*PHK1withln*

Policy Number 保單編號：

CASH WITHDRAWAL/ POLICY LOAN/

ANNUITY PAYMENT APPLICATION AXA China Region Insurance Company

保單價值 / 貸款提取 / 年金
(Bermuda) Limited
AXA China Region Insurance Company Limited
(Expressed as“AXA”/“The Company”in this

支付申請書
application form)
安盛保險（百慕達）有限公司
安盛金融有限公司
( 於本申請書表述為“AXA 安盛”“ / 本公司”“ / 貴公司”)
Simple steps for your service request submission: 請按以下步驟作有關申請：
(1) Complete this form. Please do not sign on a blank form. (1) 填寫申請表。請勿在空白申請表上簽署。
(2) “✓” the request option and provide the necessary details. (2) “✓”適用的選項並提供所需資料。
(3) Countersign any alteration on this form with the Owner/Trustee/Assignee’s (expressed as (3) 本申請書上如有任何修改，持有人 / 信託人 / 受讓人（於本申請書表述為「持有人」）必
“Owner” in this form) signature. 須在旁加簽。
(4) 請參閱所需文件指引以便處理您的申請。
(4) Please refer to the document checklist for documents required to process your request.
(5) 遞交此申請書及所需文件給您的理財顧問或 AXA 安盛客戶服務中心。
(5) Submit this form and supporting documents to your financial consultant or AXA Customer
Service Centre.
(6) The original of this form and supporting documents you submit will not be returned. (6) 您所遞交之正本申請書及所需文件將不獲退還。

IMPORTANT NOTES 重要事項

If service request is to fund the purchase of your new life and/or medical insurance policy, please contact your financial consultant or our customer service centre
to understand and submit the “Important Facts Statement – Policy Replacement”. You should carefully compare your existing insurance policy against the new
insurance policy you intend to purchase, and assess whether replacing your existing insurance policy is in your best interests before you make a final decision.
若服務申請是用以資助您購買新的人壽及 / 或醫療保險保單，請聯絡您的理財顧問或本公司客戶服務中心以了解及提交「重要資料聲明書一轉保」。您應
仔細比較現有保險保單與擬購買的新的保險保單，並在作出最終決定前評估取代現有保險保單是否最為符合您之最佳利益。

INSURED’S AND OWNER’S INFORMATION 被保人和持有人資料

Full Name of Insured
被保人姓名
Full Name of Owner
持有人姓名
1. APPLICATION OF POLICY VALUE WITHDRAWAL/TRANSFER 提取 / 調動保單價值申請
Part A – Withdrawals 甲部分 - 提取 [Please fill in Section 4 (Payment Instruction) 請同時填寫第四部分 ( 付款指示 )]
Type of Policy Value 保單價值類別 Amount (in Policy Currency) 金額 ( 以保單貨幣填寫 )

Dividend 紅利 □ All 全部 □ Partial Amount 部份金額 $

Surrender of Reversionary Bonus 退回保額增值紅利 □ All 全部 □ Partial Amount 部份金額 $
Future Premium Deposit 保費儲備金 □ All 全部
Policy Account Value 保單戶口價值 □ All 全部 □ Partial Amount 部份金額 $
Accumulation Account Value 累積戶口價值 □ All 全部 □ Partial Amount 部份金額 $
Part B – Transfers 乙部分 - 調動
Type of Policy Value Amount (in Policy Currency) To policy no. Purpose
保單價值類別 金額 ( 以保單貨幣填寫 ) 至保單編號 用途
Dividend □ All 全部 □ Premium and Levy Settlement
紅利 □ Partial Amount 部份金額 繳付保費及徵費
□ Loan Repayment 償還貸款
$ □ Other 其他
Surrender of Reversionary Bonus □ All 全部 □ Premium and Levy Settlement
退回保額增值紅利 □ Partial Amount 部份金額 繳付保費及徵費
□ Loan Repayment 償還貸款
$ □ Other 其他
Future Premium Deposit □ All 全部 □ Premium and Levy Settlement
保費儲備金 □ Partial Amount 部份金額 繳付保費及徵費
□ Loan Repayment 償還貸款
$ □ Other 其他
Policy Account Value □ All 全部 □ Premium and Levy Settlement
*PHK1WITHLN*

保單戶口價值 □ Partial Amount 部份金額 繳付保費及徵費

□ Loan Repayment 償還貸款
$ □ Other 其他
Accumulation Account Value □ All 全部 □ Premium and Levy Settlement
累積戶口價值 □ Partial Amount 部份金額 繳付保費及徵費
□ Loan Repayment 償還貸款
$ □ Other 其他
LFPA011-2306

Notes 注意 :
(1) For Part B, the Company ONLY accepts payment transfers to other life policies under the same owner. 在乙部分，本公司只接納款項轉入相同持有人的保單。
(2) The withdrawal of policy values are subject to the relevant terms and conditions of the above policy. 上述申請將根據保單之條款提取保單價值。
AXA China Region Insurance Company (Bermuda) Limited (Incorporated in Bermuda with limited liability)/ AXA China Region Insurance Company Limited
安盛保險 ( 百慕達 ) 有限公司 ( 於百慕達註冊成立的有限公司 )/ 安盛金融有限公司

1 of 4
Customer Service Centre Suite 2001, 20/F, Tower Two, Times Square, 1 Matheson Street, Causeway Bay, Hong Kong
客戶服務中心 香港銅鑼灣勿地臣街 1 號時代廣場 2 座 20 樓 2001 室
 CASH WITHDRAWAL/ POLICY LOAN/ ANNUITY PAYMENT APPLICATION 保單價值 / 貸款提取 / 年金支付申請書

2. APPLICATION FOR POLICY LOAN 保單借貸申請

Please fill in Section 4 (Payment Instruction) 請同時填寫第�部分 ( 付款指示 )
Part A – Policy Loan Part B - Transfers (in Policy Currency)
(in Policy Currency) 乙部分 - 調動 ( 按保單貨幣計算 )
甲部分 - 保單借貸 Amount To policy no. Purpose
( 以保單貨幣填寫 ) 金額 至保單編號 用途
□ Maximum Amount Available □ Maximum Amount Available □ Premium and Levy Settlement
最高借貸金額 最高借貸金額 繳付保費及徵費
□ Specified amount □ Specified amount
指定金額 指定金額 □ Other 其他
$__________________________ $__________________________
Notes :
(1) The maximum loan amount is 90% of the net cash value.
(2) If you take out policy loan from your existing life insurance policy to fund the purchase of a new life insurance policy, particularly during the early years of the policy
period, you will usually suffer loss, including by way of having to pay charges. The existing life insurance policy may also charge you interest starting from the loan
drawdown date.
(3) You are welcome to request an Illustration Summary of your policy loan.
注意：
(1) 最高貸款額為淨現金價值的 90%。
(2) 若您從現有人壽保險保單中提取保單抵押貸款用以資助購買新的人壽保險保單，您通常會蒙受損失（尤其是在保單早年的時期），包括因需要支付收費而蒙受損
失。您現有的人壽保險保單亦可能會自您提取保單貸款當日起收取利息。
(3) 歡迎您向我們索取關於保單貸款的說明摘要。
Terms and Conditions:
IT IS UNDERSTOOD AND AGREED THAT:
(1) Interest will apply on the total Policy Loan amount. The current interest rate on Policy Loan is 8.00% per annum except for specific products, of which the current interest
rate on Policy Loan is 6.00% per annum. Unless specified otherwise in the policy contract, the rate is not guaranteed and may change from time to time with a rate higher
or lower than mentioned above by giving prior notice. Specific products include Endowment @ 65 - Level Premium, Life Paid-up @ 65 - Level Premium, Whole Life - Level
Premium and 25 Payment Life - Level Premium.
(2) The amount of the existing loan indebtedness under this agreement on any date shall be the amount of the said loan with interest accumulated and accrued thereon to
such date.
(3) If the policy shall lapse or become forfeited in any manner, the amount of the existing loan indebtedness shall be deducted from any cash surrender value of the policy,
or such existing loan indebtedness shall operate provided by the terms of the policy to reduce the amount or the term or the amount and term of any extended insurance
available or to reduce the amount of any Paid-up Insurance.
(4) If the policy shall mature, the amount of the existing loan indebtedness shall be deducted from the amount otherwise payable by the Company.
(5) If the accumulated loan amount (and interest) shall at any time become equal to or exceed the account / cash value of the policy, your policy may be terminated. You
should carefully review your regular statements to understand the opening and ending loan balance as well as the interest amount charged in the relevant period.
(6) The request for taking policy loans is subject to the Company’s rules and approval.
條款及細則：
本人明白及同意下列各項：
(1) 保單總借貨額將衍生利息。除指明產品外，現行保單貸款利息之年利率為 8.00%。指明產品的現行保單貸款利息之年利率則為 6.00%。除非保單合約另有訂明，
有關息率為非保證，實際利率將不時調整，或會比上述的利率較高或較低，並將預先通知。上述指明產品包括 Endowment @ 65 - Level Premium、Life Paid-up
@ 65 - Level Premium、Whole Life - Level Premium 及 25 Payment Life - Level Premium。
(2) 此申請書在任何日期所指之欠款總額，相等於此貸款加上累積至該日期之利息。
(3) 若上述保單失效或以任何形式終止，上述保單之欠款將從退保發還金額中扣除，或根據保單條款，減低展期保險之保額及 / 或期限，或減低「減額繳清保險」之
保額。
(4) 若上述保單期滿，保單上之欠款將從貴公司應付之金額中扣除。
(5) 當累計貸款金額（及利息）等於或超過上述保單之賬戶 / 現金價值，則您的保單可能會被終止。您應該仔細檢閱定期報表，以了解於有關時期的期初和期末貸款
餘額，以及該期間收取的利息金額。
(6) 保單貸款申請須經本公司最終規則及批核為準。

