Accident insuranceFill out some info and we will be in touch with you shortly. Applicant Name * Gender * Male Female Age * Occupation and Title Email Phone * (###) ### #### Weekly income benefit from temporary total disablement Not applicable to housewife, volunteer, unemployed, retiree and Class Junior. No Yes Does any person to be covered suffer from any illness, mental disease, physical impairment, defects or deformities and/ or any condition affecting mobility, sight, speech and/ or hearing? * No Yes Does any person to be covered engage in or intend to engage in any hazardous activities (no matter is covered by the Policy or not), pursuits or duties? No Yes Has any person to be covered received any surgical and medical treatment or encountered any accidents during the past 5 years which have prevented he/ she from following his/ her occupations, business or pursuits for a period of longer than 7 days? No Yes Is any person to be covered holding other personal accident polices with a total aggregate sum insured of HK$1,000,000 or above? If yes, please state the name of the insurance company(ies), benefit and period of insurance. * No Yes Has any person to be covered ever made any claims in respect of life, accident or medical insurance during the last 5 years? * No Yes Has any person to be covered ever been declined of life or accident insurance, or been refused to renew your insurance, or had any special conditions imposed, or at a lowered sum insured? * No Yes Additional Info Thank you! General Insurance Travel insurance Post-natal carer insurance Motor insurance Home insurance Home renovation insurance Landlord insurance Pet insurance Domestic helper/ Maid insurance Accident insurance Corporate Insurance Commercial insurance Group medical insurance Event insurance Life Insurance Life/Critical illness/Medical insurance Saving insurance Other MPF
