Sun Flower

TR/Business Introducer Details 業務代表/業務引薦人資料 (if any 如有)

Name 名稱

Contact No.聯絡電話

Email Address 電子郵件

Contact Person Details 聯絡人資料

Name 名稱*

Contact No.聯絡電話*

Email Address 電子郵件*

*Mandatory fields必須填寫項目

Type of Insurance 保險類別

Private Motor 私家車 Commercial Vehicle 商用車 Motorcycle 電單車

Insurance Cover 投保細則

Cover Required 保險類別：

Comprehensive 綜合保險(簡稱全保) Third Party 第三者責任保險 Both兩者

Extension Coverage 附加保障：

Own Damage extension in Guangdong Province 附加廣東省內汽車自身損毀

Northbound Travel for Hong Kong Vehicles 港車北上

Third party property damage liability limit upgrade to 提升｢第三者財產損毁的法律責任｣賠償額

Liability for Tool of Trade Operation (Applicable for Commercial Vehicle only)
附加操作責任保證(只適用於商用車):

Tailgate Liability 升降尾板責任

Crane Liability 起重機責任

Applicant infomation 投保人資料

Individual 個人

Company 公司 (如以公司名義作為投保人 (If the proposer is a business entity/company)

Name of motor car owner (Same as vehicle registration document) 車主姓名 (須與車輛登記文件上相同)

Surname 姓 / Company Name 公司名稱：

Given Name 名：

Proposer has Driver License 投保人持有駕駛執照

是

否

Occupation/Business Nature
職業 / 業務性質

Age
年齡

No. of Years Driving Experience
駕駛年資

No claim Discount
無賠償折扣 %

Motor Car Information 車輛細節

Make
廠名

Model
型號

Year of Manufature
出廠年齡

Cylinder Capacity
汽缸容量

Electric Vehicle 電動汽車

Body Type
車身類型

Applicable for Commercial Vehicle only
只適用於商用車

Accessories Estimated Value
估計附加設備市值

Tailgate 尾板

HK$

Crane 吊機

HK$

Freezer 凍櫃

HK$

Advertisement 廣告

HK$

Vehicle Tonnage
車輛噸位

Body Type(CV)
車身類型(商用車)

Estimated Vehicle Value
(including accessories, spare parts, tailgate and crane)
車輛市值估計 (包括附件, 備件, 升降尾板和起重機)

HK$

Named Driver Details 記名駕駛者資料

	Named Driver 1 主要駕駛者一	Named Driver 2 主要駕駛者二	Named Driver 3 主要駕駛者三	Named Driver 4 主要駕駛者四
Surname 姓氏
Given Name 名字
Age 年齡
Occupation/Business Nature 職業/業務性質
Relationship with Proposer 與投保人關係
No. of Years Driving Experience 駕駛年齡
No.of Years Driving Experience(Electric Vehicle) 駕駛年資(電動車)
Offence Point 違例駕駛分數

汽車保險報價申請表 MOTOR INSURANCE REQUEST FORM

Driving Experience 駕駛經驗

Has the policyholder and/or any named driver(s) and/or any insured driver(s) to be insured under the policy made any claim(s) under an insurance policy in the last three(3) years

投保人及/或記名司機及/或受保司機，是否曾在過去3年內就保險單向保險公司做出索償？

Yes是 No否

If Yes,please give details 如有，請詳述:

Total number of claims (excluding Windscreen claims) made by policyholder and/or All named driver(s) and/or insured driver(s)?

投保人及/或記名司機及/或受保司機提出索償的總次數（不包括黨風玻璃索賠）？

Total number of claims (excluding Windscreen claims) made by policyholder and/or All named driver(s) and/or insured driver(s)?

投保人及/或記名司機及/或受保司機因黨風玻璃提出索償的總次數？

Total claim amount incurred by policyholder and All named driver(s) and/or insured driver(s)?

投保人及/或記名司機/或受保司機的總索償金額？

HK$

Has the policyholder and/or any named driver(s) and/or any insured driver(s) traffic offence points, or ever been suspended and/or revoked with the driving license in the past 3 years?

投保人及/或記名司機及/或受保司機，是否曾在過去3年內被暫停及/或吊銷駕照或被記錄違例駕駛分數？

Yes是 No否

If Yes,please give details 如有，請詳述:

Did the policyholder and/or any named driver(s) and /or any insured driver(s) have any motor policy being terminated or refused for quotation/renewal by another insurer in the past

投保人及/或記名司機及/或受保司機，有否被任何保險公司拒絕受保、拒絕續保或終止未到期之保險？

Yes是 No否

If Yes,please give details 如有，請詳述:

Will passengers or goods be carried for hire, reward, car-sharing or ride-sharing services(including but not limited to UBER or FOGOVAN or LALAMOVE)

投保汽車有否以出租或收取報酬形式接載乘客或運載貨物或作汽車共享或乘車共享服務（包括但不僅限於UBER或GOGOVAN或LALAMOVE）

Yes是 No否

If Yes,please give details 如有，請詳述: