Travel Insurance

Declaration

I hereby declare that I have been duly authorised by each of the persons covered under this application including guardian(s) of the child(ren) mentioned in this Proposal Form (together, the "Insured Persons" and each an "Insured Person") to apply for Travelsure Protection Plan and to make the following declarations for and on his/ her/ their behalf. I also hereby declare that each of the Insured Person(s) has agreed to the information under this Proposal Form including these Declarations, and that it is a condition precedent to obtain coverage for each such person that such Insured Person has agreed to all such information. (The above declaration is not applicable to a Proposer applying for his/ her own insurance only.)

I, and on behalf of each of the Insured Person(s), declare that the statements and particulars given herein are to the best knowledge and belief of each of the Insured Person(s), true and complete. I, and on behalf of each of the Insured Person(s), agree that the basis of this contract will be Travelsure Protection Plan Policy and cover will be effective as specified once the proposal is accepted by QBE General Insurance (Hong Kong) Limited and the Policy Schedule is issued. I, and on behalf of each of the Insured Person(s) further declare that:

I, and on behalf of each of the Insured Person(s), hereby apply for Travelsure Protection Plan, deemed and accepted to constitute separate insurance in respect of each such Insured Person, and declare that to the best knowledge and belief of each of the Insured Person(s), the information given in this Proposal Form is true and complete in every aspect and all disclosed information has been verified by each of the Insured Person(s) as true and correct, and that none of the Insured Person(s) is travelling contrary to the advice of a medical practitioner, for the purpose of obtaining medical treatment, or for emigration.

I, and on behalf of each of the Insured Person(s), understand that the insurance policy will be void even accepted if black-rain warning or typhoon signal number 8 or above is hoisted; strikes or industrial actions or airport or airline staff are in progress or any other reasons known to any of the Insured Person(s) that the trip may have to be cancelled or re-scheduled during the time of application.

I, and on behalf of each of the Insured Person(s), understand that this policy is only valid for travel originating from Hong Kong.

I, and on behalf of each of the Insured Person(s), declare that I have obtained the full and complete authority from the Insured Person(s) to disclose any personal information being requested to assess this insurance application and make any subsequent request for policy amendment (save for designation or amendment of beneficiary, which must be made by the relevant Insured Person).

I, and on behalf of each of the Insured Person(s), have not withheld any material facts* (i.e. facts relevant to an insurer's decision whether or not to provide coverage) from QBE General Insurance (Hong Kong) Limited and that if any material facts shall have been withheld or not truly or fairly stated, this insurance policy shall be null and void.

I, and on behalf of each of the Insured Person(s), agree that this Proposal Form and Declaration shall form the basis of each separate insurance contract between each of the Insured Person(s), QBE General Insurance (Hong Kong) Limited.

I, and on behalf of each of the Insured Person(s), agree that each of the Insured Person(s) shall review the policy documents, including but not limited to the policy terms and conditions, and ensure the information thereon is correct.

I/We acknowledge and agree that

the personal data and information with respect to me/us which are provided by me/us in my/our application may be held, used, processed or disclosed to such parties for the purposes as set out in the section “ Insurance Services (mandatory)” in the QBE General Insurance (Hong Kong) Limited's Personal Information Collection Statement ("Notice"); and

ii)

as per my / our consent given through the "Declaration, Terms & Conditions and Personal Information Collection Statement“, the Marketing Personal Data may be held, used, process and disclosed to such parties for the purpose as set out in the section “Direct Marketing of Products and Services” in the Notice.

I/We acknowledge and understand that laws and regulations of some jurisdictions outside Hong Kong may impose certain restrictions and/or requirements when their residents or citizens purchase insurance policy issued by foreign insurance companies and to the best of my knowledge have to inform both Hang Seng Bank Limited and QBE General Insurance (Hong Kong) Limited if the law of my/our country has any restrictions and/or requirements and/or prohibition.

10.

I/We acknowledge and understand that both Hang Seng Bank Limited and QBE General Insurance (Hong Kong) Limited will not accept this application and I/We are not eligible to make this application if I/we and/or the proposed insured is/are under any restrictions and/or requirements and both Hang Seng Bank Limited and QBE General Insurance (Hong Kong) Limited relies on my/our declaration provided below as evidence of my/our eligibility to make this application. If the information I/we provided in the declaration is incorrect and/or untrue which renders the arrangements contemplated under the application and the insurance policy to become illegal, invalid or ineffective, I/we acknowledge and understand that QBE General Insurance (Hong Kong) Limited shall be entitled to terminate the application with a refund of the premium paid, and QBE General Insurance (Hong Kong) Limited shall be entitled to cancel the insurance policy even after it has been issued, both Hang Seng Bank Limited and QBE General Insurance (Hong Kong) Limited shall not be liable to any losses or damages I/we may suffer arising therefrom or in connection therewith.

11.

Both Hang Seng Bank Limited and QBE General Insurance (Hong Kong) Limited provide no assurance that the application, the insurance policy and the arrangements contemplated hereunder are in compliance with the laws and regulations of the jurisdictions outside Hong Kong and disclaims any liability in whatsoever losses I/We may suffer or incur arising out of the restrictions and/or requirements.

12.

I / We acknowledge and agree that “Travelsure Protection Plan” (Plan) is underwritten by QBE General Insurance (Hong Kong) Limited which is authorised and regulated in Hong Kong by the Insurance Authority. Hang Seng Bank Limited (“Hang Seng Bank”) is an insurance agent authorised by QBE General Insurance (Hong Kong) Limited for the distribution of this Plan. Premiums will be payable to QBE General Insurance (Hong Kong) Limited upon enrolment of this Plan. QBE General Insurance (Hong Kong) Limited would provide Hang Seng Bank commission and performance bonus as remuneration for distribution of this Plan. The existing staff remuneration policy on sales offered by Hang Seng Bank takes into account various aspects of the staff performance instead of focusing solely on the sales amount.

13.

In respect of an eligible dispute arising between the Hang Seng Bank Limited and the customer out of the selling process or processing of the related transaction, Hang Seng Bank Limited is required to enter into a Financial Dispute Resolution Scheme process with the customer; however any dispute over the contractual terms of the product should be resolved directly between QBE General Insurance (Hong Kong) Limited and the customer.

*Note : If you are in doubt as to whether or not particular information or facts are material, please contact QBE General Insurance (Hong Kong) Limited Customer Service Hotline during office hours.

The Travelsure Protection Plan is underwritten by QBE General Insurance (Hong Kong) Limited which is authorised and regulated in Hong Kong by the Insurance Authority. Hang Seng Bank Limited is an insurance agent authorised by QBE General Insurance (Hong Kong )Limited.

Important Notice to Customers on Travelsure Protection Plan