更靈活及全面保障
More Flexible &
Comprehensive
CARING僱員醫療保險計劃
CARING Employee Medical Insurance Plan
EB-EMIP-BR 11.2015
Undoubtedly employees are one of the most important assets of the company and a stable and
productive workforce is the key to business success. A comprehensive medical insurance plan can
help to provide a good protection for the employees against high medical expenses when medical
care is required. We fully understand the need of employers to protect this precious asset at the most
competitive premium cost. CARING Employee Medical Insurance Plan, flexible and comprehensive in its
plan benefits, is specially designed to best suit the needs of you and your employees.
毫無疑問，員工乃公司最重要的資產之一。穩定及具生產力的員工隊伍是公司邁向成功的重要因素。
一個全面的醫療保險計劃能在需要時為員工提供週全的醫療保障，以應付高昂的醫療費用。我們充分
了解僱主的需要，為此，特別精心設計了CARING 僱員醫療保險計劃，只需付出合理的保費，就能照顧
您及您的員工各方面的需要。
Flexible Plan Design
計劃設計靈活
• Minimum number of employees as low as 4
• 僱員人數可低至 4 名
• Waiver of medical underwriting and health declaration
(at least 4 participating employees during application)
• Options for supplementary major medical, outpatient,
and dental benefits (at least 4 participating employees)
• Option for dependant coverage (at least 4 participating
employees)
• Flexible combinations of hospitalisation, outpatient and
• 無須醫療批核及健康申報 ( 最少 4 名僱員同時投保 )
• 附加額外醫療保障門診及牙科保障可供選擇
( 最少 4 名僱員參與 )
• 提供家屬保障之選擇（最少 4 名僱員參與）
• 住院門診及牙科保障可靈活配搭，以迎合不同僱員
類別的需要
• 設有富衛醫療咭以享用門診醫療網絡服務
dental benefits for different classes of employees
• Offer of FWD healthcare card to enjoy the outpatient
panel network services
Comprehensive Benefits
全面保障
• No minimum hours of hospital confinement
• 不設最低住院時數限制
• Day case surgery and clinical operation are covered
• 保障範圍包括於門診或日間進行之小手術
• Daily cash benefit for confinement in general ward of
• 入住香港醫院管理局轄下醫院之大房設有每日住院現金保障
hospitals under Hong Kong Hospital Authority
• 24-hour worldwide medical coverage (including
guarantee of hospital admission deposit in designated
hospital in Mainland China) and free emergency
assistance services
• A choice of 80% or 100% reimbursement for
supplementary outpatient benefits with offer of
Chinese medicine practitioner benefits (including
bone setting and acupuncture). Doctor referral
letter is waived for 6 specialties (Otorhinolaryngologist,
Ophthalmologist, Dermatologist, Orthopaedist &
Traumatologist, Paediatrics and Gynaecologist)
• Supplementary dental benefits in various coverage
including 1 visit of routine oral examination per year
• 24 小時全球性醫療保障 ( 包括於中國內地指定醫院支付入
院的按金保證 )，及免費緊急支援服務
• 可選擇 80% 或 100% 賠償率之附加門診保障，門診保障提
供中醫治療 ( 包括跌打及針灸治療 )，當中於 6 項專科 ( 耳
鼻喉科、眼科、皮膚科、骨科、兒科及婦科 ) 索償時無須提
供醫生轉介信
• 亦可選擇不同牙科保障，包括每年 1 次的例行口腔檢查
Ubiquitous Customer Support
全天候客戶支援
• Only dial one single number which serves 24 hours by 7 days
• 只須致電一個綜合 24 小時熱線，便可以查詢您的富衛保單
for enquiries of insurances in FWD
• Download FWD eServices Mobile App to search panel doctors
around you anytime anywhere
• Review via mobile app and website including benefits schedule
and claim status. Members can also download forms online
• Receive claim settlement notification with claim details at a
glance directly through app’s push notification and email
• 下載富衛 eServices 流動應用程式，隨時隨地輕易搜尋附
近的網絡醫生位置及詳情
• 可隨時於流動應用程式及網上查閱資料，包括保障範圍
及索償狀況等，及下載表格
• 直接收到流動應用程式提示及電郵通知有關理賠詳情，
方便快捷
Download
立即下載
FWD eServices 富衛 eServices
App now!
流動應用程式 !
24-Hour Worldwide Emergency
Assistance Services
In case emergency assistance is needed while traveling abroad
for a period not exceeding 90 days, the Worldwide Emergency
Assistance Services provide the following services:
24小時全球緊急支援服務
若受保人出外旅遊或公幹時遇上緊急事故，而旅程期間不
超過 90 天，緊急支援可提供以下服務 :
• 24 小時電話諮詢服務
• 24-hour hotline service
• 緊急醫療撤離及遣返 ( 高達 $1,000,000 美元 )
• Emergency medical evacuation and repatriation (up to
• 提供高達 $5,000 美元之入院按金保證
US$1,000,000)
• Guarantee of any required hospital admission deposit up to
US$5,000
• Compassionate visit for more than 7 days of overseas
hospitalisation
• 如在外地住院超過 7 天，可安排一位親屬前往探望
• 可安排未成年子女返國或原居地
• 運送遺體返國或原居地 ( 高達 $1,000,000 美元 )
• 中國緊急醫療支援服務
• Return of minor children to home country or usual country
of residence
• Transportation of mortal remains (up to US$1,000,000)
• Emergency Medical Assistance Services in China
Main Exclusions
主要不承保項目
Main exclusions include congenital conditions, pregnancy, sexually
主要不承保項目包括：先天性疾病懷孕性病愛滋病
transmitted diseases, AIDS, cosmetic treatments, routine physical
examinations, mental disorders, alcoholism or drug abuse,
self-inflicted injuries, war, nuclear fallout, pre-existing conditions
整容手術例行體格檢查精神病酗酒或濫用藥物自我
毀傷戰爭核漏事件，受保人在受保生效日期前90日內
for which the Insured Person received medical treatment during
曾接受過醫療或診治之傷病 ( 除非受保人已在此保單下受
the 90 days prior to the date he first becomes insured under this
保連續超過12個月 )。
Policy (unless such Insured Person affected by these conditions has
been insured under this Policy continuously for 12 months).
This brochure is designed to briefly describe the CARING Employee Medical Insurance Plan. The final
interpretation of any specific provision or its applicability is subject to the provisions of the Group Medical
Insurance Policy issued by FWD General Insurance Company Limited.
此小冊子乃 CARING 僱員醫療保險計劃之簡介，計劃的細則及條款應以富衛保險有限公司發出之團體
醫療保單為準。
Basic Hospitalisation Benefits 基本住院保障
Plan Level 計劃類別
Cover Limit (HK$) 保障金額 (港幣$)
CHG1
CHG2
CHG3
CHG4
CHG5
Ward
大房
Ward
大房
Semi-Private
二等房
Semi-Private
二等房
Private
私家房
Hospital Room & Board per day (Max.180 days)
每日住院及膳食費（最高賠償180天）
$400
$600
$1,000
$1,500
$2,500
Physician’s Visit per day (Max.180 days)
每日醫生巡房費（最高賠償180天）
$400
$600
$1,000
$1,500
$2,500
$7,000
$10,000
$14,000
$20,000
$30,000
Surgeon’s Fee 外科手術費
Complex Operation 複雜手術
Major Operation 嚴重手術
Intermediate Operation 普通手術
Minor Operation 簡單手術
Miscellaneous Hospital Services 醫院雜項費
$42,000
$14,000
$7,000
$2,800
$54,000
$18,000
$9,000
$3,600
$66,000
$22,000
$11,000
$4,400
$84,000
$28,000
$14,000
$5,600
$105,000
$35,000
$17,500
$7,000
Anaesthetist’s Fee 麻醉師費
Complex Operation 複雜手術
Major Operation 嚴重手術
Intermediate Operation 普通手術
Minor Operation 簡單手術
$12,600
$4,200
$2,100
$840
$16,200
$5,400
$2,700
$1,080
$19,800
$6,600
$3,300
$1,320
$25,200
$8,400
$4,200
$1,680
$31,500
$10,500
$5,250
$2,100
Operating Theatre Fee 手術室費
Complex Operation 複雜手術
Major Operation 嚴重手術
Intermediate Operation 普通手術
Minor Operation 簡單手術
$12,600
$4,200
$2,100
$840
$16,200
$5,400
$2,700
$1,080
$19,800
$6,600
$3,300
$1,320
$25,200
$8,400
$4,200
$1,680
$31,500
$10,500
$5,250
$2,100
Specialist’s Fee 專科治療費
$2,000
$3,000
$5,000
$7,000
$10,000
Intensive Care Unit per day (Max.15 days)
每日深切治療費（最高賠償15天）
$1,500
$2,000
$3,000
$4,000
$6,000
Home Nursing per day (Max.60 days)
每日家庭看護費（最高賠償60天）
$200
$300
$500
$600
$700
Emergency Outpatient Treatment 緊急門診費
(Outpatient treatment in a Hospital within 24 hours of an injury)
(意外發生後24小時內之醫院門診部之治療費)
$500
$800
$1,200
$1,600
$2,000
Post Hospitalisation Treatment 出院後的治療費
(Follow-up treatment within 31 days after discharge from Hospital)
(出院後31日內之跟進治療費)
$500
$800
$1,200
$1,600
$2,000
$255,700
$365,000
$562,000
$800,600
$1,244,000
$200
$300
$500
$750
$1,000
Overall Limit Per Disability 每次病症最高賠償限額
Daily Cash Benefit (for confinement in general ward of Hospital
Authority’s Hospital in Hong Kong) (Max.60 days)
每日住院現金保障（入住香港醫院管理局轄下醫院之大房）
(最高賠償60天)
Emergency Assistance Services 緊急支援服務
Evacuation / Repatriation 醫療撤離及遣返服務
US$1,000,000
Supplementary Major Medical Benefits 附加額外醫療保障
Plan Level 計劃類別
Cover Limit (HK$) 保障金額 (港幣$)
Maximum Limit Per Disability 每症最高賠償額
CMG1
CMG2
CMG3
CMG4
CMG5
Ward
大房
Ward
大房
Semi-Private
二等房
Semi-Private
二等房
Private
私家房
$50,000
$60,000
$80,000
$100,000
$150,000
Deductible 自付額
$1,000
$1,000
$1,000
$1,000
$1,000
Reimbursement 賠償率
80%
80%
80%
80%
80%
The Supplementary Major Medical Benefits provides additional benefits to the
Basic Hospitalisation Benefits. If the medical expenses during hospital confinement
incurred under Basic Hospitalisation Benefits items exceed the cover limit, 80% of
the excess amount after deductible will be reimbursed, in which, the excess amount
incurred for the Hospital Room & Board and Physician's Visit Benefits, can be
reimbursed regardless of the number of days of the confinement.
