在海外進行 之治療） $1,000,000 $500,000
全數賠償 全數賠償
3
增值服務家庭護理服務2,3
如因意外導致身體受傷而需住院，您可享用以下服務： 家務助理提供各種家居服務 兒童褓姆照顧您所撫養及照料的兒童4
寵物托管及住宿5
送餐服務
24 小時緊急支援服務
如需緊急援助，AXA安盛緊急支援熱線為您提供全球緊急支援服務： 電話醫療諮詢 緊急醫療運送 治療後護送返回原居地 遺體/骨灰運送 親友探訪 護送兒童返回原居地 旅遊諮詢 法律援助
中國住院按金保證
毋須擔心入院保證金 覆蓋超過200間網絡醫院 即時安排住院手續
住院費用代繳服務3
免費安排住院費用代繳服務 須於入院前致電我們及經過簡單的預先
批核
AXA安盛醫療咭3
投保門診保障，將獲發AXA安盛醫療咭 提供指定的普通科及專科醫生讓您選擇 於指定的醫生診所，出示AXA安盛醫療
咭，便無需支付醫療費用
投保條件 您必須為香港居民並持有香港身份證，
首次投保年齡為18至64歲。 您亦可同時為您的家庭成員投保相同保
障計劃。家庭成員包括18至64歲的合法配偶，及任何出生15天至17歲或未滿23歲但現正接受全日制教育的未婚 子女6。
註 : 1. 保證每年續保。安盛保險有限公司保留於續保時修訂保費
率、保障及條款細則的權利。2. 本服務只限於16歲或以上之受保人。有關服務按照家庭護
理服務之條款及細則提供。本服務由安盛保險有限公司提供，並由第三者服務供應商負責管理。安盛保險有限公司保留隨時修訂有關條款及細則之權利，而不另行通知。
3. 本服務只限於香港境內提供。4. 以兩名未滿12歲的兒童為限。5. 只限一隻狗或猫，寵物酒店費用以每日500港元及最多5
日為限。6. 住院現金保障（「卓越」健樂錢）不適用於受保子女。
此單張上所載之內容並不屬於保險合約的其中一部份。一切條款以保單為準，如有需要，可向本公司索取保單樣本以作參考。此為中文簡譯，如有歧異，概以英文版本為準。
2
保證續保1
凡成功投保「卓越」無憂保，不論日後身體健康狀況如何，保證能獲續保。
全年住院保障高達5,000,000港元（適用於任何年齡組別）提供全面的醫療保障，包括住院、深切治療病房、手術及麻醉師等費用。每保單年度住院保障總額可高達5,000,000港元。
全數賠償，不設手術分類
您可按所投保的計劃，獲得手術、麻醉師及手術室等費用全數支付至最高賠償額的保障，不設繁複的手術表限定各手術的分類賠償，保障更全面，令您倍加安心。
毋須等候期
除了受保前已存在的疾病，投保一經確定接納後，「卓越」無憂保可即時提供保障。
自負金額選擇，預算更有彈性
如您選擇為「基本保障─住院保障」的總醫療費用支付固定的自負金額，便可就有關保障項目享有高達60%保費折扣優惠。
自負金額選擇 (「卓越」無憂保自選計劃)
自負金額(以每名受保人及
按每保單年度為單位)
保費折扣率(適用於「卓越」無憂保
之保費表)
10,000港元 10%
50,000港元 25%
100,000港元 40%
250,000港元 60%
自選保障(1) 門診保障
普通科門診費用 專科診症費用 物理治療及脊骨治療 中醫、跌打及針灸治療 X光檢驗及化驗費用 處方藥物
(2) 牙科保障
牙齒治療 洗牙及口腔檢查 鑲牙費用
(3) 住院現金保障（「卓越」健樂錢） 每日住院現金 1,000港元、750港元或500港元之
每日住院現金保障可供選擇 全年保障高達500,000港元
1
醫療系列
「卓越」無憂保讓您毋須支付醫療費用的全額賠償保險
即享額外保費折扣優惠! 家庭折扣優惠 : 每多一位家庭成員同時投
保，可享額外5%總保費折扣 「卓越」無憂保 自選計劃 : 如選擇「自負金額」為
250,000港元，可享高達 60%保費折扣
為您打造最合適的醫療保險方案
SmartCare Optimum「卓越」無憂保Annual Premium Table 全年保費表
Elite Plan 尊貴計劃 Basic Cover 基本保障
Age Band年齡
Hospitalisation Benefits 住院保障
Female 女性 Male 男性0-5 $10,004 $9,504
6-10 $8,772 $8,448
11-15 $8,407 $8,096
16-20 $9,606 $9,123
21-25 $10,158 $9,244
26-30 $13,648 $11,946
31-35 $13,838 $12,182
36-40 $16,063 $14,327
41-45 $19,718 $17,758
46-50 $21,888 $20,192
51-55 $27,404 $25,143
56-60 $29,760 $27,730
61-65* $30,496 $28,397
66-70* $35,562 $32,330
71-75* $38,535 $34,641
≧76* $48,806 $43,073
Age Band年齡
Hospitalisation Benefits - Deductible Options (SmartCare Optimum Plus) 住院保障 ─ 自負金額選擇 (「卓越」無憂保自選計劃)
Deductible Amount 自負金額：$10,000 Deductible Amount 自負金額：$50,000 Deductible Amount 自負金額：$100,000 Deductible Amount 自負金額：$250,000
Female 女性 Male 男性 Female 女性 Male 男性 Female 女性 Male 男性 Female 女性 Male 男性
0-5 $9,003 $8,554 $7,503 $7,128 $6,002 $5,702 $4,001 $3,802
6-10 $7,895 $7,603 $6,579 $6,336 $5,263 $5,069 $3,509 $3,379
11-15 $7,566 $7,286 $6,305 $6,072 $5,044 $4,858 $3,363 $3,238
16-20 $8,645 $8,211 $7,205 $6,842 $5,764 $5,474 $3,842 $3,649
21-25 $9,142 $8,319 $7,619 $6,933 $6,095 $5,546 $4,063 $3,698
26-30 $12,283 $10,752 $10,236 $8,960 $8,189 $7,168 $5,459 $4,779
31-35 $12,454 $10,964 $10,379 $9,137 $8,303 $7,309 $5,535 $4,873
36-40 $14,457 $12,894 $12,047 $10,745 $9,638 $8,596 $6,425 $5,731
41-45 $17,746 $15,982 $14,789 $13,319 $11,831 $10,655 $7,887 $7,103
46-50 $19,699 $18,173 $16,416 $15,144 $13,133 $12,115 $8,755 $8,077
51-55 $24,664 $22,629 $20,553 $18,857 $16,442 $15,086 $10,962 $10,057
56-60 $26,784 $24,957 $22,320 $20,798 $17,856 $16,638 $11,904 $11,092
61-65* $27,446 $25,557 $22,872 $21,298 $18,297 $17,038 $12,198 $11,359
66-70* $32,005 $29,097 $26,671 $24,248 $21,337 $19,398 $14,225 $12,932
71-75* $34,682 $31,177 $28,901 $25,981 $23,121 $20,785 $15,414 $13,856
≧76* $43,925 $38,765 $36,604 $32,304 $29,283 $25,844 $19,522 $17,229
Additional Optional Cover 額外自選保障
Age Band年齡
Outpatient Benefits 門診保障
Female 女性 Male 男性
0-5 $8,510 $8,016
6-10 $8,395 $7,699
11-15 $8,395 $7,699
16-20 $8,982 $8,136
21-25 $9,626 $8,665
26-30 $12,489 $11,023
31-35 $12,984 $11,460
36-40 $14,795 $13,311
41-45 $16,950 $15,288
46-50 $19,419 $17,559
51-55 $22,249 $20,166
56-60 $25,490 $23,161
61-65* $26,249 $23,851
66-70* $30,188 $26,904
71-75* $31,654 $28,210
≧76* $35,046 $30,918
Age Band年齡
Dental Benefits 牙科保障
Female 女性 Male 男性All Ages所有年齡 $4,140 $4,140
Age Band年齡
Hospital Cash Benefits (SmartCare Essential )住院現金保障 (「卓越」健樂錢)
Gold Plan金計劃 Silver Plan 銀計劃 Bronze Plan 銅計劃
Female 女性 Male 男性 Female 女性 Male 男性 Female 女性 Male 男性
18-24 $1,030 $910 $735 $650 $500 $500
25-34 $1,650 $1,160 $1,185 $835 $785 $560
35-44 $2,145 $1,700 $1,540 $1,220 $1,015 $810
45-54 $3,005 $2,660 $2,155 $1,905 $1,410 $1,250
55-64 $3,720 $3,720 $2,670 $2,670 $1,740 $1,740
* Aged 65 or above for renewal only 65歲或以上只限續保Note 註：All amounts are in Hong Kong dollars 所有金額均以港元計算
HPO
-F-0
614
Effective from 16 June 2014 until further notice. 由2014年6月16日起生效，直至另行通知為止。IV
IV
IV
SmartCare Optimum「卓越」無憂保Annual Premium Table 全年保費表
Deluxe Plan 豪華計劃Basic Cover 基本保障
Age Band年齡
Hospitalisation Benefits 住院保障
Female 女性 Male 男性
0-5 $4,955 $4,793
6-10 $4,356 $4,260
11-15 $4,175 $4,083
16-20 $4,788 $4,811
21-25 $5,041 $5,127
26-30 $6,018 $5,426
31-35 $6,168 $5,564
36-40 $7,645 $6,898
41-45 $9,456 $8,448
46-50 $11,895 $10,687
51-55 $15,147 $13,404
56-60 $19,203 $17,403
61-65* $20,520 $17,978
66-70* $24,573 $22,526
71-75* $26,577 $24,375
≧76* $33,433 $30,099
Age Band年齡
Hospitalisation Benefits - Deductible Options (SmartCare Optimum Plus) 住院保障 ─ 自負金額選擇 (「卓越」無憂保自選計劃)
Deductible Amount 自負金額：$10,000 Deductible Amount 自負金額：$50,000 Deductible Amount 自負金額：$100,000 Deductible Amount 自負金額：$250,000
Female 女性 Male 男性 Female 女性 Male 男性 Female 女性 Male 男性 Female 女性 Male 男性
0-5 $4,459 $4,313 $3,716 $3,594 $2,973 $2,876 $1,982 $1,917
6-10 $3,920 $3,834 $3,267 $3,195 $2,614 $2,556 $1,742 $1,704
11-15 $3,757 $3,674 $3,131 $3,062 $2,505 $2,450 $1,670 $1,633
16-20 $4,309 $4,329 $3,591 $3,608 $2,873 $2,886 $1,915 $1,924
21-25 $4,536 $4,614 $3,780 $3,845 $3,024 $3,076 $2,016 $2,051
26-30 $5,416 $4,883 $4,514 $4,069 $3,611 $3,255 $2,407 $2,170
31-35 $5,551 $5,007 $4,626 $4,173 $3,701 $3,338 $2,467 $2,226
36-40 $6,881 $6,208 $5,734 $5,173 $4,587 $4,139 $3,058 $2,759
41-45 $8,510 $7,603 $7,092 $6,336 $5,674 $5,069 $3,782 $3,379
46-50 $10,705 $9,618 $8,921 $8,015 $7,137 $6,412 $4,758 $4,275
51-55 $13,632 $12,064 $11,360 $10,053 $9,088 $8,042 $6,059 $5,362
56-60 $17,282 $15,663 $14,402 $13,052 $11,522 $10,442 $7,681 $6,961
61-65* $18,468 $16,180 $15,390 $13,484 $12,312 $10,787 $8,208 $7,191
66-70* $22,116 $20,274 $18,430 $16,895 $14,744 $13,516 $9,829 $9,011
71-75* $23,919 $21,938 $19,933 $18,281 $15,946 $14,625 $10,631 $9,750
≧76* $30,090 $27,089 $25,075 $22,574 $20,060 $18,059 $13,373 $12,039
Additional Optional Cover 額外自選保障
Age Band年齡
Outpatient Benefits 門診保障
Female 女性 Male 男性
0-5 $4,502 $4,295
6-10 $4,456 $4,278
11-15 $4,456 $4,278
16-20 $4,939 $4,951
21-25 $5,026 $5,158
26-30 $6,210 $5,589
31-35 $6,325 $5,693
36-40 $7,964 $7,170
41-45 $9,748 $8,735
46-50 $11,932 $10,642
51-55 $14,605 $12,965
56-60 $17,877 $15,795
61-65* $19,303 $17,060
66-70* $21,873 $20,050
71-75* $23,167 $21,229
≧76* $25,685 $23,115
Age Band年齡
Dental Benefits 牙科保障
Female 女性 Male 男性All Ages所有年齡 $4,140 $4,140
Age Band年齡
Hospital Cash Benefits (SmartCare Essential )住院現金保障 (「卓越」健樂錢)
Gold Plan金計劃 Silver Plan 銀計劃 Bronze Plan 銅計劃
Female 女性 Male 男性 Female 女性 Male 男性 Female 女性 Male 男性
18-24 $1,030 $910 $735 $650 $500 $500
25-34 $1,650 $1,160 $1,185 $835 $785 $560
35-44 $2,145 $1,700 $1,540 $1,220 $1,015 $810
45-54 $3,005 $2,660 $2,155 $1,905 $1,410 $1,250
55-64 $3,720 $3,720 $2,670 $2,670 $1,740 $1,740
* Aged 65 or above for renewal only 65歲或以上只限續保Note 註：All amounts are in Hong Kong dollars 所有金額均以港元計算
HPO
-F-0
614
Effective from 16 June 2014 until further notice. 由2014年6月16日起生效，直至另行通知為止。IV
IV
IV
牙科檢查報告
DENTAL EXAMINATION REPORT (必須由註冊牙醫填寫，有關費用由受保人負責)
(To be completed by Registered Dentist at Person to be insured’s expense)
本表格只適用於牙科保障及每位受保人必須填寫。This form is applicable to Dental Benefits only and should be filled in for each person to be insured. 如需更多表格填寫， 請自行影印。Should you need additional forms, photocopies are acceptable.
請在適當的空格內填上 Please tick the boxes where appropriate .