3. CHANGE OF ANNUITY PAYMENT OPTION (Applicable to products with annuity payment option only)
更改年金支付選項 ( 只適用於有年金支付選項的產品 )
Payment Option 支付選項
□ Cash* 現金* □ Accumulate 積存
Same payment option will be applied to the payment of Dementia Companion Benefit (Applicable to JoyAhead Immediate Annuity Plan only)
認知障礙症關懷保障將使用相同支付選項 ( 只適用於盛載人生即享年金計劃 )
□ Change of autopay account for annuity payment* 更改年金支付自動轉帳戶口*
Notes 注意 :
* If you apply for “Cash” as annuity payment option or change your autopay account for annuity payment, please complete Section 4 PAYMENT INSTRUCTION: By Autopay.
如您申請年金支付選項為「現金」或更改年金支付的自動轉帳戶口，請填寫第 4 部分付款指示 : 自動轉帳。
(1) This section only applies to products with annuity payment option. Please refer to relevant policy provisions for details and selecting applicable payment option for
your annuity plan.
這部分只適用於有年金支付選項的產品。請參閱相關計劃之保單條款了解資料及為您的年金計劃選擇適用的支付選項。
(2) The default annuity payment mode is “Monthly”. Please refer to relevant policy provisions for other payment modes if applicable to your annuity plan.
預設的年金支付方式為「每月支付」。請參閱相關保單條款如您的年金計劃有其他適用的支付方式。

AXA China Region Insurance Company (Bermuda) Limited (Incorporated in Bermuda with limited liability)/ AXA China Region Insurance Company Limited
安盛保險 ( 百慕達 ) 有限公司 ( 於百慕達註冊成立的有限公司 )/ 安盛金融有限公司

2 of 4
Customer Service Centre Suite 2001, 20/F, Tower Two, Times Square, 1 Matheson Street, Causeway Bay, Hong Kong
客戶服務中心 香港銅鑼灣勿地臣街 1 號時代廣場 2 座 20 樓 2001 室
 CASH WITHDRAWAL/ POLICY LOAN/ ANNUITY PAYMENT APPLICATION 保單價值 / 貸款提取 / 年金支付申請書

4. PAYMENT INSTRUCTION 付款指示

By Autopay 自動轉�
□ Credit to the autopay account that paying premium of the above policy 存入至繳交上述保單保費之自動轉帳戶口
□ Credit to the bank account below 存入以下銀行戶口 (Please provide bank account proof 請提供銀行帳戶證明 )
Bank No. Branch No. Account No.
銀行號碼 分行號碼 戶口號碼

