PART A
 
  Name:  
  Sex:  
  Company Name (if applicable):  
  Occupation:  
  Corresponding Address:  
  Contact Phone:  
  e-mail Address:  
  H.K.I.D. Card No.:  
  Date of Birth:   / / (YYYY/MM/DD)
       
  Name of Beneficiary:  
  I.D. Card No. of Beneficiary:  
  Relationship:  

 

PART B - (If your answer is ˇ§Yesˇ¨, please provide full details in the space provided.)
     
1. Does your occupation involve any manual work or hazardous activities or use of machinery ?
Yes No
  for details:
2. Are you receiving or contemplating any medical attention or surgical treatment or taking any medicine ?
Yes No
  for details:
3. 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 ?
Yes No
  for details:
4. Have you ever been refused your proposal for accident or medical insurance or subject to special terms & conditions ?

Yes No

  for details:
5. Are you join any dangerous sports ? (i.e : parachuting, mountaineering, scuba diving, bungee jumping etc.)
Yes No
  for details:
     
Declaration:
  I declare that to the best of my/our knowledge and belief  
  i) the foregoing answers are true;  
  ii) all material particulars affecting the assessment of the risk have been disclosed.
Yes No

 

Procedure for application :
1. Applicant can fax the pay-in-slip to 81671003 or mailing cheque to Canadian Insurance Company Ltd.
2. Applicant should receive confirmation of acceptance from us through telephone or e-mail.
3. Applicant should receive the membership card by mailing and the normal commencement date of the membership card should be on the first and sixteen of each month.
   
Payment methods :
1. By cheque : Payable to "Canadian Insurance Company Ltd." and send it to Rm 2301, Car Po Commerical. Building., 18-20 Lyndhurst Terrace, Central, H.K.
2. By deposit : Deposit fee to our Hang Seng Bank Account 275-083889-668 and fax the pay-in-slip to 81671003.
   

 

Enquire : 2912 2017