中英人壽保險(xiǎn)有限公司廈門分公司 廈門湖濱中路9號交通銀行大廈13層 20101001版式 電話：0592-2273180 傳真：0592-2273123 團(tuán)體保險(xiǎn)被保險(xiǎn)人健康告知書 Health Statement for Group Insurance Insurants A、被保險(xiǎn)人資料： Information of Insurant: 投保人/ Company： 被保險(xiǎn)人姓名/ Name： 被保險(xiǎn)人與員工的關(guān)系：□配偶 □子女 The insured person and employee relations：□Spouse □child 附屬被保險(xiǎn)人姓名： Name of the subsidiary insured： 身份證號碼： ID： 性別/ Gender： 年齡/Age： B、健康告知： Health Statement: 1、被保險(xiǎn)人身高 cm，體重 pound/kg，過去兩年內(nèi)體重是否增減超過5公斤？ Height cm, Weight pound/kg; during the last two years, have you gained/lost weight for over 11bounds/5 kg? □是Yes □否No 2、過去兩年內(nèi)是否曾因接受健康檢查有異常情形而被建議接受其他檢查或治療？ During the last two years, have you ever been suggested to receive other kinds of physical examinations or treatments owing to some abnormal findings detected during your routine health examination? □是Yes □否No 3、最近六個(gè)月是否曾因受傷或生病接受藥物治療、外科手術(shù)或服用藥物？ During the most recent 6 months, have you ever taken pharmaceutical treatment, surgical operation or medicines owing to the cause of injury or sickness? If the answer is yes ,please give the reason. □是Yes □否No 4、目前身體是否有失明、聾啞及言語、咀嚼障礙、四肢缺損、畸形及機(jī)能障礙？ Are you currently suffering from ablepsia, deafmutism, masticatory dysfunction, defect of extremities, deformity or functional disturbance? □是Yes □否No 5、過去五年內(nèi)，是否曾患有下列疾病，而接受治療、診療或用藥？ During the past five years, have you suffered from the following diseases and taken corresponding treatments and medicines? （1）高血壓（指收縮壓140mmHg或舒張壓90mmHg以上）、狹心癥、心肌梗塞、心肌肥厚、心內(nèi)膜炎、風(fēng)濕性心臟病、先天性心臟病、主動脈血管瘤、心肌擴(kuò)大、心臟瓣膜疾?。íM窄、脫垂、缺損、閉鎖不全、畸形）、心博過速或過緩性心律不整。 Hypertension (the systolic pressure is above 140mmHg or the diastolic pressure is above 90mmHg), angina pectoris, coronary occlusion, pachynsis of cardiac muscle, endocarditis, rheumatic heart disease, congenital heart disease, angioma of aorta, broaden of cardiac muscle, valvular heart disease (coarctation, prolapsus, defect, insufficiency or deformity), overspeed of heart-beat or arrhythmia. （2）腦中風(fēng)（腦出血、腦梗塞）、短暫性腦缺血、腦瘤、腦動脈血管瘤、腦動脈硬化癥、腦動靜脈畸形、多發(fā)性硬化癥、脊髓病變、癲癇、肌肉萎縮癥、重癥肌無力、智能障礙（外表無法明顯判斷者）、帕金森氏癥、精神病、腦性麻痹、癡呆癥、躁郁癥、憂郁癥、運(yùn)動神經(jīng)原疾病。 Cerebral apoplexy (cerebral hemorrhage, cerebral infarction), transient cerebral ischemia, encephaloma, angioma of cerebral arteries, cerebral arteriosclerosis, arteriovenous malformation, multiple sclerosis, myeleterosis, epilepsy, sweeny, myasthenia gravis, disturbance of intelligence (unapparent from the appearance), Parkinsons disease, insanity, cerebral palsy, cretinism, manic depression, hypochondria and motoneuron diseases. （3）慢性支氣管炎、肺氣腫、支氣管擴(kuò)張癥、塵肺癥、肺結(jié)核、慢性阻塞性肺疾病、哮喘、肺膿腫、肺栓塞、胸膜 炎及其他呼吸系統(tǒng)疾病。 Chronic bronchitis, emphysema, bronchiectasis, pneumoconiosis, phthisis, chronic obstructive disease of lung, asthma, pulmonary abscess, pulmonary embolism, pleuritis and other respiratory diseases. （4）肝炎、肝內(nèi)結(jié)石、肝硬化、肝功能異常（肝功能檢驗(yàn)結(jié)果異于檢驗(yàn)標(biāo)準(zhǔn)的正常值）、肝炎帶原。 