团体人身保险契约变更申请书
Application for Alteration of Group Insurance Policy
保单号
/Policy number
投保单位全称/Policyholder
申请下述标记有“*”的项目时，请根据本公司要求填写相关人员信息及健康告知。
It you select items marked with a “*” below, please fill out the relevant personal information and health declaration according to the applicable requirements. 申请人数合计/Total number of new additional Insureds:_________________________ *□增加被保险人 Addition of Insured
申请原因
Reasons for application
□新入职/New hires
□其他/Other:___________________________________
申请人数合计/Total number of Insureds to be removed:_________________________ 申请原因
Reasons for application
□离职/People leaving □退休/Retirement
□丧失参保资格/Disqualification
□其他/Other:___________________________________
□减少被保险人 Removal of an Insured
□整单退保 Full policy Cancellation
□犹豫期退保
Cancellation during
cooling-off period 投保人声明：投保人已知晓自退保申请之日起相关保险责任终止并已经告知所有相应被保险人。
Applicant ’s declaration: we (I) have understood that related insurance liabilities will be
terminated upon the date of insurance cancellation application and have notified all the
Insureds involved.
申请项目
Policy selection to be altered
□新增保障计划/Adding a rider □减少保障计划/Removing a rider □层级变更/Grade change
*□保障计划变更 Alteration of policy selection
变更人数/Alteration of number of Insured:____________________________________
申请人数合计Total number of Insureds:_____________________________________ 交费合计/Total premium amount:___________________________________________ □续期交费 Payment renewal
长期险填写 Long-term insurance
□保单管理费交费Policy management fee payment:_______________ □公共账户交费金额/Paid by company account:__________________ □个人账户交费金额/Paid by personal account: __________________
items 个人账户交费金额分配
Employer contribution to personal account:_______________________
□账户领取Withdrawal □公共账户/Company account □个人账户/Personal account
领取明细/Withdrawal amount:____________________________________________
□账户转移Account transfer 转移详情/Transfer amount:_______________________________________________ _______________________________________________________________________ □单位地址信息
Employer address
__________省/直辖市/Province__________市/City_________
区/县/Borough_______________________________________□联系人
Contact person
联系电话
Contact telephone
□保单资料变更
Alteration of
policy information
□其他/Other:___________________________________________________________
_______________________________________________________________________
*□投保单位变更Change of
Policyholder 变更原因/Reasons for application:___________________________________________ _______________________________________________________________________新投保单位名称/New Policyholder:_________________________________________变更对象（被保险人姓名）/Name of Insured:_________________________________ _______________________________________________________________________申请项目
Items to be altered
□被保险人姓名/Insured’s name □年龄/性别/Age/gender
□证件信息/ID information □其他/Other:____________
□个人客户资料变更
Alteration of
client information
变更详情/Details of change:______________________________________________
_______________________________________________________________________
□受益人变更Change of Beneficiary 申请人数合计/Total number of Beneficiaries:__________________________________投保人指定身故受益人时须经被保险人同意。投保人为与其有劳动关系的劳动者投保时，不得指定被保险人近亲属以外的人为身故受益人。
The Insured has to agree with the choice of designated beneficiary who is appointed by the Policyholder. Only close relatives can be designated as a Beneficiary of the death benefit when the applicant is an employer of the Insured.
申请项目
Items to be altered
□理赔账号/Claims account
□其他账号/Other account:____________________________
□个人账号变更Alteration of
account
被保险人姓名
Name of
Insured 开户银行
Bank
户主
Account
holder
银行账号
Account number
□保单挂失补发 Report loss of policy
□挂失 □挂失解除 □补发 Report loss Cancel loss reported Reissue
若申请补发保单，则自补发之日起，原保单自动作废，且挂失状态自动取消。 When a new insurance policy is issued, the original insurance policy will be automatically cancelled and the previously reported loss will also be void.
*□特别约定
Special arrangement 变更详情/Details of arrangement:__________________________________________ _______________________________________________________________________ □其他 Other
变更详情/Details of change:______________________________________________ _______________________________________________________________________
1、
请用黑色钢笔或签字笔在变更项目前□内打√，并用正楷填写变更内容；
Please tick “√” in “□” in the front of the applicable item(s) using a black pen or a signature pen, and fill in the details in clear handwriting.