此附加額外醫療保障為基本住院保障支出提供額外保障。若住院期間的醫療費用
超過基本住院保障項目之最高賠償額，餘額於扣除自付額後可獲 80% 賠償，而當
中之每日住院及膳食費及每日醫生巡房費不受最高賠償日數限制，均可獲得賠償。
Note:
If option of Supplementary Major Medical Benefits is taken, the level of benefit
must correspond to the same level with Basic Hospitalisation Benefits.
If confinement is at higher accommodation level than the insured benefit level, the
reimbursement shall be reduced as follow:
Ward to Semi-Private : 50%
Ward to Private
: 25%
Semi-Private to Private : 50%
附註:
如選擇附加額外醫療保障，保障等級必須與基本住院保障之等級相同。
如入住之住房等級高於保障等級，賠償率將作以下調整:
大房升至二等房
: 50%
大房升至私家房
: 25%
二等房升至私家房
: 50%
Supplementary Outpatient Benefits
附加門診保障
Supplementary Dental
Benefits 附加牙科保障
Plan Level 計劃類別
Plan Level 計劃類別
COG1/CPG1 COG2/CPG2 COG3/CPG3 COG4/CPG4 COG5/CPG5
Cover Limit (HK$) 保障金額 (港幣$)
Consultation at Physician’s Office per visit
per day
醫生診所治療費(每日一次)
Reimbursement 賠償率
Network co-payment per visit#
每次網絡自付費用#
Chinese Medicine Practitioner’s (Including
Bonesetter’s & Acupuncturist’s Treatment)
per visit per day (Max.10 visits per year)
中醫、跌打及針灸治療費(每日一次)
(每年最多10次)
Reimbursement 賠償率
Network co-payment per visit#
每次網絡自付費用#
$140
$160
$180
$250
$350
80% / 100%
$40 / $30
80% / 100%
$20 / $20
80% / 100%
$0 / $0
80% / 100%
$0 / $0
80% / 100%
$0 / $0
Specialist’s Consultation per visit per day
(Max.10 visits per year)
專科醫生治療費(每日一次)(每年最多10次)
Reimbursement 賠償率
Network co-payment per visit#
每次網絡自付費用#
Diagnostic X-Ray & Laboratory Tests per year
每年X光檢驗及化驗費
Reimbursement 賠償率
Cover Limit (HK$)
保障金額 (港幣$)
$350
Routine Oral Examination
(1 visit per year)
例行口腔檢查 (每年1次)
Reimbursement 賠償率
$120
$130
$150
$200
$250
80% / 100%
$50 / $40
80% / 100%
$40 / $30
80% / 100%
$20 / $10
80% / 100%
$0 / $0
80% / 100%
$0 / $0
Max. 30 visits per year for the above 2 items 以上2項治療每年合共最多30次
Physiotherapist’s & Chiropractor’s
Treatment per visit per day (Max.10 visits
per year)
物理治療師及脊椎治療師之治療費
(每日一次)(每年最多10次)
Reimbursement 賠償率
Network co-payment per visit#
每次網絡自付費用#
CDG1 CDG2
$210
$240
$270
$300
$350
80% / 100%
$70 / $50
80% / 100%
$50 / $20
80% / 100%
$20 / $0
80% / 100%
$0 / $0
80% / 100%
$0 / $0
$280
$320
$360
$500
$700
80% / 100%
$90 / $80
80% / 100%
$60 / $40
80% / 100%
$20 / $0
80% / 100%
$0 / $0
80% / 100%
$0 / $0
$1,500
$1,800
$2,200
$3,000
$4,000
80% / 100%
80% / 100%
80% / 100%
80% / 100%
80% / 100%
100%
X-rays required prior to the
performance of dental service
(Each film)
牙科服務前之X光檢驗 (每片)
$100
Reimbursement 賠償率
Abscesses (Each abscess)
牙齦膿腫 (每膿腫)
$350
$350
$500
80%
$500
$350
Reimbursement 賠償率
Overall Maximum
Limit Per Year
整體每年最高賠償限額
$500
80%
Reimbursement 賠償率
Extractions (Each tooth)
脫牙 (每顆牙齒)
$150
80%
Reimbursement 賠償率
Filings (Each tooth)
補牙 (每顆牙齒)
$500
80%
$3,000
$5,000
Note : Written referral by the attending physician is required for Physiotherapist's & Chiropractor's Treatment, Specialist's Consultation, Diagnostic X-ray & Laboratory Tests, Prescribed Medicines & Drugs
(Consultation of Otorhinolaryngologist, Ophthalmologist, Dermatologist and Orthopaedist & Traumatologist, Paediatrician and Gynaecologist can be waived).
Network doctors include General Practitioners, Physiotherapist, Chiropractor, Specialist and Chinese Medicine Practitioner excluding acupuncture and Chinese bonesetter treatment.
附註： 物理治療師及脊椎治療師治療費、專科診治費、X 光檢驗及化驗費及處方藥物費須由主診醫生以書面推薦才可獲得賠償 ( 耳鼻喉科醫生、眼科醫生、皮膚科醫生、骨科醫生、兒科醫生及
婦科醫生之專科可獲豁免 )。
網絡醫生只限普通科醫生、物理治療師、脊椎治療師、專科醫生及中醫師，並不包括針灸及跌打治療。
# Applicable for consultation of network doctors (includes 3 days of medication or 2 packs of Chinese Medicines). 適用於網絡醫生診療費 ( 包括三天西藥或中藥兩劑 )
Annual Premium Table (HK$) 每年保費 (港幣$)
Basic Hospitalisation Benefits
基本住院保障
Age^
年齡^
0# - 18
19 - 40
41- 64
65- 69
Supplementary Major Medical Benefits
附加額外醫療保障
Age^
年齡^
Age^
年齡^
No. of
insured
受保人數
CMG2
Annual
premium
每年保費
COG1
No. of
insured
受保人數
No. of
insured
受保人數
No. of
insured
受保人數
CPG1
$2,241
$1,792
$1,792
$2,241
CDG1
No. of
insured
受保人數
0# - 18
19 - 69
No. of
insured
受保人數
Annual
premium
每年保費
No. of
insured
受保人數
Annual
premium
每年保費
No. of
insured
受保人數
$2,543
$2,035
$2,035
$2,543
Annual
premium
每年保費
CMG4
No. of
insured
受保人數
Annual
premium
每年保費
COG4
No. of
insured
受保人數
Annual
premium
每年保費
$497
$621
No. of
insured
受保人數
CPG4
Annual
premium
每年保費
$2,868
$2,294
$2,294
$2,868
Annual
premium
每年保費
$714
$892
^ Age of the last birthday. 對上一次生日的年齡。
#“0”year old means 15 days of age.「0」歲指出生滿15日。
Note 附註：
Child include any unmarried children aged more than 14 days but less than 19 years, or up to the age of 25 years if registered as full time student (please provide evidence).
子女包括任何未婚而年齡超過十四日但少於十九歲之子女、如屬全日制學生、可包括至二十五歲 (請附上有效證明文件)。
Total Annual Premium (HK$) 全年保費總額 (港幣$) :
CMG5
No. of
insured
受保人數
$3,928
$3,142
$3,142
$3,928
Annual
premium
每年保費
$1,363
$1,703
$2,111
$5,278
COG5
No. of
insured
受保人數
$3,299
$2,639
$2,639
$3,299
No. of
insured
受保人數
Annual
premium
每年保費
$3,576
$4,469
$5,022
$15,066
$793
$991
$1,229
$3,073
CDG2
Annual
premium
每年保費
CHG5
No. of
insured
受保人數
$2,080
$2,601
$2,923
$8,769
$2,409
$1,927
$1,927
$2,409
CPG3
Annual
premium
每年保費
Annual
premium
每年保費
$541
$676
$866
$2,164
$2,136
$1,709
$1,709
$2,136
No. of
insured
受保人數
CHG4
No. of
insured
受保人數
$1,422
$1,777
$1,997
$5,990
COG3
Annual
premium
每年保費
CPG2
Annual
premium
每年保費
Annual
premium
每年保費
CMG3
Annual
premium
每年保費
COG2
Annual
premium
每年保費
No. of
insured
受保人數
$370
$461
$590
$1,476
$1,882
$1,505
$1,505
$1,882
No. of
insured
受保人數
CHG3
Annual
premium
每年保費
$970
$1,212
$1,362
$4,085
$268
$334
$427
$1,068
0# - 18
19 - 40
41- 64
65- 69
Supplementary Dental Benefits
附加牙科保障
Age^
年齡^
CMG1
No. of
insured
受保人數
0# - 18
19 - 40
41- 64
65- 69
Supplementary Outpatient Benefits
(100% Reimbursement)
附加門診保障(賠償率100%)
CHG2
Annual
premium
每年保費
$701
$877
$985
$2,956
0# - 18
19 - 40
41- 64
65- 69
Supplementary Outpatient Benefits
(80% Reimbursement)
附加門診保障(賠償率80%)
Age^
年齡^
CHG1
No. of
insured
受保人數
Annual
premium
每年保費
$4,538
$3,631
$3,631
$4,538
CPG5
No. of
insured
受保人數
Annual
premium
每年保費
$5,402
$4,322
$4,322
$5,402
CORPORATE OVERVIEW
企業概覽
FWD Group spans Hong Kong & Macau, Thailand, Indonesia and the
Philippines, offering life and medical insurance, employee benefits, pension,
and general insurance across a number of its markets.
富衛集團業務遍佈香港、澳門、泰國、印尼及菲律賓，為客戶提
FWD is focused on creating fresh customer experiences, with easy-tounderstand products, supported by leading digital technologies. Through this
customer-led approach, FWD will achieve its vision to become the leading
pan-Asian insurer that changes the way people feel about insurance.
Established in Asia in 2013, FWD is the insurance business arm of investment
group, Pacific Century Group.
