團(tuán)體保險(xiǎn)個(gè)人健康告知書(shū)

1、15團(tuán)體保體保險(xiǎn)個(gè)人健康告知個(gè)人健康告知書(shū)HealthStatementfGroupInsuranceInsurants填寫(xiě)須知NoticeNotice1.在填寫(xiě)健康告知前，請(qǐng)?jiān)敿?xì)閱讀本公司相關(guān)保險(xiǎn)產(chǎn)品條款，特別是保險(xiǎn)責(zé)險(xiǎn)責(zé)任和任和責(zé)任免除任免除條款事項(xiàng)；PleasereadallthetermsconditionsofthispolicycarefullybefefillinginthisStatementofHealthespeci

2、allyarticlesconcerningthebenefitsexclusions.2.請(qǐng)您完整填寫(xiě)本告知書(shū)內(nèi)的相關(guān)部分。請(qǐng)您準(zhǔn)確填寫(xiě)、如實(shí)告知，這對(duì)于您的投保申請(qǐng)十分重要；Pleasefilloutallrelevantsectionscompletely.PleasebenotedthatitisveryimptancethatallrelevantquestionsonthisStatementofHealthareanswe

3、redaccuratelytruthfully.3.本告知書(shū)只有被保險(xiǎn)人本人親筆簽名后生效。如有修改，需在修改處加簽字；TheStatementofHealthwillnotbevaliduntilbeingsignedbytheinsuredhimherself.Incaseofanycrectionadditionalsignatureshallbeaddednexttothecrection.4.本告知書(shū)為投保人與保險(xiǎn)公司所訂立保

4、險(xiǎn)合同的組成部分。與本告知書(shū)各事項(xiàng)相違背的任何口頭承諾均屬無(wú)效。TheStatementofHealthshallbetreatedasapartoftheentireinsurancecontractbetweenpolicyholderinsurer.AnyinfmalalagreementwhichisinconsistentwiththecontentoftheStatementofHealthshallbedeemedasin

5、valid.A、被保、被保險(xiǎn)人資料（料（InfmationofInsurant）投保人Company：廈門(mén)大學(xué)大學(xué)XiamenUniversity被保險(xiǎn)人姓名Name：被保險(xiǎn)人與員工的關(guān)系：□配偶□子女NATheinsuredpersonemployeerelations：□Spouse□child附屬被保險(xiǎn)人姓名：NANameofthesubsidiaryinsured：NA身份證號(hào)碼：ID：性別Gender：年齡Age：B、個(gè)人健康

6、個(gè)人健康問(wèn)卷（IndividualHealthQuestionnaire）請(qǐng)您完整填寫(xiě)您的相關(guān)信息。假如您有連帶保險(xiǎn)人一同投保，請(qǐng)另外填寫(xiě)告知書(shū)。Pleasecompleteallthenecessaryinfmation.IfyouhavedependentspleasefillinadditionalStatementofHealthfmsfthem.請(qǐng)對(duì)本部分的問(wèn)題做出“是”或“否”的回答。對(duì)回答“是”的問(wèn)題，請(qǐng)?jiān)陔S后的空白處填寫(xiě)

7、詳細(xì)的相關(guān)信息，所有提供的信息均會(huì)被嚴(yán)格保密。申請(qǐng)人必須對(duì)相關(guān)問(wèn)題的重要事實(shí)如實(shí)告知，否則將有可能影響本保單的有效性?！爸匾聦?shí)”是指任何有可能影響本次投保的結(jié)果的信息；若你對(duì)某些事實(shí)是否屬“重要事實(shí)”有所疑問(wèn)，請(qǐng)您就這些事實(shí)一并如實(shí)告知。Thequestionsinthefollowingsectionshallbeansweredwith“YES”“NO”.Ifyespleasespecifydetailsinthespacepro

8、vided.Allinfmationprovidedherewillbekeptconfidential.Allmaterialfactspertinenttothesequestionsshallbedisclosedcrectlytruthfully.Anymisstatementinthequestionnairemayinfluencethevalidationofthepolicy.“Materialfact”refersto

9、anyinfmationthatwouldbelikelytoinfluencetheinsurer’sassessmentacceptanceofthisapplication.Ifyouhaveanydoubtaboutwhetherafactshallbetreatedasmaterialpleasediscloseitatthesametime.下列所有下列所有問(wèn)題應(yīng)該問(wèn)題應(yīng)該分別針對(duì)別針對(duì)被保被保險(xiǎn)人或其人或其連帶連帶被保被保