Hepatitis, intrahepatic concretion, hepatocirrhosis, liver dysfunction (the examination result being different from the normal value) and hepatitis carrier. （5）腎臟炎、腎病癥候群、腎功能異常、腎衰竭、尿毒、腎囊胞、尿路結(jié)石、尿路畸形、膀胱疾病、前列腺疾病或其它泌尿生殖系統(tǒng)疾病。 Nephritis, nephropathy syndrome, kidney dysfunction, renal failure, uremia, renal sac endoenzyme, urinary lithiasis, urinary tract deformity, bladder diseases, prostate diseases or other urogenital system diseases. （6）血管畸形、視網(wǎng)膜出血或剝離、視神經(jīng)病變、眼底病變。 Vessel deformity, retinal hemorrhage or decollement, optic nerve lesion, or eyeground lesion. （7）癌癥（惡性腫瘤）、未經(jīng)證實(shí)為良性或惡性之腫瘤、大腸息肉、硬塊、囊腫、贅生物。 Cancer (malignancy), unproven tumour, polypus, hard lump, cyst or excrescence of the large intestine. （8）血友病、白血病、各類貧血、紫斑癥及其它各類的血液系統(tǒng)疾病，被建議不宜獻(xiàn)血。 Hemophilia, leukaemia, anemia, purple plague and other blood system diseases, blood donation prohibited. （9）糖尿病、類風(fēng)性關(guān)節(jié)炎、肢端肥大癥、腦下垂體機(jī)能亢進(jìn)或低下、甲狀脈或副甲狀腺功能亢進(jìn)或低下。 Diabetes, arthritis, acromegaly, pituitarygland hyperfunction or hypopituitarism, thyroid or parathyroid gland hyperfunction or hypopituitarism. （10）紅斑性狼瘡、膠原癥或其它結(jié)締組織疾病。Lupus erythematosus, collagen diseases or other desmosis diseases （11）艾滋病或艾滋病帶原。AIDS or AIDS carrier （12）胸、頸、腰椎骨疾病或其它骨骼系統(tǒng)疾病。Chest, neck or lumbar vertebrae related diseases or other skeletal system diseases □是Yes □否No □是Yes □否No □是Yes □否No □是Yes □否No □是Yes □否No □是Yes □否No □是Yes □否No □是Yes □否No □是Yes □否No □是Yes □否No □是Yes □否No □是Yes □否No □是Yes □否No 6、過去一年內(nèi)是否曾因下列疾病，接受治療、診療或用藥？ During the past one year, have you the following diseases and taken corresponding treatments and medicines? （1）性病、酒精或藥物濫用成癮、各種眩暈癥。Venereal disease, alcohol or drug addiction, megrims. （2）食道、胃、十二指腸潰瘍或出血、潰瘍性大腸炎、胰臟炎。 Ulcer or hemorrhage of the gullet, stomach or duodena, ulcer related colitis or pancreatitis. （3）肝炎病毒帶原、肝膿瘍、肝脾腫大、黃疸。Hepatitis virus carrier, hepatic abscess, hepatosplenomegaly or icterus. （4）慢性支氣管炎、氣喘、肝膿瘍、肺栓塞、肋膜炎。 Chronic bronchitis, asthma, hepatic abscess, pulmonary embolism or pleurisy. （5）痛風(fēng)、高血脂癥、青光眼、白內(nèi)障。Podagra, hyperlipemia, glaucoma or cataracta. （6）口腔白斑或纖維化或潰瘍、不明皮膚色素淀、體重減輕超過10%以上。 Oral leukoplakia, fibrosis or ulcer, skin pigmentation, loss of weight for over 10%. （7）未經(jīng)證實(shí)之良性或惡性腫瘤、心臟傳導(dǎo)性疾病、心臟瓣膜缺損、氣胸、大腸躁動癥、泌尿道感染癥、風(fēng)濕癥、四肢麻痹及浮腫、白血球增多癥、椎間盤突出癥、單核白血球增多癥、B型肝炎帶原、肺炎、膽結(jié)石、尿路結(jié)石、肝內(nèi)結(jié)石、肝腫大、大腸息肉、骨盆腔炎、中耳炎、不明原因發(fā)燒超過二周、進(jìn)行性肌萎縮、硬皮癥、卵巢炎、輸卵管炎、前列腺肥大或發(fā)炎、慢性胃炎、子宮頸糜爛、子宮脫出、疝氣、腦挫傷、腦震蕩。 Unproven benign or malignant tumor, heart-conductive diseases, defect of heart valve, pneumothorax, large intestine disorder, urinary tract infection, rheumatism, quadriplegia or edema, leukocytosis, protrusion of ntervertebral disc, increase of monocyte, B-type hepatitis carrier, pneumonia, gallstone, urinary lithiasis, intrahepatic concretion, hepatomegaly, polypus of large intestine, pelvic infection, tympanitis, unknown fever of over weeks, progressive muscular atrophy, scleroderma, ovaritis, salpingitis, prostatic hypertrophy or prostatitis, chronic gastritis, cervical erosion, uterine prolapse, herniae, brain contusion or cerebral concussion. □是Yes □否No □是Yes □否No □是Yes □否No □是Yes □否No □是Yes □否No □是Yes □否No □是Yes □否No □是Yes □否No 7、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病？