健康告知書-廈門大學(xué)人事處-資料下載頁(yè)
2025-05-13 22:58本頁(yè)面
【正文】 ale insurants)□是Yes □否No□是Yes □否No□是Yes □否No□是Yes □否No□是Yes □否No★ 以上各項(xiàng)回答為“是”，請(qǐng)?jiān)诖藱谧⒚髟敿?xì)的傷病名稱、診治日期、醫(yī)院名稱、治療情形及目前狀況If your answer is Yes, please indicate here the name of disease, date of treatment, name of hospital, treatment detail you’re your current status.The name of disease：Date of treatment：Name of hospital：Treatment conditions：Your current status：C、被保險(xiǎn)人聲明及授權(quán)：Statement and authorization of the insurant: 被保險(xiǎn)人聲明及授權(quán) Statement and authorization of the insurant 本健康告知書作為保險(xiǎn)人簽發(fā)保險(xiǎn)合同之依據(jù)，本人確認(rèn)上述內(nèi)容真實(shí)無誤，如有隱匿、遺漏或不實(shí)之陳述，保險(xiǎn)公司可依據(jù)《中華人民共和國(guó)保險(xiǎn)法》第三十六條解除本人保險(xiǎn)合同；This health statement is regarded as a reference to the insurer for signing and issuing the insurance contract. I declare that all the above information is true and accurate to the best of my knowledge, and any omission or false statement will lead to the termination of my insurance contract in accordance with Article 36 of Insurance Law of the People39。s Republic of China. 本人同意并授權(quán)中英人壽保險(xiǎn)有限公司查閱本人之相關(guān)醫(yī)療記錄及病歷資料；I hereby agree to authorize AvivaCofco Life Insurance Co., Ltd to look up my medical records. 本人同意中英人壽保險(xiǎn)有限公司因業(yè)務(wù)需要對(duì)本人個(gè)人資料有搜集、計(jì)算機(jī)處理或國(guó)際傳遞的權(quán)利；I agree that AvivaCofco Life Insurance Co., Ltd has the right to conduct searching, puter processing or international delivery of my personal information whenever necessary. 本人知悉保險(xiǎn)公司對(duì)被保險(xiǎn)人投保時(shí)已患疾病或妊娠中者，對(duì)該項(xiàng)疾病或分娩不負(fù)保險(xiǎn)責(zé)任。I understand that the insurance pany will not be held responsible for the existing diseases or pregnancy of the insurant. 被保險(xiǎn)人/法定監(jiān)護(hù)人簽名 投保人蓋章/Policy holder(Unit):Insurant/Legal guardian (individual)： Date: 年 月 日 Date: 年 月 日 3 / 3
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