有 * 符號的欄位必須填寫 | All fields marked with * are required
請填寫 Please fill in:
投保人姓名 （全名） *
Proposer Name (Full Name)
投保人有否駕駛執照? * Proposer has Driving Licence? | |
請選擇語言 * Select your preferred language | |
駕駛人資料 | Drivers Information
主要駕駛者一 / Regular Driver 1
駕駛者姓名 （全名） *
Driver's Name (Full name)
駕駛年資 *
Driving Experience
與投保人關係 *
Relation with Insured
| 1. | 3年內曾否發生交通意外或要求賠償? * Any motor accident, loss or claim during the past 3 years? |
| 2. | 3年內被扣分或正待檢控? * Any prosecutions pending or have been deducted driving offence points during the past 3 years? |
| 3. | 曾否被停牌? * Have been disqualified from driving? |
| 4. | 患有不健全之視覺或聽覺或身體上或精神上的毛病而不適宜駕駛? * Suffer from defective vision or hearing or from any physical or mental infirmity which may impair your ability to drive? |
| 5. | 曾被拒絕投保或取消保單,或拒絕續保汽車保險? * Ever been decline insurance, cancelled, or renewal refused by any motor insurer? |
主要駕駛者二 / Regular Driver 2
駕駛者姓名 （全名） *
Driver's Name (Full name)
駕駛年資 *
Driving Experience
與投保人關係 *
Relation with Insured
| 1. | 3年內曾否發生交通意外或要求賠償? * Any motor accident, loss or claim during the past 3 years? |
| 2. | 3年內被扣分或正待檢控? * Any prosecutions pending or have been deducted driving offence points during the past 3 years? |
| 3. | 曾否被停牌? * Have been disqualified from driving? |
| 4. | 患有不健全之視覺或聽覺或身體上或精神上的毛病而不適宜駕駛? * Suffer from defective vision or hearing or from any physical or mental infirmity which may impair your ability to drive? |
| 5. | 曾被拒絕投保或取消保單,或拒絕續保汽車保險? * Ever been decline insurance, cancelled, or renewal refused by any motor insurer? |
增加駕駛者 Add Driver
移除駕駛者 Remove Driver #2
主要駕駛者三 / Regular Driver 3
駕駛者姓名 （全名） *
Driver's Name (Full name)
駕駛年資 *
Driving Experience
與投保人關係 *
Relation with Insured
| 1. | 3年內曾否發生交通意外或要求賠償? * Any motor accident, loss or claim during the past 3 years? |
| 2. | 3年內被扣分或正待檢控? * Any prosecutions pending or have been deducted driving offence points during the past 3 years? |
| 3. | 曾否被停牌? * Have been disqualified from driving? |
| 4. | 患有不健全之視覺或聽覺或身體上或精神上的毛病而不適宜駕駛? * Suffer from defective vision or hearing or from any physical or mental infirmity which may impair your ability to drive? |
| 5. | 曾被拒絕投保或取消保單,或拒絕續保汽車保險? * Ever been decline insurance, cancelled, or renewal refused by any motor insurer? |
增加駕駛者 Add Driver
移除駕駛者 Remove Driver #3
主要駕駛者四 / Regular Driver 4
駕駛者姓名 （全名） *
Driver's Name (Full name)
駕駛年資 *
Driving Experience
與投保人關係 *
Relation with Insured
| 1. | 3年內曾否發生交通意外或要求賠償? * Any motor accident, loss or claim during the past 3 years? |
| 2. | 3年內被扣分或正待檢控? * Any prosecutions pending or have been deducted driving offence points during the past 3 years? |
| 3. | 曾否被停牌? * Have been disqualified from driving? |
| 4. | 患有不健全之視覺或聽覺或身體上或精神上的毛病而不適宜駕駛? * Suffer from defective vision or hearing or from any physical or mental infirmity which may impair your ability to drive? |
| 5. | 曾被拒絕投保或取消保單,或拒絕續保汽車保險? * Ever been decline insurance, cancelled, or renewal refused by any motor insurer? |
車輛類別 | Class of Use *
是否綿羊仔? * Is this a Scooter? | |
有否附加尾板? * Any tailgate installed? | |
有否附加吊機? * Any crane installed? | |
投保價$是否已計算上述附加裝置? The sum insured of HK$ has included the installation of above tailgate/crane? |
投保價需包括上述裝置之價值。 Insured Value must include the value of above tailgate/ crane. |
保障類別 | Coverage Required *
投保價 （現價包括冷氣機及音響裝置） * Insured value (Present value including accessories like air conditioner and audio) |
需要附加中港保障 (廣東省內)?
Required China Extension Coverage (Guangdong Province)?
有否財務?
Any Hire Purchsae arrangement?