受保人姓名 (英文正楷) Name of Person to be Insured (English Block Letter)
年齡 Age 性別 Sex 男 Male 女 Female 香港身份證號碼 HKID Card No
1 這次檢查中有否拍攝牙科 X 光作檢查？ 有 Yes 否 No
Have any dental x-rays been taken during this examination?
若「有」，請描述 X 光性質及拍攝原因
If "Yes", please describe nature of x-rays and reason for taking
2 請描述受保人的假牙狀況(若適用)及你認為受保人的假牙狀況是否保持良好及受保人是否正確護理自己的假牙？
Please describe general condition of dentures (if any) and do you think the person to be Insured’s denture is in good condition and well taken care of?
3 就受保人現時的牙齒狀態，是否出現口腔內顎骨結構異常(包括先天性、遺傳性或後天意外所引致)一般代謝性病 是 Yes 否 No
變、發炎性病變及內分泌病變等，而此等病變會對受保人的牙齒構成已知的損害？
Is there any pre-existing pathology which could cause a worsening of the person to be insured’s dentition are included as pre-existing pathologies the maxilla deformation (congenital, hereditary or accidental) and also but not limited to all general metabolic, infections and endocrine pathologies having an incidence on dental status?
若「是」，請詳述
If "Yes", please give details below
4 現時是否有徵狀顯示牙肉有問題，包括已顯示或未曾顯示在牙齒的健康上？ 是 Yes 否 No
Is there any sign of gum problem with or without incidence on the health of the teeth?
若「是」，請詳述
If "Yes", please give details below
5 受保人對上一次接受牙齒或牙肉診治於何時及接受何種治療？
When was the person to be insured last treated for dental or gum problems and what was the treatment provided?
受保人資料 DETAILS OF THE PERSON TO BE INSURED
醫療問卷 MEDICAL QUESTIONNAIRE
Page 2 of 4 HPO-DER-0413
6 請描述其他有關的不正常狀況或觀察
Please state other abnormalities or observations
7 請在下圖圈出發現已有問題的牙齒及詳述有關狀況
Please circle the teeth with existing problems and specify the conditions
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 右 Right
左 Left
A 受保人填寫 TO BE COMPLETED BY THE PERSON TO BE INSURED
本人聲明及同意本人已填報一切重要的有關資料，就本人所知所信全部正確無訛，並無任何保留。
I hereby declare and agree that all information provided is to the best of my knowledge and belief complete and true and that I have not withheld any material facts.
本人授權任何有關的註冊牙科醫生，向安盛保險有限公司提供任何有關本人的牙科健康狀況的有關資料。本授權書的影印本將與正本具有同等
效力。
I hereby authorize any licensed dentist to release any information of my dental status to AXA General Insurance Hong Kong Limited may require. A photocopy of this authorization shall be as valid as the original.
安盛保險有限公司（下稱“本公司”）明白其就《個人資料（私隱）條例》（香港法例第 486 章）（“條例”）收集、持有、處理、使用和／或轉移個人資料所
負有的責任。本公司僅將為合法和相關的目的收集個人資料，並將採取一切切實可行的步驟，確保本公司所持個人資料的準確性。本公司將採取一切切實可行的
步驟，確保個人資料的安全性，及避免發生未經授權或者因意外而擅自取得、刪除或另行使用個人資料的情況。
敬請注意，如果閣下不向本公司提供閣下的個人資料，我們可能無法提供閣下所需的資料、產品或服務，或無法處理閣下的要求。
目的：本公司不時有必要收集閣下的個人資料，並可能因下列各項目的（“有關目的”）而供本公司使用、存儲、處理、轉移、披露或共享該等個人資料：
1. 向閣下推介、提供和營銷本公司、安盛集團的其他公司(“安盛關聯方”) 或本公司的商業合作夥伴之產品／服務，以及提供、維持、管理和操作該等產
品／服務；
2. 處理和評估閣下就本公司及安盛關聯方所提供之產品／服務提出的任何申請或要求；
3. 向閣下提供後續服務，包括但不限於執行／管理已發出的保單；
4. 與就本公司和／或安盛關聯方提供的任何產品／服務而由閣下或針對閣下提出的或者其他涉及閣下的任何索賠相關的任何目的，包括索賠調查；
5. 評估閣下的財務需求；
6. 為客戶設計產品／服務；
7. 為統計或其他目的進行市場研究；
8. 不時就本條款所列的任何目的核對所持有的與閣下有關的任何資料；
9. 作出任何適用法律、規則、規例、實務守則或指引所要求的披露或協助在香港或香港以外其他地方的警方或其他政府或監管機構執法及進行調查；
10. 進行身份和／或信用核查和／或債務追收；
11. 遵守任何適用的司法管轄區的法律；
12. 開展與本公司業務經營有關的其他服務；及
13. 與上述任何目的直接有關的其他目的。
個人資料的轉移：個人資料將予以保密，但在遵守任何適用法律條文的前提下，可提供給：
1. 位於香港或香港以外其他地方的任何安盛關聯方、本公司的任何相關聯人士、任何再保險公司、索賠調查公司、閣下之保險經紀、行業協會或聯會、基
金管理公司或金融機構，以及就此方面而言，閣下同意將閣下的資料轉移至香港境外；
2. 與就本公司和／或安盛關聯方提供的任何產品／服務而由閣下或針對閣下提出的或者其他涉及閣下的任何索賠相關的任何人士(包括私家偵探)；
3. 在香港或香港以外其他地方向本公司和／或安盛關聯方提供行政，技術或其他服務並對個人資料負有保密義務的任何代理、承包商或第三方；
4. 信貸資料機構或（在出現拖欠還款的情況下）追討欠款公司；
5. 本公司權利或業務的任何實際或建議的承讓人、受讓方、參與者或次參與者；及
6. 在香港或香港以外其他地方的任何政府部門或其他適當的政府或監管機關。
閣下的個人資料將僅為上文中規定的一個或多個有關目的而被轉移。
個人資料的查閱和更正：根據條例，閣下有權查明本公司是否持有閣下的個人資料，獲取該資料的副本，以及更正任何不準確的資料。閣下還可以要求本公司告
知閣下本公司所持個人資料的種類。
查閱和更正的要求，或有關獲取政策、常規及本公司所持的資料種類的資料，均應以書面形式發送至：
香港九龍九龍灣宏泰道 23 號 21 樓
安盛保險有限公司
個人資料保護主任
本公司可能會向閣下收取合理的費用，以抵銷本公司為執行閣下的資料查閱要求而引致的行政和實際費用。
醫療問卷 MEDICAL QUESTIONNAIRE
聲明 DECLARATION
收集個人資料的聲明
Page 3 of 4 HPO-DER-0413
AXA General Insurance Hong Kong Limited (referred to hereinafter as the “Company”) recognises its responsibilities in relation to the collection, holding, processing, use and/or transfer of personal data under the Personal Data (Privacy) Ordinance (Cap. 486) (“PDPO”). Personal data will be collected only for
lawful and relevant purposes and all practicable steps will be taken to ensure that personal data held by the Company is accurate. The Company will take all practicable steps to ensure security of the personal data and to avoid unauthorised or accidental access, erasure or other use. Please note that if you do not provide us with your personal data, we may not be able to provide the information, products or services you need or process your request. Purpose: From time to time it is necessary for the Company to collect your personal data which may be used, stored, processed, transferred, disclosed or shared by us for purposes (“Purposes”), including:
1. offering, providing and marketing to you the products/services of the Company, other companies of the AXA Group (“our affiliates”) or our business
partners, and administering, maintaining, managing and operating such products/services; 2. processing and evaluating any applications or requests made by you for products/services offered by the Company and our affiliates; 3. providing subsequent services to you, including but not limited to administering the policies issued; 4. any purposes in connection with any claims made by or against or otherwise involving you in respect of any products/services provided by the
Company and/or our affiliates, including investigation of claims; 5. evaluating your financial needs; 6. designing products/services for customers; 7. conducting market research for statistical or other purposes; 8. matching any data held which relates to you from time to time for any of the purposes listed herein; 9. making disclosure as required by any applicable law, rules, regulations, codes of practice or guidelines or to assist in law enforcement purposes,
investigations by police or other government or regulatory authorities in Hong Kong or elsewhere; 10. conducting identity and/or credit checks and/or debt collection; 11. complying with the laws of any applicable jurisdiction; 12. carrying out other services in connection with the operation of the Company’s business; and 13. other purposes directly relating to any of the above.
