A0702010-04_团体意外伤害保险投保书-GD省、SZ专用111024.docVIP

美亚团体意外伤害保险投保单Group Personal Accident Insurance Application Form Producer Code (Internal Use Only) — Producer Name (Internal Use Only) 投保单位资料Policyholder Information 投保单位 Name of Policyholder: 办公地址 Business Address: 邮政编码 Postcode: 业务性质 Nature of Business: 联络人 Contact Person: 联系电话 Contact Tel. No: 传真号码 Fax No: * 若需为关联公司投保，请另用纸张填写 Please provide details of associated or subsidiary companies in a separate sheet, if any. 保险单资料Policy Information (详细的保险计划以投保人最后确认的报价单为准Benefits details shall refer to the accepted quotation.) 保险期间Proposed Policy Period 由From: ________________ (年/月/日 YY/MM/DD) 至To: _________________ (年/月/日YY/MM/DD) 身故保险金受益人Beneficiary 详见名册As per the Attached List 总投保人数No. of Insured Person __ 人 Persons 投保人数/单位总人数Participating Percentage : _______ % 投保人员分类 Employee Classification 类别一a Class 1a 总经理级或以上 senior and top management 类别一b Class 1b 部门经理级或以上 department manager or above 类别一 Class 1 办公室员工 Office staff 类别二 Class 2 销售人员，工程师等 sales staff, engineer and etc 类别三 Class 3 工人(轻工业) Manual workers (light industry) 类别四 Class 4 工人(重工业) Manual workers (heavy industry) 被保险人总数 Total Number of Insured person 类别一a Class 1a __人 Persons 人均月收入__ average monthly income per person 类别一b Class 1b __人 Persons 人均月收入__ average monthly income per person 类别一 Class 1 __人 Persons 人均月收入__ average monthly income per person 类别二 Class 2 __人 Persons 人均月收入__ average monthly income per person 类别三 Class 3 __人 Persons 人均月收入__ average monthly income per person 类别四 Class 4 __人 Persons 人均月收入__ average monthly income per person 保障项目Benefits 各被保险人保险金额（人民币） Maximum Limit Per Insured Person(RMB) 计划一Plan One 计划二Plan Two 计划三Plan Three 意外残疾、烧伤及身故Accidental Death, Burns Dismemberment 意外医药补偿/每次意外最高限额 Accidental Medical Reimbursement / per Injury 意外每日住院Accidental Hospital Income （每一保险年度总赔偿日数以90天为限 up to 90 days per policy year） 意外伤害收入保障 Temporary Total Disablement 免赔日数 14 天/days30 天/days 最高給付数 /weeks 26