Life Policy Change

HSBCNFM

Policy Number* 保單號碼*

11

1

1

1

1

1

1

1

22

2

2

2

2

2

2

2

33

3

3

3

3

3

3

3

44

4

4

4

4

4

4

4

55

5

5

5

5

5

5

5

66

6

6

6

6

6

6

6

77

7

7

7

7

7

7

7

88

8

8

8

8

8

8

8

99

9

9

9

9

9

9

9

00

0

0

0

0

0

0

0

Request for Policy Change – Non Financial 更改保單申請表 Plan Type 計劃名稱

Name of Policyholder in English (Surname first) 保單持有人英文姓名（姓氏先行）

# ID Type & No. # 身分證明文件類別及號碼

NOTE 注意： 1. * Please mark X in the appropriate boxes to indicate the policy number. 請在適當的方格內加上 X 以註明保單號碼。

2. # ID Type 身分證明文件類別： I = HKID 香港身分證， P = Passport 護照， B = Business Registration Certificate 商業登記， X = Others 其他。 3. Please put a ‘✔ ’in the appropriate box(es) and complete in BLOCK LETTERS. 請在適當方格內加上 ✔號，並用正楷填寫。

4. Please enclose Identification copy in support, if necessary. 請附上身分證明文件副本以作證明（如適用）。

1. Change or correction of personal details (Please enclose ID Card/Passport/Birth Certificate copy in support) 更改或更正客戶資料（請附上身分證／護照／出生證明副本以作證明） (a) Insured 受保人

(b) Policyholder 保單持有人

(c) Payor 付款人

Name 姓名

# ID Type& No. 身份證明文件類別及號碼

Date of Birth 出生日期

New Signature of Policyholder 保單持有人新簽署

2. Change or correction of Address/Contact Number 更改或更正通訊地址／聯絡號碼申請表 New Address 新通訊地址 Floor 層數

Room/Flat 室/房號

Block 座數

Building 大廈 Estate/Court 屋㢏/屋苑 Street No. 街號

Street Name 街名

District 地區

Hong Kong Island 香港島

Kowloon 九龍

New Territories 新界

Country 國家 Telephone No. 電話號碼 Home 住宅

Office 工作

Mobile 手提

Fax 傳真

E-mail Address 電子郵寄地址

HSBC Life (International) Limited 㟱豐人壽保險（國際）有限公司 Request for Policy Change – Non Financial

更改保單申請表

Incorporated in Bermuda with limited liability 於百慕達註冊成立之有限公司 Hong Kong SAR Office： 18/F, Tower 1, HSBC Centre, 1 Sham Mong Road, Kowloon, Hong Kong 香港特別行政區地址：香港九龍深旺道 1號㟱豐中心 1座 18樓

Page

頁次

1/3

INHK006R11 (0809) W

3. Request for reprint of annual statement 要求重發年結通知書

4. Change of Beneficiary 更改受益人 I appoint the following person(s) as Beneficiary of the Policy. This nomination supersedes all prior nominations. 本人指定下列人士為保單受益人。此項 提名取代一切以往的提名紀錄。 Please provide all the required information as listed below, sign and return the application to us within one month. If the said information is missing, the application will not be complied with. 請提供下列所需資料，並於簽妥後一個月內遞交申請。若有關資料遺漏，此申請將不獲接納。 Name 姓名

ID No.* 身分證明文件號碼*

Relationship to Insured 與受保人關係

Share (%) 分配（百分比）

1 2 3 4 5 100% * If would like to appoint the above person(s) as Irrevocable Beneficiary, please submit along with the respective document ID copy. 若閣下指定上述人士為不可撤換受益人，請一併遞交其身分證明文件副本。