Transfer of personal data: Personal data will be kept confidential but, subject to the provisions of any applicable law, may be provided to:
1. any of our affiliates, any person associated with the Company, any reinsurance company, claims investigation company, your broker, industry association or federation, fund management company or financial institution in Hong Kong or elsewhere and in this regard you consent to the transfer of your data outside of Hong Kong;
2. any person (including private investigators) in connection with any claims made by or against or otherwise involving you in respect of any products/services provided by the Company and/or our affiliates;
3. any agent, contractor or third party who provides administrative, technology or other services to the Company and/or our affiliates in Hong Kong or elsewhere and who has a duty of confidentiality to the same;
4. credit reference agencies or, in the event of default, debt collection agencies; 5. any actual or proposed assignee, transferee, participant or sub-participant of our rights or business; and 6. any government department or other appropriate governmental or regulatory authority in Hong Kong or elsewhere.
Transfer of your personal data will only be made for one or more of the Purposes specified above. Access and correction of personal data: Under the PDPO, you have the right to ascertain whether the Company holds your personal data, to obtain a copy of the data, and to correct any data that is inaccurate. You may also request the Company to inform you of the type of personal data held by it. Requests for access and correction or for information regarding policies and practices and kinds of data held by the Company should be addressed in writing to:
Data Privacy Officer AXA General Insurance Hong Kong Limited 21/F Manhattan Place, 23 Wang Tai Road, Kowloon Bay, Kowloon, Hong Kong
A reasonable fee may be charged to offset the Company’s administrative and actual costs incurred in complying with your data access requests.
本人／我們確認本人／我們已閱讀並明白收集個人資料的聲明(“該聲明”)。本人／我們確認本人／我們已被通知本人／我們須詳細閱讀該聲明，而本人／我們
已詳細閱讀《該聲明》對貴公司所收集或持有之本人／我們的個人資料的影響(不論是否此表格所載或從其他途徑所取得)。根據以上所述，本人／我們特此確認並
同意安盛保險有限公司根據該聲明使用及轉移本人／我們的個人資料。
I/WE ACKNOWLEDGE AND CONFIRM that I/we have read and understood the Personal Information Collection Statement (“PICS”). I/We confirm that I/we
have been advised to read carefully the PICS, and I/we have read it carefully its effect and impact in respect of my/our personal data collected or held by the
Company (whether contained in this application or otherwise). Based on the foregoing, I/we hereby give my/our acknowledgement and agree to the use and
transfer of my/our personal data by AXA General Insurance Hong Kong Limited in accordance with the PICS.
受保人簽署
Signature of Person to be insured 日期 Date
(日/月/年) (dd/mm/yyyy)
PERSONAL INFORMATION COLLECTION STATEMENT
Page 4 of 4 HPO-DER-0413
B 註冊牙醫填寫 TO BE COMPLETED BY REGISTERED DENTIST
本人証明就本人所知所信全部正確無訛。本人接受及取得投保人的同意，向安盛保險有限公司提供本聲明內容的有關資料及於將來 12 個月內
就受保人的實際牙科健康狀況所發現的任何有關差異。
I certify to the best of my medical knowledge that all the information provided is exact. I accept to release, with the consent of the Person to be insured all the necessary information to AXA General Insurance Hong Kong Limited, should within the next twelve months any discrepancy arise between any statement and the actual evolution of the Person to be insured's dental condition.
註冊牙醫姓名(英文正楷)
Name of Registered Dentist (English Block Letter)
註冊牙醫簽署
Signature of Registered Dentist
日期 Date
(日/月/年) (dd/mm/yyyy)
資歷 Qualification
地址 Address
電話號碼 Tel No _____________________________________ 傳真號碼 Fax No _____________________________________
註冊牙醫資料 INFORMATION OF REGISTERED DENTIST
(
6*
:
(852) 2523 3061
(852) 2810 0706
www.axa-insurance.com.hk
安盛保險有限公司 AXA General Insurance Hong Kong Limited 香港九龍九龍灣宏泰道23號21樓 21/F, Manhattan Place, 23 Wang Tai Road, Kowloon Bay, Kowloon, Hong Kong
日 dd/ 月 mm/ 年 yyyy 本保單由 起一年內有效 Policy to commence on for one year.
名*Given Name
投保人姓名 - 姓 (必須與香港身份證相同)*Name of Proposer - Surname (as on HKID)
公司電話Office Tel
住宅電話Home Tel
電郵地址Email
香港身份證號碼*HKID Card No
身高 (厘米)*Height (cm)
體重 (公斤)*Weight (kg)
通訊地址*Correspondence Address
手提電話Mobile No
聯絡電話 (請填寫最少一項) Contact No (Please fill in at least one)*
香港 HK 九龍 KLN 新界 NT
香港 HK 九龍 KLN 新界 NT
性別*Sex
出生日期 (日/月/年)*Date of Birth (dd/mm/yyyy)
國籍Nationality
吸煙者*# 是, 每日 根Smoker Yes, cigarette per day
否 No
工作性質Job Nature
職業/職位*Occupation/Job Position
婚姻狀況Marital Status
單身 Single 已婚 Married
# 在過去三年內吸食過香煙、煙斗或雪茄。 Smoked cigarette, pipe or cigar in the past 3 years.
公司電話Office Tel
電郵地址Email
公司名稱 (與商業登記證相同)Company Name (as on Business Registration)
商業登記號碼Business Registration No
業務性質Business Type
公司地址 (如與上述通訊地址不同)Company Address (if different from above mentioned correspondence address)
手提電話Mobile No
戶口持有人 Account Holder: 公司 Company 投保人 Proposer
銀行名稱 Bank Name
戶口號碼Account No.
計劃選擇Select Plan
I) 基本保障 - 住院保障 Basic Cover - Hospitalization Benefits
自負金額 Deductible Options
尊貴計劃 Elite Plan
II) 額外自選保障 Additional Optional Cover
1) 門診保障 Outpatient Benefits
豪華計劃 Deluxe Plan
p.1
2) 牙科保障 (請另外填寫牙科報告) Dental Benefits (Please complete a separate Dental Examination Report)
所有受保人的保障計劃必須相同。 The plan(s) selected should be the same for all insured person.
