个人人身保险契约变更申请书(保益变更)

个人人身保险契约变更申请书（保益变更）Application for Alteration of Individual Insurance Policy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. 新增被保险人姓名/Name of new Insured:____________________________________ 与投保人关系 Relationship with Insured □/本人Self □配偶/Spouse□/子女Child □其他/Other :_____________________证件类型 Type of ID□身份证/Identity card □护照/Passport□其他/Other ____________________________________ 证件号/V alid ID number性别/Gender □男/Male □女/Female生日/Date of birth_________年/Year _________月/Month _________日/Day *□增加被保险人 Addition of Insured其他新增被保险人信息/Information of any additional new Insureds新增被保险人姓名/Name of additional new Insured:____________________________ 详情/Details:____________________________________________________________ _______________________________________________________________________□减少被保险人 Removal of an Insured 被保险人姓名/Name of Insured to be removed:1、________________________________2、_________________________________3、________________________________4、_________________________________ 申请项目/Policy selection to be altered□保额/Insured amount □档次计划/Plan □份数/Number of units □新增附险/Additional rider □终止附险/Cancellation of rider*□保障计划变更 Alteration of policy selection被保险人姓名 Name of Insured 险种简称及代码 Name and code of rider新保额、档次、份数New selection保单号/Policy number 投保人/Policyholder被保险人/InsuredB ．变更项目/Items to be altered*若申请新增附险，请投保人同时阅读并确认《人身保险投保提示书》。

Please read and confirm the "Life Insurance Application Notice " when applying for additional riders.□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.□整单犹豫期退保/Full policy cancellation during cooling-off period □附加险犹豫期退保/Rider cancellation during cooling-off period□犹豫期退保 Cancellation during cooling-off period申请对象（被保险人） Name of applicant (the Insured)附加险名称及代码 Name and code of rider□整单退保/Full policy cancellation □附加险退保/Rider cancellation□退保 Cancellation退保原因/Reasons for cancellation□经济原因/Financial problem □出国移居/Migration □保障不理想/Coverage problem □服务不理想/Service problem□理赔不满意/Claim problem □其它/Other reason:________________________申请对象（被保险人） Name of applicant (the Insured) 附加险名称及代码 Name and code of rider*□续保选择权变更Alteration of renewal choice 自动续保选择/Auto-renewal: □是/Yes □否/No 变更对象 Applicable to □投保人/ Policyholder □被保险人/ Insured □其他被保险人/ Other Insured*□职业变更 Alteration of occupation变更后的职业及代码 New occupation and Code职业/Occupation:_________________________________ 代码/Code:______________________________________□特别约定 Special arrangement 约定详情/Details of arrangement:________________________________________________________________________________________________________________________________________________ 告知对象/ Applicable to□投保人/Applicant □被保险人/Insured □其他被保险人/Other Insured:_____________________*□补充告知 Supplemental disclosure告知事项起始时间/Disclosed item valid since:__________________________________告知事项/Details of disclosure:______________________________________________ ________________________________________________________________________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、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.5、如果本申请书的中英文表述不一致，以中文表述为准。