10、險(xiǎn)人進(jìn)行回答。行回答。Allfollowingquestionsshouldbeansweredbytheinsuredeachdependent.1、被保險(xiǎn)人身高cm，體重poundkg，過(guò)去兩年內(nèi)體重是否增減超過(guò)5公斤？HeightcmWeightpoundkgduringthelasttwoyearshaveyougainedlostweightfover11bounds5kg□是Yes□否No2、過(guò)去兩年內(nèi)是否曾因接受健康檢查有

11、異常情形而被建議接受其他檢查或治療？Duringthelasttwoyearshaveyoueverbeensuggestedtoreceiveotherkindsofphysicalexaminationstreatments□是Yes□否No泰康人壽保險(xiǎn)股份有限公司廈門(mén)分公司廈門(mén)市蓮岳路1號(hào)磐基中心12層35includingbutnotlimitedtolipsplitpalatesplitobstructivesleepapne

12、asyndromeTMJ(tempomibularjoint)disdersetc.m)傳染性疾病，包括但不限于：艾滋病、HIV攜帶、性病、肝炎、熱帶疾病或其它疾病。TheepidemicdiseasesincludingbutnotlimitedtoAIDSHIVcarryingvenerealdiseaseshepatitistropicaldiseasesotherdisders.n)肌肉骨骼系統(tǒng)疾?。ü穷^關(guān)節(jié)脊柱椎間盤(pán)肌肉韌帶肌

13、腱），包括但不限于：背、頸肩不適，關(guān)節(jié)炎、風(fēng)濕、腕管綜合癥或其它病。Themusculoskeletaldiseases(bonesjointsspineintervertebraldiscsmusclesligamentstendons)includingbutnotlimitedtodisdersofthebackneckshouldersarthritisrheumatismcarpaltunnelsyndromeotherdis

14、ders.o)各種慢性損傷、炎癥、感染性疾病。AllchronicTraumainflammationinflectiondiseases.p)各種遺傳性疾病。AnyHereditaryDisders.q)上列未述的其他結(jié)構(gòu)異常，包括但不限于：各種天生缺陷、畸型等。Otherstructuralabnmalitiesnotlistedaboveincludingbutnotlimitedtoallkindsofcongenitaldef

15、ectsdefmitiesetc.r)上列未述的其他功能異常，包括但不限于：癱瘓、跛行等。Otherfunctionalabnmalitiesdisturbancesproblemsnot.s)您是否作過(guò)HIV抗體測(cè)試；如果是，具體結(jié)果是什么HaveyoubeentestedfHIVantibodiesIfyes:what’stheresult請(qǐng)?jiān)谙旅婵瞻椎胤教顚?xiě)相關(guān)于上述B部分的額外信息。如果空白地方不夠，請(qǐng)另附紙張?zhí)顚?xiě)，隨同本告知書(shū)

16、一同交回給我們。UsethisspacetocompleteextrainfmationrequiredfSectionB.Continueonaseparatesheetofpaperifneeded.6、父母、兄弟姐妹、子女中是否患有高血壓、心臟病、中風(fēng)、糖尿病、甲狀腺疾病、腎臟疾病、惡性腫瘤、精神病或其它遺傳性疾??？Areyourparentsbrotherssisterschildrensufferingfromhyperten

17、sionheartdiseasesapoplexydiabetesthyroiddiseaseskidneydiseasesmalignanttuminsanityotherhereditarydiseasesIftheanswerisyes.Pleaseindicatewhothediseasesuffererwaswhatthediseasehistywas.□是Yes□否No□是Yes□否No□是Yes□否No□是Yes□否No□

18、是Yes□否No□是Yes□否No□是Yes□否No□是Yes□否No7、女性被保險(xiǎn)人回答：Ifyouarefemalepleaseanswerthefollowingquestions（1）目前是否患有乳腺炎、乳漏癥、乳房或淋巴結(jié)腫大、腫塊、疼痛、血性溢乳等感覺(jué)或異常發(fā)現(xiàn)？Areyoucurrentlysufferingfrommastitisgalactrheabreastlymphadenopathtumourpainhermet

19、iclactrhea（2）目前是否有子宮內(nèi)膜異位癥、陰道異常出血、子宮頸抹片檢查異常？Areyoucurrentlysufferingfromendometriosisabnmalvaginahemrhageotherabnmalfindingsinthepapanicolaoutest（3）過(guò)去是否曾因乳房、子宮內(nèi)膜異位、卵巢等疾病而接受診斷、治療或用藥？Duringthepastyearshaveyousufferedfrombre