- -
Notes: 注意 :
(1) Bank account holder must be Policy Owner (1) 銀行�戶持有人必須為保單持有人
(2) Bank account proof must show account holder name and account (2) 銀行�戶證明須列有銀行�戶持有人姓名及銀行�號
(3) 自動轉�只適用於香港銀行及款項將以港幣支付
number
(3) Autopay is only applicable to banks in Hong Kong and the payment
will be paid in Hong Kong Dollar (4) 自動轉�的金額上限為港幣 100 萬
(4) The upper limit of autopay amount is HKD1,000,000
By Cheque Only applicable for overseas client OR cheque made in foreign currency OR payment amount larger than HKD1,000,000
支票 只適用於海外客戶或外幣支票或大於港幣 100 萬的款項
Cheque currency 支票貨幣 Place to bank in (Applicable for foreign currency cheques) 入票地區 ( 適用於外幣支票 )
□ Hong Kong Dollar 港幣 □ Hong Kong and Mainland China 香港及中國內地
□ Policy Currency 保單貨幣 □ Outside Hong Kong and Mainland China 香港及中國內地以外
Delivery Method 領取方式
□ By mail to correspondence address 郵寄通訊地址
□ To be collected at Customer Service Centre in person 本人親自於客戶服務中心領取 (Location 地點 : )
(Contact No. 聯絡電話號碼 : )
□ Through my Financial Consultant 經理財顧問轉交
Note 注意 : If not specify, the cheque will be delivered to you directly. 如沒註明，支票將直接寄給您。
By Telegraphic Transfer Only applicable for overseas client
電匯 只適用於海外客戶
□ Hong Kong Dollar 港幣 □ Policy Currency 保單貨幣
Notes: 注意 :
(1) Please submit Telegraphic Transfer Request Letter and bank account proof (1) 請提交電匯申請信及銀行帳戶證明
(2) Service fee and administration fee will be charged by bank(s) (2) 銀行或會收取手續費及服務費用

5. CHANGE OF PERSONAL INFORMATION 更新個人資料

If the identity document and/or address of Owner has/have been changed since last submission, please put a「✓」in the related box(es) below.
若持有人的身份證件和 / 或地址自上次提交後有所更改，請在下列相關的空格內加上「✓」號。
□ Change of Identity Document (Please also submit copy of the latest identification proof. If information is changed, your policy record will be updated)
更改身份證件（請同時提交最新身份證明文件副本。如資料有所更改，保單記錄將會更新）
□ Change of Residential Address/Business Address/Registered Office Address in Place of Incorporation (Please also submit copy of address
proof issued within 3 months from the date of submission and “Policy Service Application Form I”)
更改住宅地址 / 公司業務地址 / 於成立註冊地點之公司註冊辦事處地址（請同時提交於申請遞交日期 3 個月内發出之地址證明副本及
「保單服務申請書 I」）
PERSONAL INFORMATION COLLECTION STATEMENT 收集個人資料的聲明
Please visit our website (www.axa.com.hk) and read carefully the details of the Personal Information Collection Statement“PICS”
( ) which can also
be made available upon request.
請登入本公司網頁 (www.axa.com.hk) 下載或向本公司索取收集個人資料的聲明 (“ 該聲明”)，並細閱《該聲明》的詳細資料。
DECLARATIONS AND AGREEMENTS 聲明及協議
I HEREBY CONFIRM that I am not acting on behalf of any other person for this policy change/service application unless otherwise expressly indicated in
this application form or any other documents provided to the Company for this application.
I HEREBY DECLARE AND AGREE on behalf of myself and other persons referred in the relevant policy contract(s) and in this application (hereinafter
referred to as “Relevant Persons”, “We”, “Our” or “Us”) (for the avoidance of doubt, the expressions “Relevant Persons”, “We”, “Our” or “Us” include myself
and such other persons) that:
(1) the application(s) shall only take effect provided all of the following conditions are met (i) the application(s) is/are approved by the Company at the
Company’s Office during the lifetime of the person or persons insured by the above policy (ii) I am legally entitled to the benefits to be withdrawn
or surrendered under the above policy, which has not been assigned or transferred to any other party and that no proceedings in bankruptcy or
insolvency have been instituted or are pending against me;
(2) the application(s) as indicated above is/are based on my/Our own judgement and I/We have not relied on any advice provided by any insurance agent;
(3) all information in the application(s) whether or not written by my/Our own hand is to the best of my/Our knowledge and belief complete and true;
(4) I/We hereby assign to the Company, the policy and benefits now due or which may hereafter become due or be allowed by the Company on the policy,
to secure the repayment of the said loan and the interest thereon;
(5) I/We have read and understand all the terms and conditions listed in this application and agree to be bound by these terms and conditions;
(6) If I/We fail to provide any information requested in this application, it may result in the Company’s inability to accept or process this application.
I HEREBY AUTHORIZE on behalf of the Relevant Persons
The Company to give either the Insurance Authority or other parties, as required for relevant records or information. This authorization shall bind the
successors and assignees of the Relevant Persons and remains valid notwithstanding death or incapacity. A photocopy of this authorization shall be as
valid as the original.
I/WE ACKNOWLEDGE AND CONFIRM that I/We have read and understood the Personal Information Collection Statement (“PICS”).
I/We confirm that I/We have been advised to read carefully the PICS, and I/We have read it carefully its effect and impact in respect of my/Our personal
data collected or held by the Company (whether contained in this application or otherwise). Based on the foregoing, I/We hereby give my/Our
acknowledgement and agree to the use and transfer of my/Our personal data by the Company in accordance with the PICS, including the use and provision
of my/Our personal data for the purpose of direct marketing.
AXA China Region Insurance Company (Bermuda) Limited (Incorporated in Bermuda with limited liability)/ AXA China Region Insurance Company Limited
安盛保險 ( 百慕達 ) 有限公司 ( 於百慕達註冊成立的有限公司 )/ 安盛金融有限公司