Our Operations
供人壽及醫療保險、僱員福利、退休金及一般保險。
富衛致力以簡單、貼心的產品以及利用數碼科技，為客戶創造嶄
新體驗。富衛秉持以客為先的服務理念及方針，矢志成為泛亞洲
區領先的保險公司，實現創造保險新體驗的願景。
富衛於 2013 年在亞洲成立，是投資集團「盈科拓展集團」的保險
業務公司。
業務運作
Life Insurance
As one of the major authorised insurers in Hong Kong and Macau, FWD Life
Insurance Company (Bermuda) Limited and FWD Life Insurance Company
(Macau) Limited are committed to offering customers a comprehensive range
of quality insurance products and services. Our extensive portfolio of
insurance products includes individual life, group life, medical, education,
retirement, and savings schemes, which are tailored to meet customers’ needs
throughout the different stages of their lives.
人壽保險
General Insurance#
FWD General Insurance Company Limited provides quality services to
individual and corporate clients in the local market. The company offers
various types of insurance products, ranging from property, household,
marine, motor vehicles, individual and group medical, personal accident to
travel etc.
一般保險 #
作 為 香 港 及 澳 門 主 要 獲 授 權 的 保 險 公 司 之 一， 富 衛 人 壽 保 險
(百慕達) 有限公司及富衛人壽保險 (澳門) 股份有限公司致力為客
戶提供全面及優質的保險產品及服務。我們提供全方位的保險產
品，包括個人壽險、團體人壽、醫療保險、教育、退休計劃以及
儲蓄計劃等，充份照顧客戶於人生各階段的不同需要。
富衛保險有限公司致力為本港企業及個人客戶提供多元化的保險
產品和優質服務，產品包括財產、家居、貨運、汽車、個人及團
體醫療保障、個人意外以至旅遊保險等。
Employee Benefits#
FWD Pension Trust Limited is committed to contributing its expertise to
provide quality pension trust services (MPF and ORSO) to corporate and
individual customers.
僱員福利 #
Financial Planning#
FWD Financial Planning Limited is committed to setting the standard as a
market leader in Independent Financial Advice, attracting the best financial
advisers in the industry to deliver quality financial planning advice to clients.
The customer-centric focus of the company ensures that clients receive the
most suitable solution from advisers to meet their financial needs.
財務策劃 #
#
#
operates in Hong Kong only
富衛退休金信託有限公司致力以其專才為企業及個人客戶提供優
質的退休金計劃信託服務 (強積金及公積金)。
富衛財務策劃有限公司致力建構獨立理財建議的行業領導者標準，
以及吸納行業中最優秀的理財顧問，為客戶提供專業的財務意見。
我們秉承「以客為先」的服務理念，確保客戶獲得最適切的理財
方案。
僅於香港提供
CARING Employee Medical Insurance Plan ƉƉůŝĐĂƟŽŶ Form
CARING ᾯ⎟恩䔀ẛ敨壆⅁䏱妉圦
E-mail 方徳 ĞŵƉůŽLJĞĞďĞŶĞĮƚƐΛĨǁĚ͘ĐŽŵ
Fax ά䗝 2850 3003
Please complete in Block LeƩĞrs 妉ᶣ㨡㠵✩⪩
Details of Applicant 䏱妉ᵸ失⾃
Name of Company ‪⊶⋋䣯
Business Nature 㠫↗⻥宨
ŽŶƚĂĐƚWĞƌƐŽŶΘWŽƐŝƟŽŶ伭䰟ᵸ⊈‴伵ḋ
Fax
Tel
Email Address
Address ◮◾
Period of Insurance ㅓẛ㔀㗝 (DD/MM/YYYY 㒣㗆ⴲ)
īĞĐƟǀĞĨƌŽŵ䏝㐆㗝䏯
/
/
Total no. of Employeesᾯ⎟䳻ᵸ㐶
to 傱
/
/
Eligibility⊁⅞宅㛺
&Žƌy/^d/E'ƉĞƌŵĂŶĞŶƚĨƵůůͲƟŵĞĞŵƉůŽLJĞĞ 䊼ᶹ…伵ᾯ⎟
&Žƌ&hdhZƉĞƌŵĂŶĞŶƚĨƵůůͲƟŵĞĞŵƉůŽLJĞĞ⫅Ṅ…伵ᾯ⎟
KŶƉŽůŝĐLJĞīĞĐƟǀĞĚĂƚĞẛ⑬䏝㐆㒣⊁⅞
months of employment
/ŵŵĞĚŝĂƚĞĐŽǀĞƌĂŌĞƌ
⊕ᾯ
On employment date ⊕ᾯ㒣⊁⅞
months of employment
/ŵŵĞĚŝĂƚĞĐŽǀĞƌĂŌĞƌ
ỉ㗆⹊⊁⅞
⊕ᾯ
ỉ㗆⹊⊁⅞
WůĂŶ>ĞǀĞů壆⅁䨇䯘
Plan no.
壆⅁
e.g.
ὲ
,ŽƐƉŝƚĂůŝƐĂƟŽŶ
⚸㗪ḍ攠ẛ敚
CHG1
Supplementary
Major Medical
攂⅞朋⟔恩䔀ẛ敚
Supplementary
KƵƚƉĂƟĞŶƚ
ĞŶĞĮƚƐ
攂⅞搾壸ẛ敚
CMG1
CPG1
Dependant
ŽǀĞƌĂŐĞ
(Yes/No)
ůĂƐƐŝĮĐĂƟŽŶŽĨŵƉůŽLJĞĞdLJƉĞ
ᾯ⎟朜⃣
Supplementary
ĞŶƚĂůĞŶĞĮƚƐ
;Ğ͘Ő͘:ŽďƉŽƐŝƟŽŶṉ伵ḋ)
⩴⬪ẛ敚
㗇⋤
攂⅞䄗䢏ẛ敚
CDG1
ůů^ƚĂīヾ㗇ᾯ⎟/Managers 䱑䋄/Directors 匡ᵉ
Yes/No
㗇⋤
1.
Yes/No
㗇⋤
2.
Yes/No
㗇⋤
3.
Yes/No
㗇⋤
Plan Rules壆⅁⩆℅
ϭ͘ dŚŝƐŝŶƐƵƌĂŶĐĞƉůĂŶŝƐŽŶůLJĂƉƉůŝĐĂďůĞƚŽĐŽŵƉĂŶLJƌĞŐŝƐƚĞƌĞĚŝŶ,ŽŶŐ<ŽŶŐǁŝƚŚĂƚůĞĂƐƚϰƉĂƌƟĐŝƉĂƟŶŐĞŵƉůŽLJĞĞƐ͘
㭋ῄ暑姯≪⏑恐䔏㖣榀㸖娢ⅱ⎱凚⯸㛰⛂⏴⃘Ⓢ⎪凮Ḳ⅓⏟䔚媲˛
Ϯ͘ dŚĞ ĞŵƉůŽLJĞĞƐ ĂŶĚͬŽƌ ƚŚĞŝƌ ƐƉŽƵƐĞƐ ǁŚŽ ĂƌĞ ƵŶĚĞƌ ƚŚĞ ĂŐĞ ŽĨ ϲϵ ĂŶĚ ƚŚĞ ĞŵƉůŽLJĞĞƐ͛ ƵŶŵĂƌƌŝĞĚ ĐŚŝůĚƌĞŶ ǁŚŽ ĂƌĞ ŽǀĞƌ ƚŚĞ ĂŐĞ ŽĨ ϭϰ ĚĂLJƐ ďƵƚ ƵŶĚĞƌ
ϭϵLJĞĂƌƐĂŶĚƚŚŽƐĞĂƚƚŚĞĂŐĞŽĨϭϵďƵƚƵŶĚĞƌϮϱǁŚŽĂƌĞƌĞĐĞŝǀŝŶŐĨƵůůƟŵĞĞĚƵĐĂƟŽŶĂƌĞĞůŝŐŝďůĞƚŽĞŶƌŽůů͘
⅔⌨Ṅ㭙ỌᷲḲ⃘Ⓢ⎱ㇽ⅝愴⁝⎱ㇽ⃘ⓈḲ㜑⩁俳⹛潈嵬怵⌨⛂㗌Ἥ㜑㻦⌨Ṅ㭙˚⎱ⷙ㻦⌨Ṅ㭙Ἥ㜑㻦ṳ⌨ṻ㭙俳㭊✏㎌⎾⅏㗌∝㕀備䙫⬷⥚✮⏯ḵ岮㠣
⎪⊇˛
ϯ͘ ůůĞůŝŐŝďůĞĞŵƉůŽLJĞĞƐŵƵƐƚƉĂƌƟĐŝƉĂƚĞŝŶƚŚĞƉůĂŶ ĂŶĚďĞĂĐƟǀĞůLJĂƚǁŽƌŬ͘
㈧㛰⏯岮㠣⃘Ⓢ⾬柯⎪⊇㭋姯≪⎱㭊⸟ᷱ䏔˛
ϰ͘ ůůĞůŝŐŝďůĞĞŵƉůŽLJĞĞƐǁŝƚŚƐĂŵĞĐůĂƐƐŝĮĐĂƟŽŶŽĨŵƉůŽLJĞĞdLJƉĞŵƵƐƚĞŶƌŽůůŝŶƚŚĞƐĂŵĞƉůĂŶ͘
㈧㛰⏳⃘ᷧⓈ桅∌Ḳ⏯岮㠣⃘Ⓢ⾬柯⎪凮⏳ᷧ姯≪˛
ϱ͘ /ĨĚĞƉĞŶĚĂŶƚĐŽǀĞƌĂŐĞŝƐƉƌŽǀŝĚĞĚ͕ĂůůĞůŝŐŝďůĞĚĞƉĞŶĚĂŶƚƐŵƵƐƚĞŶƌŽůůŝŶƚŚĞƉůĂŶ͘
⥩㛰⮝ⱓῄ暃Ə㈧㛰⏯岮㠣⮝ⱓ✮⾬柯⎪⊇㭋姯≪˛
ϲ͘ &ŽƌŽƉƟŽŶĂů^ƵƉƉůĞŵĞŶƚĂƌLJDĂũŽƌDĞĚŝĐĂů͕KƵƚƉĂƟĞŶƚŽƌĞŶƚĂůĞŶĞĮƚƐ͕ƚŚĞŶƵŵďĞƌŽĨƉĂƌƟĐŝƉĂƟŶŐĞŵƉůŽLJĞĞƐŵƵƐƚŶŽƚďĞůĞƐƐƚŚĂŶϰ͘
⥩柯䔚媲昫⊇栴⣽憒䘩ῄ暃˚敧娡ㇽ䉀䦸ῄ暃Ə⎪⊇⃘Ⓢ䙫ạ㕟⾬柯ᷴ⯸㖣⛂ạ˛
EB-EMIP-APP 10.2015
CARING Employee Medical Insurance Plan ƉƉůŝĐĂƟŽŶ Form
CARING ᾯ⎟恩䔀ẛ敨壆⅁䏱妉圦
The Applicant understands and agrees that䔚媲ạ㗵䙤⎱⏳ヶ
1. The Applicant shall pay all the premium and all eligible employees and their dependants (if applicable) shall enroll in the plan.
