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國際留學生保險估價
(
請用英語填寫 )
您的
稱謂
Mr
Mrs
Ms
Miss
電子郵件
地址
1. 姓 :
名 :
2. 生日 (日/月/年) :
3.國籍(原居地) :
4.
微信
號 :
5. 所欲讀之學校(校名) :
6.保險開始日期 (日/月/年) :
7. 住址 :
8. 目前所持的簽證VISA :
任何補充 :
9. 有無重大疾病?
Yes
No
(Any serious disease?)
10.過去既有病例 如心臟病, 糖尿病...等
Yes
No
(Any Pre-existing medical conditions?)
a. Suffering from a medical condition, illness or injury, including sports-related injuries?
Yes
No
b. Been hospitalised in the past 12 months?
Yes
No
c. Currently taking medication?
Yes
No
d. Ever received treatment for any type of heart ailment, circulatory condition, cancer
or back or spinal problems?
Yes
No
11.有否一起投保之家庭成員?
(yes 者保費會多另計)
Yes
No
(Any Family member want to insure? If yes, extra charge)
12.想投保帶個人財產, 例如手機,電腦...等
(yes 者保費會多另計)
Yes
No
(Any personal Items to be insured? eg. computer, mobile)
13.想投保多久
個
月
(Period of insurance you want to cover) / month
14.緊急聯絡人
Emergency contact
姓名 :
電話 :
15.
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