Are your parents, brothers, sisters or children suffering from hypertension, heart diseases, apoplexy, diabetes, thyroid diseases, kidney diseases, malignant tumor, insanity or other hereditary diseases? If the answer is yes. Please give details about who’s the disease sufferer and the disease history. 8、女性被保險(xiǎn)人回答：If you are female, please answer the following questions （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、血性溢乳等感覺或異常發(fā)現(xiàn)？Are you currently suffering from mastitis, galactorrhea, breast lymphadenopath/tumour/pain or hematic lactorrhea? （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？Are you currently suffering from endometriosis, abnormal vagina hemorrhage or other abnormal findings in the papanicolaou test? （3）過去是否曾因乳房、子宮內(nèi)膜異位、卵巢等疾病而接受診斷、治療或用藥？During the past years, have you suffered from breast, endometriosis or ovarium related diseases and taken corresponding treatments and medicines? （4）目前是否已懷孕？如是，已經(jīng) 周（女性被保險(xiǎn)人回答）Are you currently pregnant? If yes, please indicate the number of weeks _______(for female insurants) □是Yes □否No □是Yes □否No □是Yes □否No □是Yes □否No □是Yes □否No ★ 以上各項(xiàng)回答為“是”，請?jiān)诖藱谧⒚髟敿?xì)的傷病名稱、診治日期、醫(yī)院名稱、治療情形及目前狀況 If your answer is "Yes", please indicate here the name of disease, date of treatment, name of hospital, treatment detail you’re your current status. The name of disease： Date of treatment： Name of hospital： Treatment conditions： Your current status： C、被保險(xiǎn)人聲明及授權(quán)：Statement and authorization of the insurant: 被保險(xiǎn)人聲明及授權(quán) Statement and authorization of the insurant 1、本健康告知書作為保險(xiǎn)人簽發(fā)保險(xiǎn)合同之依據(jù)，本人確認(rèn)上述內(nèi)容真實(shí)無誤，如有隱匿、遺漏或不實(shí)之陳述，保險(xiǎn)公司可依據(jù)《中華人民共和國保險(xiǎn)法》第三十六條解除本人保險(xiǎn)合同；This health statement is regarded as a reference to the insurer for signing and issuing the insurance contract. I declare that all the above information is true and accurate to the best of my knowledge, and any omission or false statement will lead to the termination of my insurance contract in accordance with Article 36 of "Insurance Law of the Peoples Republic of China". 2、 本人同意并授權(quán)中英人壽保險(xiǎn)有限公司查閱本人之相關(guān)醫(yī)療記錄及病歷資料；I hereby agree to authorize Aviva-Cofco Life Insurance Co., Ltd to look up my medical records. 3、 本人同意中英人壽保險(xiǎn)有限公司因業(yè)務(wù)需要對本人個(gè)人資料有搜集、計(jì)算機(jī)處理或國際傳遞的權(quán)利；I agree that Aviva-Cofco Life Insurance Co., Ltd has the right to conduct searching, computer processing or international delivery of my personal information whenever necessary. 4、 本人知悉保險(xiǎn)公司對被保險(xiǎn)人投保時(shí)已患疾病或妊娠中者，對該項(xiàng)疾病或分娩不負(fù)保險(xiǎn)責(zé)任。I understand that the insurance company will not be held responsible for the existing diseases or pregnancy of the insurant. 被保險(xiǎn)人/法定監(jiān)護(hù)人簽名 投保人蓋章/Policy holder(Unit): Insurant/Legal guardian (individual)： Date: 年 月 日 Date: 年 月 日 3