3) 住院現金保障 -「卓越」健樂錢 ∞
Hospital Cash Benefits - SmartCare Essential ∞
金計劃 Gold Plan
銀計劃 Silver Plan
銅計劃 Bronze Plan
∞ 詳情請參閱「卓越」健樂錢 之產品小冊子。Please refer to product brochure of SmartCare Essential for details.
## 若以公司名義作為投保人，以上「投保人」均解作「受保人」。 In case the Proposer is a business entity/company, above “Proposer” will be interpreted as “Insured Person/Member”.
$10,000 $50,000 $100,000 $250,000
/ /
「卓越」無憂保 自選計劃SmartCare OptimumPlus
無 Nil
請以英文正楷填寫，並在適當的空格內填上 ✔ Please fill in this form in English block letters and tick the boxes where appropriate ✔
投保書 Proposal Form「卓越」無憂保個人醫療保險SmartCare Optimum Individual Health Insurance
投保人資料 ProPoser Details
公司資料 ComPany Details ## (如以公司名義作為投保人 If the proposer is a business entity/company)
銀行戶口資料 bank aCCount Details (只作賠償之用For claim payment purpose only)
投保細則 insuranCe Cover
此保單所提供的保障，必須在本公司確定接納投保後，及收妥保費後，才能正式生效。 The liability of the Company does not commence until this proposal has been accepted
by the Company and the premium is received.
* 必須填寫項目 Mandatory fields
經紀業務適用For broker business
是 Yes 否 No2.受保人†是否曾經在投保人壽或醫療保險時被保險公司拒絕，被延期，在特別條款和情況下被接受，或被拒絕續保？ Has any person to be insured ever been rejected, postponed, accepted under special terms and conditions for a Life or Health application by an insurance company, or its renewal been refused?
3.受保人†是否持有仍然生效的人壽或醫療保單？ Does any person to be insured have any Life or Health insurance policy currently in force?
如以上任何問題答「是」，請列明詳細資料（包括保險公司名稱及受保期） If the answer to any of the above questions is “Yes”, please provide details below. (including Name of the Insurance Company & Period of Insurance)
p.2
受保家屬 Insured Dependent (1)
1) 姓* Surname
註: 若受保人的未婚子女年齡為18至22歲並是全日制學生亦可以投保本計劃，請提供學生身份證明或有效的證明文件以作確認（接受影印本）。NB: Your unmarried child(ren) can be insured under this policy if they are aged 18 to 22 and are full time students. Please provide student identification document(s)
or other documentation(s) for validation (photocopies are acceptable).
2) 名* Given Name
3) 性別* Sex
4) 香港身份證號碼* HKID Card No
5) 出生日期（日/月/年）* Date of Birth (dd/mm/yyyy)
6) 國籍 Nationality
7) 與投保人關係 Relationship to Proposer
8) 身高（厘米）* Height (cm)
9) 體重（公斤）* Weight (kg)
10) 職業/職位* Occupation/Job Position
11) 工作性質 Job Nature
12) 吸煙者*#
Smokers
†「受保人」均解作「受保人」及/或「受保家屬」。“The person(s) to be insured” will be interpreted as “Insured Person/Member” and/or “Insured Dependent(s)”.
1. 受保人†的家庭醫生全名、地址及電話號碼。（必須填寫） Full name, address and telephone number of the usual Physician for the person(s) to be insured (Please complete).
受保人†在過去六個月內曾求診的醫生全名、地址及電話號碼。（必須填寫）Full name, address and telephone number of any other Physician(s) that the person(s) to be insured have visited in the last 6 months (Please complete).
是, 每日 根 Yes, cigarette per day
否 No
是, 每日 根 Yes, cigarette per day
否 No
是, 每日 根 Yes, cigarette per day
否 No
受保家屬 Insured Dependent (2) 受保家屬 Insured Dependent (3)
醫生全名 Physician’s Full Name 地址 Address 電話號碼 Tel No
醫生全名 Physician’s Full Name 地址及電話號碼 Address & Tel No 該次診斷結果 Diagnosis 現時狀況 Current Condition
若空位不敷應用，請另加紙張填寫。 Should there be insufficient space, please continue on a separate sheet.
受保家屬資料 Details oF tHe DePenDent(s) to be insureD
保險有關資料 insuranCe inFormation*
是 Yes 否 No
1. 受保人†是否慣常飲用酒精類飲品/服用藥物？ 1. Does any person to be insured take alcohol/medication?
2. 受保人†是否曾經入住醫院或接受任何手術、醫療輔助、治療或檢驗包括X光/掃描/心電圖/磁力共振掃描/實驗室化驗等？ 2. （如「是」，請提供有關醫療報告副本） Has any person to be insured been admitted to a hospital or received any surgery, medical advice, treatment or examination including X-ray/imaging/ECG/MRI/laboratory test, etc.? [If “Yes”, please provide a copy of the original medical report(s)]
3. 受保人†是否患有或曾患有以下疾病？ Has any person to be insured suffer, or have ever suffered from any of the disorders, deformations or symptoms described below?
a) 內分泌系統 Endocrine System 3a) 甲狀腺、腎上腺、垂體疾病、糖尿病、肥胖症等； thyroid, adrenal, pituitary, diabetes, obesity, etc.
b) 神經系統 Nervous System 3b) 神經炎、中風、癱瘓、震傷、癲癇、痙攣等； neuritis, stroke, paralysis, concussion, epilepsy, spastic disorders, etc.
c) 眼睛 Eyes 3c) 眼疾、斜視、弱視或其他眼疾； eye diseases, squinting, amblyopia, other disorders
d) 耳 Ears 3d) 耳疾、失聰、弱聽等； ear disorders, deafness or partial deafness, hard of hearing, etc.
e) 支氣管 Bronchial Tubes 3e) 鼻腔發炎、支氣管炎、哮喘、肺炎、胸膜炎、肺結核等； inflammation of nasal cavity, bronchitis, asthma, pneumonia, pleuritis, tuberculosis, etc.
f) 心臟及血管系統 Heart and Vascular System 3f) 心臟病、心臟（瓣膜）疾病、靜脈曲張、高血壓、膽固醇過高等； heart attack, heart (valve) disorder, varicose veins, high blood pressure, high cholesterol level, etc.
g) 血液及/或淋巴系統、白血病等 Blood and/or Lymphatic System, Leukemia, etc. 3g)
h) 女性生殖器官及乳房 Female Genital Organs and Breast 3h) 內臟器官疾病、月經失調及乳房手術/乳房檢查 disease of the internal organs, menstrual disorders and breast operation/breast tests, etc.
i) 消化系統 Digestive System 3i) 食道、胃、腸、肝、痔瘡、膽囊、腹股溝等毛病； gullet, stomach, intestines, liver, hemorrhoids, gall-bladder, groin, etc.
j) 腎及泌尿系統 Kidney and Urinary System 3j) 腎石、膀胱炎、遺尿、前列腺疾病等； stones, inflammation of the bladder, bed wetting, prostate, etc.
k) 男性生殖器官 Male Genital Organs 3k) 包皮緊縮、睪丸未降、發炎等； prepuce narrowing, undescended testicles, inflammations, etc.
l) 骨骼及肌肉系統 Bone and Musculo-skeletal System 3l) 背部及/或股骨不適、風濕、（手、腳）折斷、肌肉系統疾病、曾接受切除手術等； back and/or hip disorders, rheumatism, fractures (arm, leg), muscular system, amputations, etc.
m) 皮膚及四肢 Skin and Limbs 3m) 慢性皮膚病、如牛皮癬、曾接受整形外科手術、外形、面積及位置偏差等； chronic skin diseases, e.g. psoriasis, plastic surgery, shape, size and positional deviations, etc.
n) 精神病治療 Psychiatry 3n) 精神病、長期頭痛、過份緊張、精神分裂症等； psychological disorders, prolonged headaches, overstrains, schizophrenia, etc.
o) 敏感 Allergies 3o)
4. 受保人†曾否患有以上未有提及的疾病？ 4. Has any person to be insured suffer from any disease not mentioned above?