ῄ岢⾬柯䔘䔚媲ạ㔖ếƏỌ⎱㈧㛰⏯岮㠣䙫⃘Ⓢ⎱⅝⮝ⱓ⥩恐䔏⾬柯⎪⊇㛰旃姯≪˛
2. dŚĞƉŽůŝĐLJƐŚĂůůƚĂŬĞĞīĞĐƚƵƉŽŶĂĐĐĞƉƚĂŶĐĞŽĨƚŚŝƐƉƉůŝĐĂƟŽŶĂŶĚƚŚĞĞīĞĐƟǀĞĚĂƚĞƐŚĂůůďĞĂƉƉƌŽǀĞĚďLJ&t'ĞŶĞƌĂů/ŶƐƵƌĂŶĐĞŽŵƉĂŶLJ>ŝŵŝƚĞĚ;͟&t͟Ϳ͘
ῄ▕⯮㖣⮳塂ῄ暑㛰昷⅓⏟˥⮳塂˦㎌䳴㭋䔚媲⎱䔆㔯㗌㜆䔘⮳塂㉠㠟⽳㈴㭊⻶䔆㔯˛
ϯ͘ dŚĞŝŶƐƵƌĂŶĐĞĐŽǀĞƌĂŐĞŽĨĞĂĐŚŝŶƐƵƌĞĚƐŚĂůůƚĂŬĞĞīĞĐƚŝŵŵĞĚŝĂƚĞůLJĂŌĞƌƚŚĞĂƉƉůŝĐĂƟŽŶĨŽƌŵŝƐĂĐĐĞƉƚĞĚďLJ&t͘
⎾ῄạḲῄ暃⯮㖣⮳塂㎌䳴⅝⎪⊇塏㠣⽳㈴㭊⻶䔆㔯˛
ϰ͘ hƉŽŶĂƉƉƌŽǀĂůŽĨƚŚŝƐƉƉůŝĐĂƟŽŶ͕ƚŚŝƐĂƉƉůŝĐĂƟŽŶĨŽƌŵƐŚĂůůĨŽƌŵƉĂƌƚŽĨƚŚĞĐŽŶƚƌĂĐƚďĞƚǁĞĞŶƚŚĞWŽůŝĐLJŚŽůĚĞƌĂŶĚ&t͘
㭋䔚媲䵺㉠㠟⽳Ə㭋䔚媲塏⯮ㇷ䂡㉼ῄ⅓⏟凮⮳塂㈧姩䪲䙫⏯䳫Ḳᷧ惏Ụ˛
dŚĞƉƉůŝĐĂŶƚĨƵƌƚŚĞƌĚĞĐůĂƌĞƐĂŶĚĐŽŶĮƌŵƐƚŚĂƚ䔚媲ạ偙㗵⎱䢡婴
ϭ͘ dŚĞŝŶĨŽƌŵĂƟŽŶƌĞůĂƟŶŐƚŽƚŚĞĞůŝŐŝďůĞĞŵƉůŽLJĞĞƐĂŶĚͬŽƌƚŚĞŝƌĚĞƉĞŶĚĞŶƚƐ;ŝĨĂƉƉůŝĐĂďůĞͿƉƌŽǀŝĚĞĚŝŶƚŚŝƐƉƉůŝĐĂƟŽŶŝƐĐŽƌƌĞĐƚƚŽƚŚĞďĞƐƚŽĨŵLJͬŽƵƌ
knowledge; and
Ⱈ㜓ạ␥䬰㈧䟌Ə✏㭋䔚媲㎷ᾂ䙫⃘Ⓢ⎱ㇽ⅝⮝ⱓ⥩恐䔏䙫岮㖀✮ⱓ㭊䢡䄈媋⎱
2. dŚĞƉƉůŝĐĂŶƚŚĂƐĐŽŵƉůŝĞĚǁŝƚŚƚŚĞWĞƌƐŽŶĂůĂƚĂ;WƌŝǀĂĐLJͿKƌĚŝŶĂŶĐĞĂŶĚŚĂǀĞŽďƚĂŝŶĞĚƚŚĞĐŽŶƐĞŶƚĨƌŽŵƚŚĞĞůŝŐŝďůĞĞŵƉůŽLJĞĞƐĂŶĚͬŽƌƚŚĞŝƌĚĞƉĞŶĚĞŶƚƐ
;ŝĨĂƉƉůŝĐĂďůĞͿĨŽƌƚŚĞƚƌĂŶƐĨĞƌŽĨƚŚĞŝŶĨŽƌŵĂƟŽŶƉƌŽǀŝĚĞĚŝŶƚŚŝƐƉƉůŝĐĂƟŽŶƚŽ&tĨŽƌƚŚĞƉƵƌƉŽƐĞŽĨĞŶƌŽůůŝŶŐƚŚĞĞůŝŐŝďůĞĞŵƉůŽLJĞĞƐĂŶĚͬŽƌƚŚĞŝƌ
dependents (if applicable) in the group medical insurance plan.
㜓ạ␥䬰ⷙ恜⭯ῲạ岮㖀Ƌ䦨暘ƌ㢄ὲƏḍⷙ䍙⽾㛰旃⃘Ⓢ⎱ㇽ⅝⮝ⱓƋ⥩恐䔏ƌ䙫⏳ヶƏỌ䔚媲㭋⛿檻憒䘩ῄ暑姯≪ὃ䂡䛕䙫Ə⯮㛰旃⃘Ⓢ⎱ㇽ⅝⮝ⱓ
Ƌ⥩恐䔏ƌ䙫岮㖀䧢ẋ䵍⮳塂˛
ƉƉůŝĐĂďůĞƚŽ/ŶƐƵƌĂŶĐĞƌŽŬĞƌŽŶůLJ͗
dŚĞ ĂƉƉůŝĐĂŶƚ ƵŶĚĞƌƐƚĂŶĚƐ͕ ĂĐŬŶŽǁůĞĚŐĞƐ ĂŶĚ ĂŐƌĞĞƐ ƚŚĂƚ͕ ĂƐ Ă ƌĞƐƵůƚ ŽĨ ƚŚĞ ĂƉƉůŝĐĂŶƚ ƉƵƌĐŚĂƐŝŶŐ ĂŶĚ ƚĂŬŝŶŐ ƵƉ ƚŚĞ ƉŽůŝĐLJ ƚŽ ďĞ ŝƐƐƵĞĚ ďLJ &t 'ĞŶĞƌĂů
/ŶƐƵƌĂŶĐĞŽŵƉĂŶLJ>ŝŵŝƚĞĚ͕&t'ĞŶĞƌĂů/ŶƐƵƌĂŶĐĞŽŵƉĂŶLJ>ŝŵŝƚĞĚǁŝůůƉĂLJƚŚĞĂƵƚŚŽƌŝƐĞĚŝŶƐƵƌĂŶĐĞďƌŽŬĞƌĐŽŵŵŝƐƐŝŽŶĚƵƌŝŶŐƚŚĞĐŽŶƟŶƵĂŶĐĞŽĨƚŚĞ
ƉŽůŝĐLJŝŶĐůƵĚŝŶŐƌĞŶĞǁĂůƐ͕ĨŽƌĂƌƌĂŶŐŝŶŐƚŚĞƐĂŝĚƉŽůŝĐLJ͘tŚĞƌĞƚŚĞĂƉƉůŝĐĂŶƚŝƐĂďŽĚLJĐŽƌƉŽƌĂƚĞ͕ƚŚĞĂƵƚŚŽƌŝƐĞĚƉĞƌƐŽŶǁŚŽƐŝŐŶƐŽŶďĞŚĂůĨŽĨƚŚĞĂƉƉůŝĐĂŶƚ
ĨƵƌƚŚĞƌĐŽŶĮƌŵƐƚŽ&t'ĞŶĞƌĂů/ŶƐƵƌĂŶĐĞŽŵƉĂŶLJ>ŝŵŝƚĞĚƚŚĂƚŚĞŽƌƐŚĞŝƐĂƵƚŚŽƌŝƐĞĚƚŽĚŽƐŽ͘
dŚĞĂƉƉůŝĐĂŶƚĨƵƌƚŚĞƌƵŶĚĞƌƐƚĂŶĚƐƚŚĂƚƚŚĞĂďŽǀĞĂŐƌĞĞŵĞŶƚŝƐŶĞĐĞƐƐĂƌLJĨŽƌ&t'ĞŶĞƌĂů/ŶƐƵƌĂŶĐĞŽŵƉĂŶLJ>ŝŵŝƚĞĚƚŽƉƌŽĐĞĞĚǁŝƚŚƚŚĞĂƉƉůŝĐĂƟŽŶ͘
⊨ょ䏦㑺ẛ敨䱑䮾
䏱妉ᵸ㓌䔻Ʊ䝸䚣⊈⋊⿍濕⪊圙ẛ敨㗇攎‪⊶㗁⫯䏱妉ᵸ宺孵⊈㉣⊕‴䫻䔺䕂ẛ⑬濕㑺ẛ⑬㗇㐆㗝‥ ⇃ㆪ䵊ẛ㗝 ⋏孞孪⩇㉐㗇撚ẛ⑬䕂䈰㉆㧈ẛ敨䱑䮾㏭ᶖḡ
悏Ʋ⡀䏱妉ᵸ㽸㮓ᵸ◖榒濕ᶡ圦䏱妉ᵸ䫻丰䕂䈰㉆㧈ᵸ⎟◦㨢⋏⪊圙ẛ敨㗇攎‪⊶䝸奋ᶔ濘⠷Ⲱ䈰夰㮓ᵸ◖榒㉆㧈Ʋ
䏱妉ᵸᵤ㓌䔻⪊圙ẛ敨㗇攎‪⊶⺃曆⊔⹕䏱妉ᵸ䕂⋊⿍濕ㄋ⊭ᶣ唓䋄‴ẛ敨䏱妉Ʋ
Authorised Signature on behalf of the Applicant with Company Chop
Ị塏䔚媲ạ䙫䍙㍯㫱ạ䰤余⎱⅓⏟咲䫇
Date (DD/MM/YYYY)
䰤余㗌㜆㗌㛯⹛
WŽƐŝƟŽŶ
偞ἴ
EĂŵĞŽĨĚǀŝƐĞƌͬŐĞŶƚͬƌŽŬĞƌ䏭岈桎┶Ị䏭ạ䵺䳧⦺⏴
Code ䷏噆
Contact No. 偖䵈曢婘
WůĞĂƐĞĞŶĐůŽƐĞƚŚĞĨŽůůŽǁŝŶŐĚŽĐƵŵĞŶƚƐĂŶĚƉƌĞŵŝƵŵƉĂLJŵĞŶƚƚŽ&tĨŽƌƉƌŽĐĞƐƐŝŶŐ͗
媲昫ᷱỌᷲ㕮ờ⎱ῄ岢ẋ⛅⮳塂Ọ徍䏭㭋䔚媲
ͻ dŚŝƐĂƉƉůŝĐĂƟŽŶĨŽƌŵ㭋䔚媲塏
