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人身保险个人投保单

2015-08-24 
全文兹拟向中国平安保险股份有限公司投保人身保险,内容如下:投保单编号:--------------------------------

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 全文
    兹拟向中国平安保险股份有限公司投保人身保险,内容如下:  投保单编号:
----------------------------------------------------
|    保险种类    |                                                                                  |
|--------|-----------------------------------------|
|投保人|  姓名  |          |  身份证号码  |                |  与被保险人关系  |                |
|      |----|--------------------------------|--------|
|情  况|  地址  |                                  |邮  编|              |电话|                |
|---|----|-----------------|---|-------|-----------|
|被保险|  姓名  |          |  年龄  |      |性别|      |  身份证号码  |                      |
|      |----|-----------------|---|-------|-----------|
|人情况|  地址  |                                  |邮  编|              |        电话          |
|--------|-----------------|-----------|-----------|
|    保险年期    |          |  保险份数  |        |受益人  |            |领取日期|            |
|--------|-----|------|----|----|------------------|
|    领取年龄    |          |  领取方式  |        |领取金额|                                    |
|--------------------------------------------------|
|    保险期限      |  自        年    月    日中午12时起至        年    月    日中午12时止      |
|--------------------------------------------------|
|                                基本保险金额                        |            附加保险金额      |
|----------------------------------|---------------|
|  意外伤残保额    |                                                |  附加险别  |                |
|  意外身故保额    |                                                |      保额  |                |
|  疾病伤残保额    |                                                |      费率  |                |
|  疾病身故保额    |                                                |            |                |
|  满期保险金额    |                                                |            |                |
|  生存给付金      |                                                |  附加险别  |                |
|                  |                                                |      保额  |                |
|  费      率      |                                                |      费率  |                |
|---------|----------------------------------------|
|    保险费        |                                                                                |
|---------|----------------------------------------|
|    保险本金      |                                                                                |
|---------|----------------------------------------|
|    缴费形式      |一次性缴费□    年缴□    半年缴□    季缴□    月缴□    其他:                |
|---------|----------------------------------------|
|    付款方式      |                                                |  币    种  |                |
|---------|------------------------|------|--------|
|    开户银行      |                                                |  帐    号  |                |
----------------------------------------------------
---------------------------------------------------
|特别约定:                                                                                        |
|                                                                                                  |
|                                                                                                  |
|                                                                                                  |
|-------------------------------------------------|
|被保险人健康状况:                                                                                |
|    1.目前尚在病假中?  □有□无                                                                |
|    2.因病休或因病减轻劳动量?  □有□无                                                        |
|    3.因患有其他慢性病而不能全勤工作或经常缺勤?  □有□无                                      |
|    4.有无严重病史?  □有□无                                                                  |
|    5.癌症、肝硬化、癫痫病、脑震荡、精神病、心脏病、高血压病、血管硬化、性病等?  □有□无      |
|                                                                                                  |
|投保人是否健康?  □是□否                                                                        |
|                                                                                                  |
|-------------------------------------------------|
|投保声明:                                                                                        |
|    1)本投保单所填写的各项内容,均属真实,可作为你公司签发保单的根据,并成为双方合约的组        |
|成部分,如日后发现与事实不符,即使保单签发,你公司仍可不负任何责任。                              |
|    2)本投保单方格内填列√者,即作为本投保人“同意”或“是”的答复。                            |
|    3)保户在投保时应填具确实年龄,保户年龄计算以身份证为根据,计算办法以保户在起保日最          |
|后一个生日时的足岁年龄计算,如误将年龄报小,应随时申请更正,并补缴保费及其利息,否则在发          |
|生给付时,其应得利益当按保户所付保费与实际年龄应付保费之比例计算。                                |
|                                                                                                  |
|                                                    投保人(签章)          年    月    日        |
|                                                                                                  |
---------------------------------------------------
(以下由保险公司填写)
--------------------------------------------
|审核意见:                                                                          |
|                                                                                    |
|                                                                                    |
|                                                      审核人(签章)      公司章    |
|                                                                                    |
|------------------------------------------|
|保险单号码:      签单人代码:        签单日期:        年    月    日              |
------------------------------------------

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