出廠年份 * Manufacture Year | |
廠名 * Make | |
| 型號 * Model | |
汽缸用量 * Cylinder Capacity (CC) | CC |
許可車輛總重 * Permitted Gross Vehicle Weight | |
閣下曾否在俊銘保險投保? * Have you ever insured with Wellsmart Insurance? |
閣下曾否在俊銘保險投保? * Have you ever insured with Wellsmart Insurance? | |
投保人姓名 （全名）
Proposer Name (Full Name)
年齡 Age | |
投保人有否駕駛執照? Proposer has Driving Licence? | |
請選擇語言 Select your preferred language | |
駕駛人資料 | Drivers Information
主要駕駛者一 / Regular Driver 1
駕駛者姓名 （全名）
Driver's Name (Full name)
與投保人關係
Relation with Insured
| 1. | 3年內曾否發生交通意外或要求賠償? Any motor accident, loss or claim during the past 3 years? | |
| 2. | 3年內被扣分或正待檢控? Any prosecutions pending or have been deducted driving offence points during the past 3 years? | |
| 3. | 曾否被停牌? Have been disqualified from driving? | |
| 4. | 患有不健全之視覺或聽覺或身體上或精神上的毛病而不適宜駕駛? Suffer from defective vision or hearing or from any physical or mental infirmity which may impair your ability to drive? | |
| 5. | 曾被拒絕投保或取消保單,或拒絕續保汽車保險? Ever been decline insurance, cancelled, or renewal refused by any motor insurer? | |
主要駕駛者二 / Regular Driver 2
駕駛者姓名 （全名）
Driver's Name (Full name)
與投保人關係
Relation with Insured
| 1. | 3年內曾否發生交通意外或要求賠償? Any motor accident, loss or claim during the past 3 years? | |
| 2. | 3年內被扣分或正待檢控? Any prosecutions pending or have been deducted driving offence points during the past 3 years? | |
| 3. | 曾否被停牌? Have been disqualified from driving? | |
| 4. | 患有不健全之視覺或聽覺或身體上或精神上的毛病而不適宜駕駛? Suffer from defective vision or hearing or from any physical or mental infirmity which may impair your ability to drive? | |
| 5. | 曾被拒絕投保或取消保單,或拒絕續保汽車保險? Ever been decline insurance, cancelled, or renewal refused by any motor insurer? | |
主要駕駛者三 / Regular Driver 3
駕駛者姓名 （全名）
Driver's Name (Full name)
與投保人關係
Relation with Insured
| 1. | 3年內曾否發生交通意外或要求賠償? Any motor accident, loss or claim during the past 3 years? | |
| 2. | 3年內被扣分或正待檢控? Any prosecutions pending or have been deducted driving offence points during the past 3 years? | |
| 3. | 曾否被停牌? Have been disqualified from driving? | |
| 4. | 患有不健全之視覺或聽覺或身體上或精神上的毛病而不適宜駕駛? Suffer from defective vision or hearing or from any physical or mental infirmity which may impair your ability to drive? | |
| 5. | 曾被拒絕投保或取消保單,或拒絕續保汽車保險? Ever been decline insurance, cancelled, or renewal refused by any motor insurer? | |
主要駕駛者四 / Regular Driver 4
駕駛者姓名 （全名）
Driver's Name (Full name)
與投保人關係
Relation with Insured
| 1. | 3年內曾否發生交通意外或要求賠償? Any motor accident, loss or claim during the past 3 years? | |
| 2. | 3年內被扣分或正待檢控? Any prosecutions pending or have been deducted driving offence points during the past 3 years? | |
| 3. | 曾否被停牌? Have been disqualified from driving? | |
| 4. | 患有不健全之視覺或聽覺或身體上或精神上的毛病而不適宜駕駛? Suffer from defective vision or hearing or from any physical or mental infirmity which may impair your ability to drive? | |
| 5. | 曾被拒絕投保或取消保單,或拒絕續保汽車保險? Ever been decline insurance, cancelled, or renewal refused by any motor insurer? | |
出廠年份 Manufacture Year | |
廠名 Make | |
| 型號 Model | |
汽缸用量
Cylinder Capacity (CC)
許可車輛總重
Permitted Gross Vehicle Weight
閣下曾否在俊銘保險投保? Have you ever insured with Wellsmart Insurance? | |
車輛號碼 Registration Mark | |
是否綿羊仔? Is this a Scooter? | |
有否附加尾板? Any tailgate installed? | |
有否附加吊機? Any crane installed? | |
投保價 （現價包括冷氣機及音響裝置） Insured value (Present value including accessories like air conditioner and audio) |
需要附加中港保障 (廣東省內)? Required China Extension Coverage (Guangdong Province)? | |
有否財務? Any Hire Purchsae arrangement? | |
本公司有權使用、儲存、透露及／或轉移（不論在本港或海外）本公司不時所收集或持有之任何個人資料給本公司認為有需要之人士、團體及／或機構（不論是否與本公司有關），用作處理閣下提出之要求、執行閣下的保單、推廣及提供本公司、任何關聯公司及／或商業夥伴其後或其他服務或產品、直銷推廣、資料核對、聯絡閣下及／或遵守任何適用司法區域之法律或監管規定。閣下有權依據個人資料（私隱）條例要求查閱及更正任何本公司持有有關閣下之個人資料，所有要求均可以書面向客戶服務部之主管提出（地址：香港金鐘統一中心二樓商場二零二八室）。
Any personal information collected or held by our Company from time to time may be used, stored, disclosed and/or transferred (whether within or outside Hong Kong) to such individuals, entities and/or organisations as our Company may consider necessary (whether associated with our Company or otherwise) for the purpose of processing your request(s), administering your policies with our Company, promoting or providing subsequent or other services or products of our Company, any of our affiliated companies and/ or business partners, direct marketing, data matching, communicating with you and/or complying with the laws or regulatory requirements of any applicable jurisdiction. You have the right under the Personal Data (Privacy) Ordinance to request access to and correct any of your personal data held by our Company. Any request may be made in writing and addressed to the Shop 2028, 2/F., United Centre, 95 Queensway, Hong Kong.