5. Change of Payment Method 更改繳付保費方式 Monthly autopay from bank account* 每月由銀行戶口自動轉賬* ( 1st day 1日 15th day 15日) Monthly autopay from HSBC credit card*# 每月由㟱豐信用卡自動轉賬*# Annual autopay from bank account* (effective on policy anniversary and not applicable to SPP/SPL policies applied for before Nov 2001, IPP policies applied for before 6 Oct 2003, and SSPP policies) 每年自動轉賬*（於保單周年日生效而不適用於樂綢繆多保計劃、於2001年11月前申請之儲全保/卓㟱投資壽險計劃、及於2003年10月6日前申請之 㟱全保保障計劃） Annual autopay from HSBC credit card*# (effective on policy anniversary and not applicable to SPP/SPL policies applied for before Nov 2001, IPP policies applied for before 6 Oct 2003, and SSPP policies) # 每年由㟱豐信用卡自動轉賬*（於保單周年日生效而不適用於樂綢繆多保計劃、於2001年11月前申請之儲全保/卓㟱投資壽險計劃、及於2003年 10月6日前申請之㟱全保保障計劃） Annual premium notice (effective on policy anniversary and not applicable to SPP, SPL, IPP and SSPP) 每年郵寄賬單（於保單周年日生效而不適用於儲全保、卓㟱投資壽險計劃、㟱全保及樂綢繆多保計劃） * To apply for direct debit, please complete the Direct Debit Authorisation below. Premium will be collected in HKD. 申請自動轉賬，請填寫以下之直接付款授權 書。保費將以港幣收取。 #

Not applicable to Investment Linked Insurance Plan 不適用於投資壽險計劃

If “Standing Instruction” has been set up for premium payment arrangement, please be reminded that you should complete and return the “Standing Instruction Request form” to The Hongkong and Shanghai Banking Corporation Limited for the amendment / cancellation of the said arrangement. Normally, it takes 5 business days to processing such request. 若上述保單已設立「常行指示」以繳付保費，請注意，閣下需填妥並交回「常行指示申請表」予香港上海㟱豐銀行有限公 司，以修改或取消有關常行指示的安排。有關安排，一般需時5個工作天方可生效。

6. Change of Direct Debit Account 更改自動轉賬賬戶* I/We authorise HSBC Life (International) Limited to initiate deductions from my/our account, or to debit my/our HSBC credit card account, as specified below, for the premium due. 本人／我等授權㟱豐人壽保險（國際）有限公司在本人／我等的戶口或在本人／我等的㟱豐信用卡戶口內，直接轉賬支付保費。

Bank Name and Branch 銀行及分行之名稱

Bank No. 銀行編號

Branch No. 分行編號

Account No. 賬戶號碼

OR 或 For Integrated Account, if the debit is from the Current account, please write the last 3 digits of the bank Account No. with 001. 如支賬戶口為綜合理財戶口內之往來戶口，請將賬戶號碼最後3個數字寫為001。

HSBC Credit Card Account No.# 㟱豐信用卡號碼 #

Signature of Account Holder 戶口持有人簽署

Relationship to Policyholder (if not Policyholder) 與保單持有人關係（如非保單持有人）

MM月 / YY年 Signature of Joint Account Holder 聯名戶口持有人簽署

Name in English 英文姓名：

Name in English 英文姓名：

ID Type & No. 身分證明文件類別及號碼：

ID Type & No. 身分證明文件類別及號碼：

Date 日期：

Date 日期：

INHK006R11 (0809) W

Expiry Date 到期日：

* Premium will be collected in HKD. 保費將以港幣收取。 # Not applicable to Investment Linked Insurance Plan 不適用於投資壽險計劃

