國際留學生保險估價 (請用英語填寫 )


您的稱謂          電子郵件地址  

1. 姓 :        名 : 

2. 生日 (日/月/年) :

3.國籍(原居地) :

4.手機號碼 :

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   月    
      
(Period of insurance you want to cover)    / month       

14.緊急聯絡人 
Emergency contact

     姓名 :        電話 :
    


15. 本人授權三姐妹代辦保險


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