ͻ ĐŽƉLJŽĨƵƐŝŶĞƐƐZĞŐŝƐƚƌĂƟŽŶĞƌƟĮĐĂƚĞŽƌĞƌƟĮĐĂƚĞŽĨ/ŶĐŽƌƉŽƌĂƟŽŶ┭㥔䙢姿ㇽ⅓⏟娢ⅱ嬰㛟≖㜓
ͻ ĐŚĞƋƵĞƉĂLJĂďůĞƚŽ͞&t'ĞŶĞƌĂů/ŶƐƵƌĂŶĐĞŽŵƉĂŶLJ>ŝŵŝƚĞĚ͟Ọ「⮳塂ῄ暑㛰昷⅓⏟」䂡㊓栔䙫㔖䥏
ͻ ŵƉůŽLJĞĞŶƌŽůůŵĞŶƚĨŽƌŵĨŽƌŵƉůŽLJĞĞĞŶĞĮƚƐ/ŶƐƵƌĂŶĐĞ⃘Ⓢ䥶∐ῄ暑⎪⊇塏㠣
&tŵĂLJƌĞƋƵĞƐƚĂĚĚŝƟŽŶĂůĚŽĐƵŵĞŶƚƐĨŽƌƉƌŽĐĞƐƐŝŶŐ͘⮳塂⏖僤曧奨栴⣽㕮ờỌὃ㉠㠟˛
ŽƌƉŽƌĂƚĞĞŶĞĮƚƐĞƉĂƌƚŵĞŶƚ
ϳͬ&͕͘&t&ŝŶĂŶĐŝĂůĞŶƚƌĞ͕ϯϬϴĞƐsŽĞƵdžZŽĂĚĞŶƚƌĂů͕,ŽŶŐ<ŽŶŐ
Ứ㥔䥶∐惏
榀㸖Ḕ䒗⾚廻怺ḔϯϬϴ噆⮳塂憸坴Ḕ⾪7㧺
dϯϭϮϯϯϭϮϯ&ϮϴϱϬϯϬϬϯǁǁǁ͘ĨǁĚ͘ĐŽŵ͘ŚŬ
ŚŝŶĞƐĞǀĞƌƐŝŽŶŽĨƚŚŝƐƉƉůŝĐĂƟŽŶ&ŽƌŵŝƐĨŽƌƌĞĨĞƌĞŶĐĞŽŶůLJ͘/ĨƚŚĞƌĞŝƐĂŶLJ
ŝŶĐŽŶƐŝƐƚĞŶĐLJďĞƚǁĞĞŶƚŚĞŶŐůŝƐŚĂŶĚŚŝŶĞƐĞǀĞƌƐŝŽŶƐ͕dŚĞŶŐůŝƐŚǀĞƌƐŝŽŶ
ƐŚĂůůƉƌĞǀĂŝů͘
㜓䔚媲㛟ḲḔ㕮孖㜓䤮ᾂ⎪俪Ḳ䔏Ə⥩㛰䈔侐ƏㆰỌ勘㕮⎆侐䂡㹽˛
7
6
5
4
3
2
1
*
#
⃘Ⓢ⦺⏴
Employee’s Name
;/ĨĂƉƉůŝĐĂďůĞ⥩恐䔏)
⮝ⱓ⦺⏴
ĞƉĞŶĚĂŶƚ͛ƐEĂŵĞ
EE – Employee ⃘Ⓢ͕^Wʹ^ƉŽƵƐĞ愴⁝͕,ʹŚŝůĚ⬷⥚
^ʹ^ŝŶŐůĞ㜑⩁͕DʹDĂƌƌŝĞĚⷙ⩁͕ʹŝǀŽƌĐĞĚ曉⩁͕tͲtŝĚŽǁĞĚ⯈Ⱜ
;/ĨĂƉƉůŝĐĂďůĞ
⥩恐䔏)
⃘Ⓢ䷏噆
旃ᾩ
Rel.*
『∌
^Ğdž
;ͬDDͬzzzzͿ
⇡䔆㗌㜆
ĂƚĞŽĨŝƌƚŚ
庒Ụ嬰ͬ孞䅎噆䢣
/ĂƌĚͬWĂƐƐƉŽƌƚ
No.
⃘Ⓢ桅∌
Employee
Type
;ͬDDͬzzzzͿ
⎾⃘㗌㜆
Employment
ĂƚĞ
WŽƐŝƟŽŶ偞ἴ
: 2850 3003
ͲŵĂŝůĚĚƌĞƐƐ曢惜✗✧
䫜員之銀行戶口號碼
䔆㔯㗌㜆
;ͬDDͬzzzzͿ
EīecƟǀe ate
EB-UW-EF 10.2015
(䫜員必須提供此項資料用作醫療賠償用途)
;dŚŝƐŝŶĨŽƌŵĂƟŽŶŵƵƐƚďĞƉƌŽǀŝĚĞĚĂŶĚǁŝůůďĞ
ƵƐĞĚĨŽƌŵĞĚŝĐĂůďĞŶĞĮƚƌĞŝŵďƵƌƐĞŵĞŶƚͿ
ŵƉůŽLJĞĞ͛ƐĂŶŬĐĐŽƵŶƚEŽ͘
&Ădžₚ䜆
E-mail 曢惜 : ĞŵƉůŽLJĞĞďĞŶĞĮƚƐΛĨǁĚ͘ĐŽŵ
** Monthly Salary 㛯喑Ͳ&Žƌ>ŝĨĞĐŽǀĞƌĂŐĞŽŶůLJ⏑恐䔏㖣ạ⣤ῄ暑
##
ůĂŝŵĚũƵƐƚŵĞŶƚ^ƚĂƚĞŵĞŶƚǁŝůůďĞƐĞŶƚďLJĞŵĂŝůŝĨĞŵĂŝůĂĚĚƌĞƐƐŝƐƉƌŽǀŝĚĞĚ͘⥩㛰㎷ᾂ曢惜✗✧Ə憒䘩䴉℆䏭峇塏⯮Ọ曢惜忨恅˛
⩁⧢
䊧㲨
Marital
#
Status
Monthly**
Salary 㛯喑
'ƌŽƵƉ>ŝĨĞWŽůŝĐLJEŽ͘ ⛿檻ạ⣤ῄ▕噆䢣:
ĸůŝĂƚĞĚŽŵƉĂŶLJ昫ⱓ⅓⏟ :
Employee
ŽĚĞ
Group Medical Policy No. ⛿檻憒䘩ῄ▕噆䢣
Policyholder ῄ▕㋨㛰ạ
2 &Žƌ'ƌŽƵƉ>ŝĨĞ/ŶƐƵƌĂŶĐĞ͗/ĨƚŚĞƐƵŵĂƐƐƵƌĞĚŽĨƚŚĞŶĞǁĞŵƉůŽLJĞĞĞdžĐĞĞĚƐƚŚĞƵƚŽŵĂƟĐĐĐĞƉƚĂŶĐĞ>ŝŵŝƚ͕ƚŚĞŶĞǁĞŵƉůŽLJĞĞŝƐƌĞƋƵŝƌĞĚƚŽĐŽŵƉůĞƚĞƚŚĞ,ĞĂůƚŚĞĐůĂƌĂƟŽŶ&ŽƌŵĂŶĚƌĞƚƵƌŶŝƚƚŽƵƐƚŽŐĞƚŚĞƌǁŝƚŚƚŚŝƐĨŽƌŵ
ĨŽƌƵŶĚĞƌǁƌŝƟŶŐƉƵƌƉŽƐĞƐ͘
恐䔏㖣⛿檻ạ⣤ῄ暑⥩㖗⢅⊇Ḳ⃘ⓈḲ㉼ῄ栴嵬怵凑⊼⎾ῄ栴Ə㖗⢅⊇Ḳ⃘Ⓢ柯⡒⯒⁌⺞䔚⠘塏⎱柯怊⏳㭋塏㠣ᷧ὜ẋ⛅㜓⅓⏟Ọὃ㠟ῄḲ䔏˛
Note ₀娢
1 &Žƌ'ƌŽƵƉDĞĚŝĐĂů/ŶƐƵƌĂŶĐĞ͗&ŽƌĐŽŵƉĂŶŝĞƐǁŝƚŚůĞƐƐƚŚĂŶϰĞŵƉůŽLJĞĞƐŽŶƚŚĞƉŽůŝĐLJĞīĞĐƟǀĞĚĂƚĞ͕ƚŚĞŶĞǁĞŵƉůŽLJĞĞŝƐƌĞƋƵŝƌĞĚƚŽĐŽŵƉůĞƚĞƚŚĞ,ĞĂůƚŚĞĐůĂƌĂƟŽŶ&ŽƌŵĂŶĚƌĞƚƵƌŶŝƚƚŽƵƐƚŽŐĞƚŚĞƌǁŝƚŚƚŚŝƐĨŽƌŵĨŽƌ
ƵŶĚĞƌǁƌŝƟŶŐƉƵƌƉŽƐĞƐ͘
恐䔏㖣⛿檻憒䘩ῄ暑⥩㖣ῄ▕䔆㔯㗌⅓⏟⃘Ⓢạ㕟⯸㖣⛂ạƏ㖗⢅⊇Ḳ⃘Ⓢ柯⡒⯒⁌⺞䔚⠘塏⎱柯怊⏳㭋塏㠣ᷧ὜ẋ⛅㜓⅓⏟Ọὃ㠟ῄḲ䔏˛
ᾯ⎟䡍⃧ẛ敨⊁⅞圦㛺
ŵƉůŽLJĞĞŶƌŽůůŵĞŶƚ&ŽƌŵĨŽƌŵƉůŽLJĞĞĞŶĞĮƚƐ/ŶƐƵƌĂŶĐĞ
;/ĨĂƉƉůŝĐĂďůĞ⥩恐䔏)
⮝ⱓ⦺⏴
ĞƉĞŶĚĂŶƚ͛ƐEĂŵĞ
EE – Employee ⃘Ⓢ͕^Wʹ^ƉŽƵƐĞ愴⁝͕,ʹŚŝůĚ⬷⥚
^ʹ^ŝŶŐůĞ㜑⩁͕DʹDĂƌƌŝĞĚⷙ⩁͕ʹŝǀŽƌĐĞĚ曉⩁͕tͲtŝĚŽǁĞĚ⯈Ⱜ
⃘Ⓢ⦺⏴
Employee’s Name
旃ᾩ
Rel.*
^Ğdž
『∌
;ͬDDͬzzzzͿ
⇡䔆㗌㜆
ĂƚĞŽĨŝƌƚŚ
庒Ụ嬰ͬ孞䅎噆䢣
/ĂƌĚͬWĂƐƐƉŽƌƚ
No.
