Application Form for Non-Hong Kong Residents -- Additional Declaration

非香港居民申請書 —— 附加聲明

本人 （申請人姓名）確認xxxxxx（xx）有限公司之『 保險計劃』合約（以下稱為“本合約”）受香港法律管轄，並按香港法律解釋。凡因本合約產生或與本合約有關的任何爭議或分歧均應提交香港國際仲裁中心並按其《本地仲裁規則》通過仲裁解決。

本人特此聲明，此申請表於香港特別行政區簽署，並同時提供有關本人之有效、準確及完整的入境記錄及個人身份證明文件予xxxxxx（xx）有限公司以作是次申請之用。

Application Form for Non-Hong Kong Residents -- Additional Declaration

I (Applicant Name) acknowledge that China Taiping Insurance (HK) Company Limited “ Insurance Scheme ” contract （hereinafter referred to as “the Contract”） is governed by and construed in accordance with the laws of Hong Kong. Any disputes or differences arising out of or in connection with the Contract shall be referred to and determined by arbitration at the Hong Kong International Arbitration Centre and in accordance with its Domestic Arbitration Rules.

I declare that I am in Hong Kong Special Administrative Region at the time of signing this application and have, at such time, presented to China Taiping Insurance (HK) Company Limited my effective, accurate and complete travel records and personal identification documents.

Applicant Signature:

申請人簽署

Applicant Name:

申請人姓名

Date of signing in Hong Kong:

於香港簽署之日期