2、若您申请的变更项目中，存在部分或全部申请项目不符合法律规定或者保险合同约定的，该申请项目无
效。
The application will not take effect if any or all of the alteration applied for conflicts with relevant laws, regulations, or the insurance contract.
3、请保持申请书签名与留存于本公司的签名样本一致。为维护您的权益，请勿在空白申请书上签名。 The signature on the application form has to be the same as the signature sample left with the Insurer. To protect your rights and interest, please do not sign a blank application form.
4、必要时请同时提供具体清单。
Please attach papers with additional information when required.
5、本人同意提供给平安集团（指中国平安保险（集团）股份有限公司及其直接或间接控股的公司）的信息， 及本人享受平安集团金融服务产生的信息（包括本单证签署之前提供和产生的），可用于平安集团及因服 务必要而委托的第三方为本人提供服务及推荐产品，法律禁止的除外。平安集团及其委托的第三方对上 述信息负有保密义务。本条款自本单证签署时生效，具有独立法律效力，不受合同成立与否及效力状态 变化的影响。
I hereby agree that all information provided by me to the Ping An Group (Ping An Insurance (Group) Company of China, Ltd. and its direct or indirect holding companies), and all information arising from the financial services I receive from Ping An Group (including information provided or generated prior to the signing of this application) may be used by the Ping An Group and its appointed third party(ies) (necessitated by
service-related reasons) for the purpose of providing client services and product recommendations, excluding those prohibited by law. Ping An Group and its appointed third party(ies) have the obligation to keep the aforementioned information confidential. This authorization clause shall take effect upon the signing of this application and carry legal effect on its own regardless of whether or not the contract is signed or any change(s) to its legal effect
.6、如果本申请书的中英文表述不一致，以中文表述为准。
Should there be any discrepancies between the Chinese and English versions, the Chinese version shall prevail.
结算方式
Method of settlement
□即时结算(Instant settlement) *□定期结算/Periodic direct debit □其他:_________________________________________________________________ 说明：“定期结算”收付款方式仅适用于已经与我公司签订《定期结算协议》的保单。 Please note: The Periodic Direct Debit service is only available when the Policyholder signs a Periodic Direct Debit Agreement with Ping An Health.
账户信息 Account details
开户银行/Bank:__________________________________________________________ 支行及分行/Branch & Sub-branch:___________________________________________ 户主姓名/Name of account holder:___________________________________________ 账号/Account number:_____________________________________________________
授权人（申请资格人）声明 / Declaration of the applicant:
本人/本单位 （申请资格人）已经详细阅读并同意申请书填写相关注意事项，现全权委托__________________ _______________________（受托人）办理以上指定申请事项，日后如有任何法律纠纷由本人/本单位自行负责，特此声明。
I (the applicant) have read and agreed the “Notes of the Application ”, and authorize the above person to handle my application. I will be responsible for any legal disputes caused by this application. 受托人声明/Declaration of the assignee:
受托人保证本申请书填写内容及授权人签名的真实有效性，并在授权范围内代为办理委托事项，严格遵循授权人的真实意愿，如果所实施的行为超出授权范围，受托人自愿承担相应责任。
The person authorised to complete this application (assignee) has to ensure the authenticity of the information provided in this application form as well as the signature,and has to follow the true will of the applicant and proceed with authorization. The assignee agrees to be responsible for any unauthorized action. 投保人签章/Applicant signature (seal)
经办人/Agent:_________________________________ 新投保人签章/New Policyholder signature (seal)
经办人/Agent:_________________________________
被保险人签字/Insured signature:
_____________________________________________________________________________________________ _____________________________________________________________________________________________ 申请日期/Date of application: _________年/Year _________月/Month _________日/Day 受托人/Assignee:______________________________ 证件号/ID number:_____________________________ 日期/Date:____________________________________ 联系电话/Tel No.______________________________ 保险公司意见/Insurer ’s comments:
经办 Handled by
核保
Underwritten by
公司服务热线 Service Hotline :4008833663