⃘Ⓢ桅∌
Employee
Type
;ͬDDͬzzzzͿ
⎾⃘㗌㜆
Employment
ĂƚĞ
WŽƐŝƟŽŶ偞ἴ
Monthly**
Salary㛯喑
ŵƉůŽLJĞĞ͛ƐĂŶŬĐĐŽƵŶƚEŽ͘
ͲŵĂŝůĚĚƌĞƐƐ曢惜✗✧
(䫜員必須提供此項資料用作醫療賠償用途)
䫜員之銀行戶口號碼
;dŚŝƐŝŶĨŽƌŵĂƟŽŶŵƵƐƚďĞƉƌŽǀŝĚĞĚĂŶĚǁŝůůďĞ
ƵƐĞĚĨŽƌŵĞĚŝĐĂůďĞŶĞĮƚƌĞŝŵďƵƌƐĞŵĞŶƚͿ
** Monthly Salary 㛯喑Ͳ&Žƌ>ŝĨĞĐŽǀĞƌĂŐĞŽŶůLJ⏑恐䔏㖣ạ⣤ῄ暑
##
ůĂŝŵĚũƵƐƚŵĞŶƚ^ƚĂƚĞŵĞŶƚǁŝůůďĞƐĞŶƚďLJĞŵĂŝůŝĨĞŵĂŝůĂĚĚƌĞƐƐŝƐƉƌŽǀŝĚĞĚ͘⥩㛰㎷ᾂ曢惜✗✧Ə憒䘩䴉℆䏭峇塏⯮Ọ曢惜忨恅˛
⩁⧢
䊧㲨
Marital
#
Status
䔆㔯㗌㜆
;ͬDDͬzzzzͿ
EīecƟǀe ate
ŽƌƉŽƌĂƚĞĞŶĞĮƚƐĞƉĂƌƚŵĞŶƚ Ứ㥔䥶∐惏
ϳͬF͕͘FW Financial Ğntre͕308 es VoeƵdž Road entral͕,oŶŐ KoŶŐ
榀㸖Ḕ䒗⾚廻怺Ḕ308 噆⮳塂憸坴Ḕ⾪7 㧺
uthorised SiŐŶature with ompany hop ㍯㫱ạ䰤余⎱⅓⏟咲䫇
___________________________________________________________
ĂƚĞ 㗌㜆
______________________________
EB-UW-EF 10.2015
ϭ dŚĞĂďŽǀĞŝŶĨŽƌŵĂƟŽŶƌĞůĂƟŶŐƚŽƚŚĞŵƉůŽLJĞĞƐĂŶĚͬŽƌƚŚĞŝƌĞƉĞŶĚĞŶƚƐ;ŝĨĂƉƉůŝĐĂďůĞͿŝƐĐŽƌƌĞĐƚƚŽƚŚĞďĞƐƚŽĨŵLJͬŽƵƌŬŶŽǁůĞĚŐĞ͖ĂŶĚ
Ⱈ㜓ạ␥䬰㈧䟌Əᷱ⇾⃘Ⓢ⎱ㇽ⅝⮝ⱓƋ⥩恐䔏ƌ䙫岮㖀✮ⱓ㭊䢡䄈媋⎱
Ϯ /ͬǁĞŚĂǀĞĐŽŵƉůŝĞĚǁŝƚŚƚŚĞWĞƌƐŽŶĂůĂƚĂ;WƌŝǀĂĐLJͿKƌĚŝŶĂŶĐĞĂŶĚŚĂǀĞŽďƚĂŝŶĞĚƚŚĞĐŽŶƐĞŶƚĨƌŽŵƚŚĞŵƉůŽLJĞĞƐĂŶĚͬŽƌƚŚĞŝƌĞƉĞŶĚĞŶƚƐ;ŝĨĂƉƉůŝĐĂďůĞͿĨŽƌƚŚĞƚƌĂŶƐĨĞƌŽĨƚŚĞĂďŽǀĞŝŶĨŽƌŵĂƟŽŶƚŽ&t'ĞŶĞƌĂů/ŶƐƵƌĂŶĐĞŽŵƉĂŶLJ>ŝŵŝƚĞĚĂŶĚͬŽƌ&t>ŝĨĞ
/ŶƐƵƌĂŶĐĞŽŵƉĂŶLJ;ĞƌŵƵĚĂͿ>ŝŵŝƚĞĚĨŽƌƚŚĞƉƵƌƉŽƐĞŽĨĞŶƌŽůůŝŶŐƚŚĞŵƉůŽLJĞĞƐĂŶĚŽƌƚŚĞŝƌĞƉĞŶĚĞŶƚƐ;ŝĨĂƉƉůŝĐĂďůĞͿŝŶƚŚĞŐƌŽƵƉŵĞĚŝĐĂůĂŶĚͬŽƌŐƌŽƵƉůŝĨĞŝŶƐƵƌĂŶĐĞƉůĂŶ͘
㜓ạ␥䬰ⷙ恜⭯ῲạ岮㖀Ƌ䦨暘ƌ㢄ὲƏḍⷙ䍙⽾㛰旃⃘Ⓢ⎱ㇽ⅝⮝ⱓƋ⥩恐䔏ƌ䙫⏳ヶƏỌ䔚媲㭋⛿檻憒䘩ㇽạ⣤ῄ暑姯≪ὃ䂡䛕䙫Ə⯮㛰旃⃘Ⓢ⎱ㇽ⅝⮝ⱓƋ⥩恐䔏ƌ䙫岮㖀䧢ẋ䵍⮳塂ῄ暑㛰昷⅓⏟⎱ㇽ⮳塂ạ⣤ῄ暑䙥ㄼ总㛰昷⅓⏟˛
䏱妉ᵸ估㓌⊈䝸奋
dŚĞƉƉůŝĐĂŶƚĚĞĐůĂƌĞƐĂŶĚĐŽŶĮƌŵƐƚŚĂƚ͗
*
#
15
14
13
12
11
10
9
8
;/ĨĂƉƉůŝĐĂďůĞ
⥩恐䔏)
⃘Ⓢ䷏噆
Employee
ŽĚĞ
FWD General Insurance Company Limited and
FWD Life Insurance Company (Bermuda) Limited
(collectively, “the Company”)
(iv)
Personal Information Collection Statement
1. From time to time, it is necessary for you to supply the Company with
personal information and particulars in connection with the provision,
continuation and administration of insurance or other financial services
and products by the Company. Failure to provide the necessary information
and particulars may result in the Company being unable to provide or
continue to provide these services and products to you.
2. The Company may also generate and compile information about you.
Personal information and particulars provided by you and all information
generated and compiled by the Company about you from time to time is
collectively referred to as "Your Personal Data".
3. The purposes for which Your Personal Data may be used are as follows:
(i)
offering and providing services and products to you, and administering,
implementing, maintaining, managing and operating such services and
products which may include, without limitation, insurance, financial
and wealth management services and products;
(ii) processing, assessing and determining any applications or requests
made by you in connection with the Company's services or products,
issuing or arranging insurance contracts and maintaining your account
with the Company;
(iii) designing insurance and other financial services and products for
customers;
(iv) marketing services and products to you (please see further details in
paragraphs 5 to 8 below);
(v) operating, maintaining and providing subsequent services in relation to
the applications for services and/or products;
(vi) creating and maintaining the credit and risk related models of the
Company;
(vii) processing and implementing payment instructions;
(viii) determining any amount of indebtedness owing to or from you, and
collecting and recovering any amount owing from you or any person
who has provided any security or undertaking for your liabilities;
(ix) exercising any rights that the Company may have in connection with
the services and/or products provided to you;
(x) verifying and conducting any eligibility, credit, physical, medical,
security, underwriting and/or identity checks in connection with
provision of services or products;
(xi) any purposes in connection with any claims made by or against or
otherwise involving you in respect of any services and/or products
provided by the Company, including, without limitation, making,
defending, analysing, investigating, processing, assessing, determining,
responding to, resolving or settling such claims;
(xii) performing policy review and needs analysis (whether or not on a
regular basis);
(xiii) meeting disclosure obligations or requirements imposed by or for
the purposes of any law, rules, regulations, codes of practice or
guidelines (whether applicable in or outside Hong Kong) binding on the
Company or any of its subsidiaries, holding companies, associated or
affiliated companies of, or companies controlled by, or under common
control with the Company (collectively, "the Group") including, without
limitation, making disclosure to any legal, regulatory, governmental,
tax, law enforcement or other authorities, self-regulatory or industry
bodies such as federations or associations of insurers;
(xiv) meeting any present or future contractual or other commitment with
any legal, regulatory, governmental, tax, law enforcement or other
authorities, self-regulatory or industry bodies such as federations or
associations of insurers in Hong Kong or any other jurisdictions that is
assumed by or imposed on the Company or any member of the Group
by reason of its financial, commercial, business or other interests or
activities in or related to the relevant jurisdiction;
(xv) complying with any obligations, requirements, policies, procedures,
measures or arrangement for sharing data and information within the
Group and/or other use of data and information in accordance with
any group-wide programmes from time to time for compliance with
sanctions or prevention or detection of money laundering, terrorist
financing or other unlawful activities; and
(xvi) fulfilling any other purposes directly related to (i) to (xv) above.