5. 上述情況是否因懷孕所致? 5. Was the above mentioned condition due to or associated with pregnancy?
6. 受保人†的直系親屬當中是否曾經患有心臟病、中風、高血壓、糖尿病、癌症或其他遺傳性疾病？ 6. Has any direct relatives of the person to be insured suffered from heart disease, stroke, high blood pressure, diabetes, cancer or other hereditary disease?
7. 如以上任何問題答「是」，請確保在以下填妥有關的詳盡資料？ If you have answered “Yes” to any of the above questions, please give full details:
若空位不敷應用，請另加紙張填寫。 Should there be insufficient space, please continue on a separate sheet.
問題編號Question
No
受保人†全名Name (in Full)
疾病性質 Nature ofComplaint
與受保人關係 Relationshipwith Insured
診斷結果Diagnosis
所接受的治療TreatmentReceived
治療日期(月/年)Date (mm/yyyy)
現時的健康狀況Current
Situation
醫生姓名、地址及電話號碼Name, Address & Telephone No
of Attending Physician由 From 至 To
p.3
醫療問卷 meDiCal Questionnaire
安盛保險有限公司（下稱「本公司」）明白其就《個人資料（私隱）條例》（香港法例第486章）（「條例」）收集、持有、處理、使用和/或轉移個人資料所負有的責任。本公司僅將為合法和相關的目的收集個人資料，並將採取一切切實可行的步驟，確保本公司所持個人資料的準確性。本公司將採取一切切實可行的步驟，確保個人資料的安全性，及避免發生未經授權或者因意外而擅自取得、刪除或另行使用個人資料的情況。敬請注意，如果閣下不向本公司提供閣下的個人資料，我們可能無法提供閣下所需的資料、產品或服務，或無法處理閣下的要求。目的：本公司不時有必要收集閣下的個人資料，並可能因下列各項目的（「有關目的」）而供本公司使用、存儲、處理、轉移、披露或共享該等個人資料：(1) 向閣下推介、提供和營銷本公司、安盛集團的其他公司（「安盛關聯方」）或本公司的商業合作夥伴 (參閱下文「在直接促銷中使用及將其個人資料提供予其他人士」部份）之產品/服務，以及提供、維持、
管理和操作該等產品/服務；(2) 處理和評估閣下就本公司及安盛關聯方所提供之產品/服務提出的任何申請或要求；(3) 向閣下提供後續服務，包括但不限於執行/管理已發出的保單；(4) 與就本公司和/或安盛關聯方提供的任何產品/服務而由閣下或針對閣下提出的或者其他涉及閣下的任何索賠相關的任何目的，包括索賠調查；(5) 評估閣下的財務需求；(6) 為客戶設計產品/服務；(7) 為統計或其他目的進行市場研究；(8) 不時就本條款所列的任何目的核對所持有的與閣下有關的任何資料；(9) 作出任何適用法律、規則、規例、實務守則或指引所要求的披露或協助在香港或香港以外其他地方的警方或其他政府或監管機構執法及進行調查；(10) 進行身份和/或信用核查和/或債務追收；(11) 遵守任何適用的司法管轄區的法律；(12) 開展與本公司業務經營有關的其他服務；及(13) 與上述任何目的直接有關的其他目的。個人資料的轉移：個人資料將予以保密，但在遵守任何適用法律條文的前提下，可提供給：(1) 位於香港或香港以外其他地方的任何安盛關聯方、本公司的任何相關聯人士、任何再保險公司、索賠調查公司、閣下之保險經紀、行業協會或聯會、基金管理公司或金融機構，以及就此方面而言，閣
下同意將閣下的資料轉移至香港境外；(2) 與就本公司和/或安盛關聯方提供的任何產品/服務而由閣下或針對閣下提出的或者其他涉及閣下的任何索賠相關的任何人士（包括私家偵探）；(3) 在香港或香港以外其他地方向本公司和/或安盛關聯方提供行政，技術或其他服務（包括直接促銷服務）並對個人資料負有保密義務的任何代理、承包商或第三方；(4) 信貸資料機構或（在出現拖欠還款的情況下）追討欠款公司；(5) 本公司權利或業務的任何實際或建議的承讓人、受讓方、參與者或次參與者；及(6) 在香港或香港以外其他地方的任何政府部門或其他適當的政府或監管機關。如欲了解本公司為促銷目的使用閣下的個人資料的政策，請參閱下文「在直接促銷中使用及將其個人資料提供予其他人士」 部份。閣下的個人資料將僅為上文中規定的一個或多個有關目的而被轉移。在直接促銷中使用及將其個人資料提供予其他人士
本公司有意：(1) 使用本公司不時持有的閣下的姓名、聯絡資料、產品及服務的組合資料、交易模式及行為、財政背景及人口統計數據以進行直接促銷；(2) 就本公司，安盛關聯方，本公司合作品牌夥伴及商業合作夥伴可能提供關於下列類別的服務及產品而進行直接促銷（包括但不限於提供獎賞、客戶或會員或優惠計劃）：
(a) 保險、銀行、公積金或公積金計劃、金融服務、證券和相關產品及服務；(b) 健康、保健及醫療、餐飲、體育運動及會員服務、娛樂、健身浴或類似的休閒活動、旅遊及交通、家居、服裝、教育、社交網絡、媒體的產品及服務及高級消費類產品；
(3) 以上服務及產品將會由本公司及/或以下機構提供：(a) 任何安盛關聯方；(b) 第三方金融機構；(c) 提供上文2. 所列之服務及產品之本公司及/或安盛關聯方的商業合作夥伴或合作品牌夥伴；(d) 向本公司或任何以上所列機構提供支援的第三方獎賞、客戶或會員或優惠計劃提供者；
(4) 除由本公司促銷上述服務及產品外，本公司亦有意將上文1. 段部份所述的資料提供予上文3. 段部份所述的全部或任何人士，以供該等人士在促銷該等服務及產品中使用，而本公司為此目的須獲得客戶書面同意（包括表示不反對）。
在使用閣下的個人資料作上文所述的目的或提供予上文所述的人士之前，本公司須獲得閣下的書面同意，及只在獲得閣下的書面同意後方可使用閣下的個人資料及提供予其他人士作任何推廣及促銷用途。閣下日後可撤回閣下給予本公司有關使用閣下的個人資料及提供予其他人士作任何促銷用途的同意。閣下如欲撤回閣下給予本公司的同意，請發信至下文「個人資料的查閱和更正」 部份所列的地址通知本公司。本公司會在不收取任何費用的情況下確保不會將閣下納入日後的直接促銷活動中。個人資料的查閱和更正：根據條例，閣下有權查明本公司是否持有閣下的個人資料，獲取該資料的副本，以及更正任何不準確的資料。閣下還可以要求本公司告知閣下本公司所持個人資料的種類。查閱和更正的要求，或有關獲取政策、常規及本公司所持的資料種類的資料，均應以書面形式發送至：
香港九龍灣宏泰道23號21樓安盛保險有限公司個人資料保護主任
本公司可能會向閣下收取合理的費用，以抵銷本公司為執行閣下的資料查閱要求而引致的行政和實際費用。
AXA General Insurance Hong Kong Limited (referred to hereinafter as the “Company”) recognises its responsibilities in relation to the collection, holding, processing, use and/or transfer of personal data under the Personal Data (Privacy) Ordinance (Cap. 486) (“PDPO”). Personal data will be collected only for lawful and relevant purposes and all practicable steps will be taken to ensure that personal data held by the Company is accurate. The Company will take all practicable steps to ensure security of the personal data and to avoid unauthorised or accidental access, erasure or other use.
