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Please complete the Application in English

Golfer Insurance Application Form

Name of Insured:
Date of Birth:
(dd/mm/yyyy)
HKID Card Number:

(For example : A123456(7), please input A1234567)
Correspondence Address:
Contact Tel No.:

Daytime -

Mobile -

E-Mail Address:

The policy and other documents will be sent to this email address. Please input the email address clearly.
We may contact you via your email address. By providing this information, you have agreed to this mode of communication between yourself and Shanghai Commercial Bank Ltd.
Policy Effective Date:
Plan Selection:


Plan Annual Premium Less 30% Online Application Discount Annual Premium Payable
Eagle Plan (A) HKD 770.00 HKD 231.00 HKD 539.00
Eagle Plan (B) HKD 900.00 HKD 270.00 HKD 630.00

Insurance Details:
Do you suffer or have you ever suffered from any serious illness, nervous or mental diseases,
physical disability or infirmity, impairment of vision or hearing?
 No  Yes

Have you ever submitted any claim to insurance company under similar policy in the past 3 years?
 No  Yes

Have your proposal for accident or medical insurance ever been refused or subject to special
terms and conditions?
 No  Yes

Special Offer

Offer Code:
Applicable to designated customer only #
# Please input Offer Code and press the button "Get Offer" to enjoy special offer.


Note:

  1. The Insured must be a Hong Kong Permanent Resident holding a valid HKID card.



Opt-out from Use of Personal Data in Direct Marketing :
Paofoong Insurance Company (Hong Kong) Limited (the "Company") may use your personal data for direct marketing but the Company cannot use your personal data for such purpose without your consent.
You should check ("✓") this box if you do not wish the Company to use your personal data in direct marketing.

The Company may provide your personal data to other persons including subsidiary companies of the Company for their use in direct marketing, which in any event the Company will not receive any money or other property in return and, whether or not such persons are members of the Company's group.

You should check ("✓") this box if you do not wish the Company to provide your personal data to any other persons for their use in direct marketing.

The above represents your present choice whether or not to receive direct marketing contact or information. This choice supersedes any choice communicated by you in any form to the Company prior to this application. If none of the above boxes are checked, it represents your consent to receive direct marketing contact or information.

Please note that your above choice applies to the direct marketing of the classes of products, services and/or subjects as set out in the Company's Personal Information Collection Statement (the "PICS"). You may refer to the PICS on the kinds of personal data which may be used in direct marketing and the classes of persons to which your personal data may be provided for them to use in direct marketing.



Declaration:

I/We have already read and understood the Important Notes , Declaration , Insurance Coverage, Exclusions and Terms and Conditions and Personal Information Collection Statement for the application of this Golfer Insurance Plan and agree to be bound by the same. I/We also confirm that I/we have read and understood the part titled "Opt-out from Use of Personal Data in Direct Marketing" above, and have made the choice(s) as specified therein.



Terms and Conditions Copyright (c) 2007 Shanghai Commercial Bank Ltd.. All rights reserved.