4. To facilitate the purposes set out in paragraph 3 above, the Company may
transfer, disclose, grant access to or share Your Personal Data with the
following parties (whether within or outside Hong Kong) and Your Personal
Data may be transferred outside Hong Kong:
(i)
members of the Group;
(ii) any person or company which is acting for or on behalf of the Company,
or jointly with the Company, in respect of a purpose or a directly
related purpose for which Your Personal Data was provided;
(iii) any person or company which is under a duty of confidentiality to the
Company and has undertaken to keep such information confidential,
provided that such person or company has a legitimate right to access
such information (e.g. professional advisors of the Company);
5.
6.
7.
8.
9.
10.
11.
any person or company carrying on insurance-related and/or
reinsurance-related business which is engaged by the Company in
connection with the Company's business;
(v) any physicians, hospitals, clinics, medical practitioners, laboratories,
technicians, loss adjustors, risk intelligence providers, claim
investigation companies, administrators or other professional advisors
which are engaged by the Company in connection with the Company's
business;
(vi) any business partners of the Company ("Our Partners");
(vii) any agents, contractors or service providers which provide
administrative, credit reference, debt collection, telecommunications,
computer, payment, printing, redemption or other services in relation
t o t h e o p e ra t i o n o f b u s i n e s s e s o f t h e C o m p a ny ; a n d /o r
(viii) any person or company to whom the Company or the Group is under
an obligation or otherwise required or expected to make disclosure
under the requirements of any law, rules, regulations, codes of practice
or guidelines (whether applicable in or outside Hong Kong) including,
without limitation, any legal, regulatory, governmental, tax, law
enforcement or other authorities, self-regulatory or industry bodies
such as federations or associations of insurers.
The Company is allowed to (i) use Your Personal Data in direct marketing
only if you consent or do not object, or (ii) provide Your Personal Data to
another person or company for its use in direct marketing only if you consent
or do not object in writing.
In connection with direct marketing, the Company intends:
(i)
to use your name, contact details, services and products portfolio
information, financial background and demographic data held by the
Company from time to time in direct marketing;
(ii) to market the following classes of services and products offered by the
Company, other members of the Group and/or Our Partners from time
to time:
a. insurance services and products;
b. wealth management services and products;
c. financial services and products;
d. reward, loyalty or privileges programmes and related services and
products; and
e. donations and contributions for charitable and/or non-profit making
purposes.
(iii) to provide Your Personal Data described in paragraph 6(i) above to any
members of the Group and/or Our Partners for their use in direct
marketing the classes of services and products described in paragraph
6(ii) above.
If you do NOT wish the Company to use Your Personal Data in direct
marketing or provide Your Personal Data to other persons or companies for
their use in direct marketing, please tick (3) the appropriate box(es) below
to exercise your opt-out right.
† Please do not send direct marketing information to me.
† Please do not provide my personal data to other persons or companies
for their use in direct marketing.
You may also write to the Company at the address below to opt out from