Please note that if you do not provide us with your personal data, we may not be able to provide the information, products or services you need or process your request.
Purpose: From time to time it is necessary for the Company to collect your personal data which may be used, stored, processed, transferred, disclosed or shared by us for purposes (“Purposes”), including:
(1) offering, providing and marketing to you the products/services of the Company, other companies of the AXA Group (“our affiliates”) or our business partners (see “Use and provision of personal data in direct marketing” below), and administering, maintaining, managing and operating such products/services;
(2) processing and evaluating any applications or requests made by you for products/services offered by the Company and our affiliates;
(3) providing subsequent services to you, including but not limited to administering the policies issued;
收集個人資料的聲明 Personal inFormation ColleCtion statement
投保人聲明 DeClaration
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請細閱下列各項條文及投保人須知，然後在指定空位內簽署。Please read the following statements and Important Notes to Proposer carefully and sign in the space provided.
本人聲明 I declare that
• 本投保書內所載問題的陳述及答覆，均為全部正確無訛。本人並特此同意，此等陳述及答覆均會成為保單的基礎及其中一部份△。 All statements and answers to all questions stated in this proposal are to the best of my knowledge and belief complete and true and I hereby agree that these statements and answers shall form the
basis and become a part of any policy issued hereunder △.
• 本人特此授權任何擁有本人或上述任何成員的任何記錄或資料的註冊醫生、醫院、診所或保險公司，可向安盛保險有限公司提供上述有關資料。 I hereby authorize any licensed physician, hospital, clinic or insurance company that has any records or knowledge of me or any members listed above to give any such information to AXA General
Insurance Hong Kong Limited.
• 本人明白在保單內的信用設備包括安盛醫療咭及醫院費用代繳服務均為保單保障範圍內作門診及住院接受治療之用。如在某種情況或某些原因下醫療費用不屬保單賠償範圍之內，本人將承擔此不屬保單賠償範圍內的費用並於繳款通知書發出兩星期內支付安盛保險有限公司。
I also understand that any credit facility including AXA medical card or hospital credit offered for the Policy are to be used for clinical visits or admission to hospitals for treatments falling under the scope of the Policy. In the event the charges incurred which are in excess of my benefits entitlement or any ineligible benefit not provided under the Policy, I shall undertake to pay AXA General Insurance Hong Kong Limited within two weeks from the date of the Debit Note.
• 本人已填報一切重要的有關資料，絕無隱瞞或保留，並同意將本投保書和聲明作為與安盛保險有限公司和本人所訂合約的根據，並以保單各條款為準則△。 I have not withheld any material information and accept that this proposal and declaration shall be the basis of, and be incorporated in, the contract between AXA General Insurance Hong Kong Limited
and myself △.
• 就此投保申請，本人已取得所有家屬同意及授權透過本人向貴公司提供有關資料；倘若本人及其所有家屬未能提供所須資料，貴公司可能因此不能處理此投保申請。本人之家屬均同意該等資料可供貴公司使用，致使貴公司之業務得以順利運作。
I have obtained all necessary consent from my dependents to supply their information and data to the Company by myself otherwise if they fail to provide any such information requested, it may result in the Company’s inability to process and deal with this application. My dependents agree that these information and data can be used by the Company to carry on its businesses.
(4) any purposes in connection with any claims made by or against or otherwise involving you in respect of any products/services provided by the Company and/or our affiliates, including investigation of claims;
(5) evaluating your financial needs;
(6) designing products/services for customers;
(7) conducting market research for statistical or other purposes;
(8) matching any data held which relates to you from time to time for any of the purposes listed herein;
(9) making disclosure as required by any applicable law, rules, regulations, codes of practice or guidelines or to assist in law enforcement purposes, investigations by police or other government or regulatory authorities in Hong Kong or elsewhere;
(10) conducting identity and/or credit checks and/or debt collection;
(11) complying with the laws of any applicable jurisdiction;
(12) carrying out other services in connection with the operation of the Company’s business; and
(13) other purposes directly relating to any of the above.
transfer of personal data: Personal data will be kept confidential but, subject to the provisions of any applicable law, may be provided to:
(1) any of our affiliates, any person associated with the Company, any reinsurance company, claims investigation company, your broker, industry association or federation, fund management company or financial institution in Hong Kong or elsewhere and in this regard you consent to the transfer of your data outside of Hong Kong;
(2) any person (including private investigators) in connection with any claims made by or against or otherwise involving you in respect of any products/services provided by the Company and/or our affiliates;
(3) any agent, contractor or third party who provides administrative, technology or other services (including direct marketing services) to the Company and/or our affiliates in Hong Kong or elsewhere and who has a duty of confidentiality to the same;
(4) credit reference agencies or, in the event of default, debt collection agencies;
(5) any actual or proposed assignee, transferee, participant or sub-participant of our rights or business; and
(6) any government department or other appropriate governmental or regulatory authority in Hong Kong or elsewhere.
For our policy on using your personal data for marketing purposes, please see the section below “Use and provision of personal data in direct marketing”.
Transfer of your personal data will only be made for one or more of the Purposes specified above.
use and provision of personal data in direct marketing: The Company intends to:
(1) use your name, contact details, products and services portfolio information, transaction pattern and behaviour, financial background and demographic data held by the Company from time to time for direct marketing;
(2) conduct direct marketing (including but not limited to providing reward, loyalty or privileges programmes) in relation to the following classes of products and services that the Company, our affiliates, our co-branding partners and our business partners may offer:
(a) insurance, banking, provident fund or scheme, financial services, securities and related products and services;
(b) products and services on health, wellness and medical, food and beverage, sporting activities and membership, entertainment, spa and similar relaxation activities, travel and transportation, household, apparel, education, social networking, media and high-end consumer products;
(3) the above products and services may be provided by the Company and/or:
(a) any of our affiliates;
(b) third party financial institutions;
(c) the business partners or co-branding partners of the Company and/or affiliates providing the products and services set out in (2) above;
(d) third party reward, loyalty or privileges programme providers supporting the Company or any of the above listed entities
(4) in addition to marketing the above products and services, the Company also intends to provide the data described in (1) above to all or any of the persons described in (3) above for use by them in marketing those products and services, and the Company requires your written consent (which includes an indication of no objection) for that purpose;
Before using your personal data for the purposes and providing to the transferees set out above, the Company must obtain your written consent, and only after having obtained such written consent, may use and provide your personal data for any promotional or marketing purpose.