7. Others 其他

Request for Policy Change – Non Financial

更改保單申請表

Page

頁次

2/3

Personal Information Collection Statement 收集個人資料聲明 Statement relating to the Personal Data (Privacy) Ordinance (“PDPO”) As our customer, it is necessary from time to time for you to supply us with your personal data to enable us and other companies of the HSBC Group ("our affiliates") to provide and administer products and services and to effect transactions for or with you. Failure to supply such data may result in our being unable to provide or continue to provide products and services to you. During the continuation of the relationship, we may collect and/or compile further data relating to you. The purposes for which data relating to you may be used by us and our affiliates are as follows: 1. offering and providing products and/or services to customers from time to time, and administering, maintaining, managing and operating such products and/or services which may include, without limitation, insurance, banking, provident fund or scheme, or other financial products or services, 2. processing, assessing and determining any applications or requests made by you for products or services, 3. any purposes in connection with any claims made by or against or otherwise involving you in respect of any products and/or services provided by us or our affiliates including, without limitation, making, defending, analysing, investigating, processing, assessing, determining or responding to such claims, 4. performing any functions and activities related to the products and/or services provided by us or our affiliates including, without limitation, marketing, audit, reporting, market research, and general servicing and maintenance of on-line and other services, 5. designing products and/or services for customers, and promoting, improving and furthering the provision of products and/or services by us or our affiliates, 6. matching any data held by us or our affiliates relating to you from time to time for any of the purposes listed in this statement, 7. making disclosure under the requirements of any law, rules, regulations, codes of practice or guidelines binding on us or our affiliates including, without limitation, making disclosure to applicable regulators, governmental bodies, or industry recognised bodies such as federations or associations of insurers or credit reference agencies, 8. exercising any rights we or our affiliates may have in connection with the provision to you of products and/or services from time to time, 9. conducting identity and/or credit checks, 10. determining any amount of indebtedness owing to or from you, and collecting and recovering any amount owing from you or any person who has provided any security or undertaking for your liabilities, 11. enabling an actual or proposed assignee, transferee, participant or sub-participant of our rights or business to evaluate the transaction intended to be the subject of the assignment, transfer, participation or sub-participation, 12. any purposes relating to the above or any other purposes in accordance with our general policies or those of the HSBC Group in relation to insurance, banking and financial services as set out in statements, circulars, notices or other terms and conditions made available by us or the HSBC Group to customers from time to time. Data held by us will be kept confidential but we may provide such data inside or outside the Hong Kong Special Administrative Region, to the following persons: • any of our affiliates for the purposes specified above, • any person in connection with any claims made by or against or otherwise involving you in respect of any products and/or services provided by us or our affiliates, • any agent, contractor or third party service provider who provides administrative, telecommunications, computer, payment, data