direct marketing at any time.
Under the Personal Data (Privacy) Ordinance:
(i)
you have the right to request access to Your Personal Data held by the
Company and request correction of any of Your Personal Data which is
incorrect; and
(ii) the Company has the right to charge you a reasonable fee for
processing and complying with your data access request.
Requests for access to or correction of Your Personal Data should be made in
writing to:
Corporate Data Protection Officer
FWD General Insurance Company Limited
1st Floor, FWD Financial Centre,
308 Des Voeux Road Central
Hong Kong
Should you have any queries, please do not hesitate to call our Customer
Service Hotline 3123 3123.
In case of discrepancies between the English and Chinese versions, the
English version shall apply and prevail.
I have read and I understand and accept this Personal Information Collection
Statement.
Signature:
Name:
(Name of applicant/individual to whom this Statement is given)
HKID/Passport number:
Jul 2013 (EB)
⮳塂ῄ暑㛰昷⅓⏟⎱
⮳塂ạ⣤ῄ暑 䙥ㄼ总 㛰昷⅓⏟ 䵘䨘˥㜓⅓⏟˦
(iv) ỢἼ⛇㜓⅓⏟㥔⋀俳倿䔏Ḳ䵺䇆ῄ暑䛟旃⎱ƒㇽⅴῄ暑䛟旃㥔
⋀Ḳạ⣒ㇽ⅓⏟ƞ
(v)
㔝暭ῲạ岮㖀偙㗵
1. ✏㜓⅓⏟㎷ᾂ˚⻝乳⎱䮈䏭ῄ暑ㇽ⅝ẽ憸坴㛴⋀⎱䔉⒨㘩Ə斊ᷲ曧
奨ᷴ㘩⏸㜓⅓⏟㎷ᾂῲạ岮㖀⎱婚ガ˛⥩㜑僤㎷ᾂ㈧曧岮㖀⎱婚
ガƏ⏖僤㛪⯵凛㜓⅓⏟䄈㲼⏸斊ᷲ㎷ᾂㇽ乣乳㎷ᾂ㛰旃㛴⋀⎱
䔉⒨˛
2. 㜓⅓⏟ẍ⏖壤ὃ⎱⌖䷏凮斊ᷲ㛰旃䙫岮㖀˛斊ᷲ㎷ᾂ䙫ῲạ岮㖀⎱
婚ガỌ⎱㜓⅓⏟ᷴ㘩壤ὃ⎱⌖䷏凮斊ᷲ㛰旃䙫㈧㛰岮㖀ƏỌᷲ䵘䨘
䂡˥斊ᷲ䙫ῲạ岮㖀˦˛
3. 斊ᷲ䙫ῲạ岮㖀⏖僤䔏㖣Ọᷲ䔏忻Ɲ
(i)
(ii)
⏸斊ᷲ奨䳫⎱㎷ᾂ㛴⋀⎱䔉⒨Ə䮈䏭˚⟞堳˚䶔㋨˚嘼䏭⎱怲
ὃ㛰旃㛴⋀⎱䔉⒨Ə⋬㋓Ἥᷴ昷㖣ῄ暑˚憸坴⎱岈⮳䮈䏭㛴⋀
⎱䔉⒨ƞ
嘼䏭˚娼἗⎱㱡⮁斊ᷲⰘ㜓⅓⏟䙫㛴⋀ㇽ䔉⒨俳㎷⇡䙫ỢἼ䔚
媲ㇽ奨㰩 ; 䙣⇡ㇽ⭰㍹ῄ暑⏯䳫ƏỌ⎱䶔㋨斊ᷲ✏㜓⅓⏟䙫
峓㈝ƞ
(iii) 䂡⮉㈝娔姯ῄ暑⎱⅝ẽ憸坴㛴⋀⎱䔉⒨ƞ
(iv) ⏸斊ᷲ㎷ᾂ㛴⋀⎱䔉⒨択┕Ƌ㛰旃婚ガƏ媲⎪斘ᷲ㕮䬓 5 凚
8 㮜ƌƞ
(v)
(vi) ỢἼ㜓⅓⏟䙫㥔⋀⤌ἛƋ˥㜓⅓⏟Ḳ⤌Ἓ˦ƌƞ
(vii) ⏸㜓⅓⏟Ḳ䵺䇆㥔⋀㎷ᾂ堳㔦˚Ὲ岟岮㖀⺒˚ₜ⋀忤姵˚曢姱˚
曢免˚ế㬥˚⍗∞˚峽⛅ㇽ⅝ẽ㛴⋀䙫ỢἼỊ䏭ạ˚㉦⋬┭ㇽ
㛴⋀ᾂㆰ┭ƞ⎱ƒㇽ
(viii) ỢἼ㜓⅓⏟ㇽ㜓暭⛿岇㛰岓Ợㇽ柯奨ㇽ柷㜆奨㠠㓁ỢἼ㲼⽲˚
奶∮˚奶ὲ˚⯍⋀⭯∮ㇽ㋮⻼Ƌᷴ媽✏榀㸖⡪ⅎㇽ⡪⣽恐䔏ƌ
ὃ⇡㊒朙䙫ạ⣒ㇽ⅓⏟Ə⋬㋓Ἥᷴ昷㖣ỢἼ㲼⽲㩆㦲˚䛊䮈㩆
㦲˚㔦⺃㩆㦲˚䧬⋀㩆㦲˚⟞㲼㩆㦲ㇽ⅝ẽ㩆㦲˚䍏䪲䛊䮈ㇽ
堳㥔⛿檻Ƌ⥩ῄ暑㥔偖㛪ㇽ⌻㛪䬰ƌ˛
5. ⮠娘㜓⅓⏟ (i) ✏斊ᷲ⏳ヶㇽᷴ⎴⯴䙫ガ㲨ᷲƏὦ䔏斊ᷲ䙫ῲạ岮㖀
ὃ䛛㎌ᾪ択䔏忻Əㇽ (ii) ✏斊ᷲỌ㛟杉㖠⻶⏳ヶㇽᷴ⎴⯴䙫ガ㲨ᷲƏ
⯮斊ᷲ䙫ῲạ岮㖀㎷ᾂṯ⅝ẽạ⣒ㇽ⅓⏟ὃ⅝䛛㎌ᾪ択䔏忻˛
6. Ⱈ䛛㎌ᾪ択俳姧Ə㜓⅓⏟㓓Ɲ
(i)
ὦ䔏㜓⅓⏟ᷴ㘩㋨㛰䙫斊ᷲ⦺⏴˚偖䵈岮㖀˚㛴⋀⎱䔉⒨䴫⏯
岮㖀˚岈⋀傳㙖⎱ạ⏊䵘姯岮㖀ὃ䛛㎌ᾪ択䔏忻ƞ
(ii)
択┕㜓⅓⏟˚㜓暭⛿⅝ẽㇷⓈ㩆㦲⎱ƒㇽ㜓⅓⏟Ḳ⤌Ἓᷴ㘩㎷
ᾂ䙫ᷲ⇾㛴⋀⎱䔉⒨Ɲ
怲ὃ˚䶔㋨㛰旃䔚媲Ḳ㛴⋀⎱ƒㇽ䔉⒨⎱㎷ᾂ䛟旃Ḳ⽳乳
㛴⋀ƞ
a. ῄ暑㛴⋀⎱䔉⒨ƞ
b. 岈⮳䮈䏭㛴⋀⎱䔉⒨ƞ
(vi) ⻡䪲⎱䶔㋨㜓⅓⏟䙫Ὲ岟⎱梏暑䛟旃㨈❲ƞ
c. 憸坴㛴⋀⎱䔉⒨ ;
(vii) 嘼䏭⎱⟞堳ế㬥㋮䤡ƞ
(viii) 憷姩ỢἼ㬇ế斊ᷲㇽ斊ᷲ㈧㬇䙫岇ₜ憸栴Ə⎱⏸斊ᷲㇽỢἼ䂡
斊ᷲ䙫ₜ⋀㎷ᾂ㒻ῄㇽ㉦嫥䙫ạ⣒㔝⎽⎱忤姵㬇㬥ƞ
(ix) 堳ὦ㜓⅓⏟Ⱈ⏸斊ᷲ㎷ᾂ㛴⋀⎱ƒㇽ䔉⒨俳⏖僤Ẓ㛰䙫ỢἼ
㫱∐ƞ
(x)
Ⱈ㎷ᾂḲ㛴⋀ㇽ䔉⒨ὃ⇡⎱怙堳岮㠣˚Ὲ岟˚庒檻˚憒䘩˚
㒻ῄ˚㉦ῄ⎱ƒㇽ庒Ụ㠟娣ƞ
(xi) 䔏㖣ỢἼ⛇㜓⅓⏟㎷ᾂ䙫䔉⒨⎱ƒㇽ㛴⋀俳䔘斊ᷲ㎷⇡ㇽ㜓⅓
⏟⯴斊ᷲ㎷⇡䙫䔚䴉Ə⋬㋓Ἥᷴ昷㖣ὃ⇡˚㉾徖˚⇭㝷˚媦㟌˚
嘼䏭˚娼㠟˚㱡⮁˚⛅ㆰ˚姊㱡ㇽ⑳姊㛰旃䔚䴉ƞ
(xii) 怙堳ῄ▕⯐斘⎱曧㰩⇭㝷Ƌᷴ媽㘖␍⮁㜆怙堳ƌƞ
(xiii) 㜓⅓⏟ㇽ⅝ỢἼ昫ⱓ⅓⏟˚㎎傈⅓⏟˚偖䇆ㇽ偖ⱓ⅓⏟Əㇽ㜓
⅓⏟㎎∝䙫⅓⏟ㇽ凮㜓⅓⏟⎾⅘⏳㎎∝䙫⅓⏟Ƌ䵘䨘˥㜓暭
⛿˦ƌ㠠㓁ỢἼ㲼⽲˚奶∮˚奶ὲ˚⯍⋀⭯∮ㇽ㋮⻼Ƌᷴ媽✏
榀㸖⡪ⅎㇽ⡪⣽恐䔏ƌ奨㰩俳柯ὃ⇡㊒朙Ə⋬㋓Ἥᷴ昷㖣⏸Ợ
Ἴ㲼⮁㩆㦲˚䛊䮈㩆㦲˚㔦⺃㩆㦲˚䧬⋀㩆㦲˚⟞㲼㩆㦲ㇽ⅝
ẽ㩆㦲˚䍏䪲䛊䮈ㇽ堳㥔⛿檻Ƌ⥩ῄ暑㥔偖㛪ㇽ⌻㛪䬰ƌὃ⇡
㊒朙ƞ
ỢἼ⛇㜓⅓⏟㥔⋀俳倿䔏䙫㲢䘩⸒˚憒晉˚娡㈧˚憒䔆˚⋽樾
㈧˚㉧⸒˚㏴⤘䏭䭾ạ˚梏暑ガ⠘ᾂㆰ┭˚䴉峇媦㟌⅓⏟˚堳
㔦䮈䏭ạ⣒ㇽ⅝ẽ⯯㥔桎┶ƞ
d. 䌵峅˚⮉㈝⿇媇ㇽℑデ姯≪⎱䛟旃㛴⋀⎱䔉⒨ ; ⎱
e. 䂡ㄯ╫⎱ / ㇽ杅䉆∐䔏忻䙫㌷㬥⎱㌷峯˛
(iii) ⯮ᷱ㕮䬓 6(i) 㮜㈧廰斊ᷲ䙫ῲạ岮㖀㎷ᾂṯ㜓暭⛿ㇷⓈ㩆㦲⎱ƒ
ㇽ㜓⅓⏟Ḳ⤌ἛƏ孺⅝䔏㖣䛛㎌ᾪ択ᷱ㕮䬓 6(ii) 㮜㈧廰䙫㛴⋀
ㇽ䔉⒨˛
7. 勌斊ᷲᷴⷳ㜂㜓⅓⏟ὦ䔏斊ᷲ䙫ῲạ岮㖀Əㇽ⯮斊ᷲ䙫ῲạ岮㖀㎷
ᾂṯ⅝ẽạ⣒ㇽ⅓⏟ὃ䛛㎌ᾪ択䔏忻Ə媲✏Ọᷲ㛰旃㖠㠣ⅎ⊇ᷱ∻
(3) 噆Ə喰Ọ堳ὦ斊ᷲᷴ⏳ヶ㭋柬⭰㍹䙫㫱∐˛
†
媲ᷴ奨⯮䛛㎌ᾪ択岮㖀䙣䵍㜓ạ˛
†
媲ᷴ奨⯮㜓ạ䙫ῲạ岮㖀㎷ᾂṯ⅝ẽạ⣒ㇽ⅓⏟ὃ⅝䛛㎌ᾪ択
䔏忻˛
8. 斊ᷲẍ⏖㖣ỢἼ㘩敺凛⇤㜓⅓⏟Ọᷲ✗✧Ə喰Ọ㊹䴼䛛㎌ᾪ択˛
9. 㠠㓁ˣῲạ岮㖀Ƌ䦨暘ƌ㢄ὲˤƝ
(i)
斊ᷲ㛰㫱奨㰩㟌斘㜓⅓⏟㈧㋨㛰斊ᷲ䙫ῲạ岮㖀Əḍ奨㰩㔠㭊
斊ᷲ䙫ᷴ㭊䢡ῲạ岮㖀ƞ⎱
(ii)
㜓⅓⏟㛰㫱Ⱈ嘼䏭⎱恜堳斊ᷲ䙫㟌斘岮㖀奨㰩俳㔝⎽⏯䏭
岢䔏˛
(xiv) ⱌ堳ỢἼ㜓⅓⏟ㇽ㜓暭⛿ỢἼㇷⓈ㩆㦲䏥㛰ㇽ⯮ὭḲ⏯䳫侐⋀
ㇽ凮⅝ẽ✏榀㸖ㇽ⅝ẽ⌧⟆䙫㲼⮁㩆㦲˚䛊䮈㩆㦲˚㔦⺃㩆
㦲˚䧬⋀㩆㦲˚⟞㲼㩆㦲ㇽ⅝ẽ㩆㦲˚䍏䪲䛊䮈ㇽ堳㥔⛿檻Ƌ⥩
ῄ暑㥔偖㛪ㇽ⌻㛪䬰ƌƏ⛇⅝䛟旃Ḳ憸坴˚┭㥔˚㥔⋀ㇽ⅝ẽ
∐䚱ㇽ㴢⊼俳㉦㒻Ḳ侐⋀ƞ
10. 㟌斘ㇽ㔠㭊斊ᷲ䙫ῲạ岮㖀奨㰩ƏㆰỌ㛟杉⽉⻶⏸ᷲ⇾ạ⣒㎷⇡Ɲ
(xv) 恜⭯ỢἼ㖣㜓暭⛿ⅎ怙堳䙫㕟㓁⎱岮㖀⅘Ẓ⎱ƒㇽ⅝ẽ㕟㓁⎱
岮㖀䔏忻䙫岓Ợ˚奨㰩˚㔦䬽˚䧲⹶˚㎑㖤ㇽ⭰㍹Ọ䬍⏯ỢἼ
∝墨˚昙㭉ㇽ⁜㟌㳾溸按˚〷⿽⇭⬷岮憸䰳暭ㇽ⅝ẽ杅㲼㴢⊼ƞ⎱
⥩斊ᷲ㛰ỢἼ䕸┶Ə㕓媲凛曢㜓⅓⏟Ḳ⮉㈝㛴⋀䆘䷁ 3123 3123˛
(xvi) ⱌ堳凮ᷱ㕮䬓 (i) 凚 (xv) 㮜䛛㎌㛰旃䙫⅝ẽ䔏忻˛
4. 䂡总ㇷᷱ㕮䬓 3 㮜⇾⇡䙫䔏忻Ə㜓⅓⏟⏖僤⯮斊ᷲ䙫ῲạ岮㖀弰䧢˚
㊒朙˚孺⅝㟌斘ㇽ凮Ọᷲ⏫㖠Ƌᷴ媽✏榀㸖⡪ⅎㇽ⡪⣽俬ƌ⅘⏳ὦ
䔏Ə俳斊ᷲ䙫ῲạ岮㖀㛰⏖僤墒弰䧢⽧榀㸖⡪⣽Ɲ
(i)
㜓暭⛿䙫ㇷⓈ㩆㦲ƞ
(ii)
ỢἼạ⣒ㇽ⅓⏟⎾㜓⅓⏟㋮䤡ㇽỊ塏㜓⅓⏟ㇽ凮㜓⅓⏟⅘⏳嘼
䏭斊ᷲ㎷ᾂ䙫ῲạ岮㖀Ọ总∗㎷ᾂ㛰旃岮㖀Ḳ䛕䙫ㇽ䛛㎌䛟旃
Ḳ䛕䙫ƞ
(iii) ⯴㜓⅓⏟岇㛰ῄ⮭岓Ợḍ㉦嫥⯮㛰旃岮㖀ῄ⮭䙫ỢἼạ⣒ㇽ⅓
⏟Ə俳㭋ạ⣒ㇽ⅓⏟柯㛰⏯㲼㫱∐㟌斘㛰旃岮㖀Ƌὲ⥩Ɲ㜓⅓
⏟䙫⯯㥔桎┶ƌƞ
岮㖀ῄ孞ḢỢ
⮳塂ῄ暑㛰昷⅓⏟
榀㸖⾞廻怺Ḕ 308 噆⮳塂憸坴Ḕ⾪ 1 㧺
11. Ḕ勘㕮㜓⥩㛰㭎䕗Ə㥩Ọ勘㕮㜓䂡㹽˛
㜓ạⷙ䴗斘⎱㜓ạ㗵䙤⎱㎌⎾㜓㔝暭ῲạ岮㖀偙㗵˛
䰤⏴Ɲ
⦺⏴Ɲ
( 䔚媲ạƒ䍙䙣㜓偙㗵ạ⣒⦺⏴ )
榀㸖庒Ụ嬰 / 孞䅎䷏噆Ɲ
2013 ⹛ 7 㛯 (EB)