You may in future withdraw your consent to the use and provision of your personal data for direct marketing.
If you wish to withdraw your consent, please inform us in writing to the address in the section on “access and correction of personal data”. The Company shall, without charge to you, ensure that you are not included in future direct marketing activities.
access and correction of personal data: Under the PDPO, you have the right to ascertain whether the Company holds your personal data, to obtain a copy of the data, and to correct any data that is inaccurate. You may also request the Company to inform you of the type of personal data held by it.
Requests for access and correction or for information regarding policies and practices and kinds of data held by the Company should be addressed in writing to:
Data Privacy OfficerAXA General Insurance Hong Kong Limited21/F Manhattan Place, 23 Wang Tai Road, Kowloon Bay, Kowloon, Hong Kong
A reasonable fee may be charged to offset the Company’s administrative and actual costs incurred in complying with your data access requests.
本人/我們確認本人/我們已閱讀並明白收集個人資料的聲明（「該聲明」）。本人/我們確認本人/我們已被通知本人/我們須詳細閱讀該聲明，而本人/我們已詳細閱讀該聲明對貴公司所收集或持有之本人/我們的個人資料的影響（不論是否此表格所載或從其他途徑所取得）。根據以上所述，本人/我們特此確認並同意安盛保險有限公司根據該聲明使用及轉移本人/我們的個人資料，包括在直接促銷中使用及將本人/我們個人資料提供予其他人士。[重要通知：如閣下不同意根據「收集個人資料的聲明」使用和轉移閣下的個人資料作直接促銷用途（參閱「在直接促銷中使用及將其個人資料提供予其他人士」部份），請在下列方格內□加上剔號（「✔」），本公司將不會使用閣下的個人資料作為直接促銷用途。I/WE ACKNOWLEDGE AND CONFIRM that I/we have read and understood the Personal Information Collection Statement (“PICS”). I/We confirm that I/we have been advised to read carefully the PICS, and I/we have read it carefully its effect and impact in respect of my/our personal data collected or held by the Company (whether contained in this application or otherwise). Based on the foregoing, I/we hereby give my/our acknowledgement and agree to the use and transfer of my/our personal data by AXA General Insurance Hong Kong Limited in accordance with the PICS, including the use and provision of my/our personal data for the purpose of direct marketing.
[Important: If you do not agree to the use and provision of your personal data for direct marketing as set out in the section “Use and provision of personal data in direct marketing”, please tick the box below and we will not use your personal data for direct marketing.]
本人/我們不同意貴公司根據「收集個人資料的聲明」使用和轉移本人/我們的個人資料作直接促銷用途（參閱「在直接促銷中使用及將其個人資料提供予其他人士」部份）及並不願意接收任何貴公司的推廣及直接促銷的材料。I/ we do not agree with the use and provision of my/our personal data for direct marketing purposes as set out above in the Personal Information Collection Statement (see “Use and provision of personal data in direct marketing”) and do not wish to receive any promotional and direct marketing materials.
佣金披露聲明 Commission DisClosure DeClaration
本人╱我們明白、確知及同意安盛保險有限公司（「貴公司」）會就本人╱我們購買及接受貴公司簽發的保單，於保單有效期內（包括續保期）向負責安排有關保單的獲授權保險經紀支付佣金。假如本人╱我們
為法人團體，代表本人╱我們簽署的獲授權人員並向貴公司確認他╱她已獲法人團體授權簽署。
本人╱我們亦明白貴公司必須取得本人╱我們以上的同意，才可以處理有關申請。
i/We understand, acknowledge and agree that, as a result of the my/our purchasing and taking up the policy to be issued by the Company, the Company will pay the authorized insurance broker commission during the continuance of the policy including renewals, for arranging the said policy. Where i/We am/are a body corporate, the authorized person who signs on my/our behalf further confirms to the Company that he or she is authorized to do so.
i/We further understand that the above agreement is necessary for the Company to proceed with the application.
本人謹此聲明及同意已獲相關人士授權及同意本人作出以上聲明、協議及授權。
i Hereby DeClare anD aGree that i have the full authority from and consent of the relevant Persons to make the above declarations, agreements and authorizations.
投保人簽署/公司印章及授權簽署（如以公司名義作投保人）Proposer’s Signature/Company Chop and Authorized Signature
(if the proposer is a business entity)（請勿於空白投保書上簽署 Do not sign a blank form）
日期 (日/月/年 ) Date (dd/mm/yyyy)
△ 如投保人或其授權人於申請有關保險或索償時，有意提供虛假資料或聲明，本公司有權拒絕賠償而有關保單亦等同無效。 If you or anyone acting on your behalf applies for this insurance or makes a claim knowing that the information supplied is untrue, we will not pay any claim and this policy shall be void.
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投保人須知 important notes to Proposer1 閣下必須在其知悉範圍內提供所有有關會影響保險公司於接納或釐定此保單條文的資料，如對應透露的資料有任何疑問，請即向本公司或閣下的保險代理 / 經紀查詢。我們建議閣下將有關的資料作記錄
(包括信件副本)，以備日後作參考之用。為確保閣下的利益，閣下應如實呈報所有有關資料，否則此保單將可能無法提供閣下所需的保障，甚至可能會導致此保單無效。 Any other facts known to you which are likely to affect acceptance or assessment of the insurance cover you are requesting must be disclosed. Should you have any doubt about what you should disclose,
do not hesitate to ask us or your insurance agent/broker. We recommend you keep a record (including copies of letters) for your future reference of any additional information given. Providing correct answers and making sure we are informed is for your own protection, as failure to disclose such information may mean that your policy will not provide you with the cover you require and may even invalidate the policy altogether.
2 本公司致力發展及改良產品的質素，務求滿足閣下個人保險上的需要。作為本公司的寶貴客戶，我們會時刻為閣下提供新產品及服務的最新消息。倘若閣下日後不希望收到此等資料，請來信通知本公司。 Our Company is committed to developing products to meet your personal insurance requirements. As you are a valued customer of our Company we will keep you informed of new products and services
when they become available. If you do not want to receive this information either now or in the future, please write and tell us.
「註：本中文簡譯，概以英文原文為準」
持咭人簽署 Cardholder’s Signature 日期 (日/月/年) Date (dd/mm/yyyy)
本人選擇以下列方式繳交保費港幣 元正I wish to pay my premium HK$ by
支票抬頭請填「安盛保險有限公司」Cheque payable to aXa General insurance Hong kong limited
VISA 咭 萬事達咭 MasterCard
本人授權安盛保險有限公司從本人上述的信用咭賬戶支取有關保險保單的保費。I hereby authorize AXA General Insurance Hong Kong Limited to charge my above credit card for the insurance premiums of this insurance policy.
持咭人姓名 Cardholder’s Name
信用咭有效期至 Credit Card Expiry Date月mm 年yyyy
信用咭號碼 Credit Card No
付款方法 Payment metHoD
HPO
-P-0
61
4-B
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