processing or storage, or other services to us or our affiliates in connection with the operation of business, • any credit reference agencies or, in the event of default, any debt collection agencies, • any person under a duty of confidentiality to us or our affiliates which has undertaken to keep such data confidential, • any actual or proposed assignee, transferee, participant or sub-participant of our rights or business, • any person to whom we or our affiliates are under an obligation to make disclosure under the requirements of any law, rules, regulations, codes of practice or guidelines binding on us or our affiliates including, without limitation, any applicable regulators, governmental bodies, or industry recognised bodies, and where otherwise required by law. Under and in accordance with the terms of the PDPO, you have the following rights: (i) to check whether we hold data relating to you and to access such data, (ii) to require us to correct any data relating to you which is inaccurate, (iii) to ascertain our policies and practices in relation to personal data and to be informed of the kind of personal data held by us, (iv) to request us not to use your data for direct marketing purposes. In accordance with the terms of the PDPO, we have the right to charge a reasonable fee for processing any data access request. Requests may be made in writing to the Data Protection Officer, c/o HSBC Life (International) Limited, 18/F, Tower 1, HSBC Centre, 1 Sham Mong Road, Kowloon, Hong Kong. Nothing in this statement shall limit your rights under the PDPO. In case of discrepancies between the English and Chinese versions of this statement, the English version shall prevail. 關於個人資料（私隱）條例（「條例」）致客戶的通知 閣下作為本公司客戶，有需要不時向本公司及㟱豐集團其他公司（統稱「聯營公司」）提供個人資料，以使本公司能夠為閣下提供及管理產品和服務，並與閣下進行交易或代 閣下執行交易。若閣下未能提供該等資料，可能令本公司無法向閣下提供或繼續提供產品或服務。 在維繫本公司與閣下的客戶關係的過程中，本公司可能收集及／或編製與閣下有關的其他資料。 本公司及聯營公司可能使用與閣下相關的資料作下列用途： 1. 不時向客戶推薦及提供產品及／或服務，並管理、維護，並營運該等產品及／或服務，包括但不限於，保險、理財、退休金或退休計劃，或其他金融產品或服務； 2. 處理和評估閣下就產品或服務作出的任何申請或要求，及決定該等申請或要求的批核結果； 3. 與任何由本公司或聯營公司提供的產品及／或服務相關，而由閣下提出或對閣下作出的索償，或以其他形式涉及閣下的索償有關的用途，包括但不限於，作出、分析、 調查、處理、評估、釐定或回應該等索償； 4. 執行任何與本公司或聯營公司提供的產品及／或服務相關的功能及活動，包括但不限於，市場推廣、審核、報告、市場調查，以及一般維護和更新網上及其他服務等 功能及活動； 5. 為客戶設計產品及／或服務，及推廣、改善並提升本公司或聯營公司提供的產品及／或服務； 6. 不時與本公司或聯營公司所持有與閣下相關的任何資料進行核對，以供作本聲明列明的任何一項用途； 7. 根據任何對本公司或聯營公司有約束力的法律、規則、規例，行業守則或指引的規定而作出披露，包括但不限於，向適用監管機構、政府機構或相關行業內有地位機 構，包括保險業協會或商會或資信調查機構披露資料； 8. 行使本公司或聯營公司就不時向閣下提供任何產品及／或服務而可能擁有的任何權利； 9. 進行身份及／或信用狀況檢查； 10. 釐定本公司欠付閣下或閣下拖欠本公司的任何款項的金額，及向閣下或任何已為閣下的債務提供任何擔保或承諾的人士，追收和收回閣下拖欠的任何款項； 11. 允許本行的權益或業務的實際或建議受讓人，或參與人或附屬參與人，就涉及的轉讓、參與或附屬參與的交易進行評估；及 12. 供作任何與上述事項相關的用途，或根據本公司及／或㟱豐集團不時提供給客戶的聲明、通告、通知或其他條款及細則中已列明的本公司的一般政策或㟱豐集團就保 險、理財及金融服務制訂的該等政策而作出的任何其他用途。 存於本公司的資料將受到保密，但本公司可能向以下人士透露閣下的資料（不論在香港特別行政區境內或境外）： • 任何聯營公司，以供作上述指定用途； • 與由本公司或聯營公司提供的產品及／或服務相關，而由閣下提出或對閣下作出的索償的任何有關人士； • 在業務上向本公司或聯營公司提供行政、電訊、電腦、支付、數據處理或儲存，或其他任何服務的代理機構、承辦商或第三方服務供應者； • 資信調查機構，以及於涉及拖欠還款時，追收債務的收數公司； • 已向本公司或聯營公司承擔保密責任，並已承諾為資料保密的任何其他人士； • 本公司的權益或業務的任何實際或建議受讓人，或權益的參與人或附屬參與人； • 根據任何對本公司或聯營公司有約束力的法律、規則、規例，行業守則或指引的規定，本公司或聯營公司有責任向其作出披露的人士，包括但不限於，任何適用監管 機構、政府機構或相關行業內有地位機構，及在其他情況下，法律規定本公司必須向其披露資料的人士。 根據《個人資料（私隱）條例》，閣下有權： (i) 查詢本公司是否持有閣下的資料記錄並查閱該等資料； (ii) 要求本公司更正任何有關閣下的不正確資料記錄； (iii) 查明本公司的資料收集政策和實務，以及獲告知閣下存於本公司的個人資料的類別；及 (iv) 要求本公司不將該等資料用於直接促銷的用途。 根據《個人資料（私隱）條例》的條文，本公司有權為辦理個人資料記錄的查詢收取合理費用。 有關個人資料的所有查詢，請以書面作出，並寄往香港九龍深旺道1號㟱豐中心1座18樓㟱豐人壽保險（國際）有限公司，註明「資料保護主任」收。 本聲明並未載有任何內容限制閣下根據《個人資料（私隱）條例》可享有的任何權利。 本聲明的中英文本如有任何歧義，概以英文本為準。 Signature of Irrevocable Beneficiary (if any) 不可撤換受益人簽署（如適用） Date 日期

INHK006R11 (0809) W

Signature of Policyholder 保單持有人簽署

For Bank Use Client’s ID copy attached

Staff Name and ID:

Servicing Staff IA No.

Client’s original ID sighted

Contact No.:

Servicing Staff RI No.

Request for Policy Change – Non Financial

更改保單申請表

Branch Code and Chop

Page

頁次

3/3