3 of 4
Customer Service Centre Suite 2001, 20/F, Tower Two, Times Square, 1 Matheson Street, Causeway Bay, Hong Kong
客戶服務中心 香港銅鑼灣勿地臣街 1 號時代廣場 2 座 20 樓 2001 室
 CASH WITHDRAWAL/ POLICY LOAN/ ANNUITY PAYMENT APPLICATION 保單價值 / 貸款提取 / 年金支付申請書
I HEREBY DECLARE that I understand that the Company may deduct any outstanding amount applicable from the payout and/or sum received by the
Company under the policy according to the applicable statutory and/or regulatory requirement(s), including levy collected by the Insurance Authority.
I HEREBY DECLARE AND AGREE that I have the full authority from and consent of the Relevant Persons to make the above declarations, agreements and
authorizations.
In the event of any inconsistency between the English version and the Chinese version, the English version shall prevail.
本人謹此確認本人並沒有代表任何其他人士提出此保單更改 / 服務申請；如在此申請書或就此申請提交的任何其他文件上另有註明則除外。
本人謹此代表本人及其他在此申請書提及之人士（下稱「相關人士」或「我們」） （為免存疑，「相關人士」或「我們」指包括本人及此申請書上
及有關的保單合約內提及之其他人士）聲明及同意 :
(1) 此申請需符合下列條件後方可生效 (i) 申請是於受保人在生之情況下經貴公司在公司辦事處批核 (ii) 上述保單之利益為本人 / 我們合法所擁
有及未有轉讓予任何人等，及本人 / 我們現未有或沒有尚未判決因破產或清盤之訴訟 ;
(2) 上述之申請是基於本人 / 我們之個人判斷，並沒有依賴任何理財顧問所提供的意見 ;
(3) 上述一切陳述及問題的所有答案，不論是否本人 / 我們親手所寫，就本人 / 我們所知所言，均為事實之全部並確實無訛 ;
(4) 本人 / 我們謹此將上述保單及其應付或將付或貴公司容許之利益轉讓予貴公司，以確保此貸款及利息得以償還 ;
(5) 本人 / 我們已閱讀並明白所有此申請上的條款，而且同意受此條款和細則的約束 ;
(6) 如本人 / 我們不能提供任何此申請所需的資料，貴公司或不能接受或處理此申請。
本人謹此代表相關人士授權
貴公司於有需要時，向保險業監管局或其他機構提供相關紀錄或資料。此授權對相關人士之繼承人及受讓人具有約束力；即使相關人士死亡
或無行為能力時，此授權仍具效力。此授權書的影印本與正本均有同等效力。
本人 / 我們確認本人 / 我們已閱讀並明白收集個人資料的聲明《該聲明》。本人 / 我們確認本人 / 我們已被通知本人 / 我們須詳細閱讀《該聲
明》，而本人 / 我們已詳細閱讀《該聲明》對貴公司所收集或持有之本人 / 我們的個人資料的影響 ( 不論是否此表格所載或從其他途徑所取得 )。
根據以上所述，本人 / 我們特此確認並同意貴公司根據《該聲明》使用及轉移本人 / 我們的個人資料，包括在直接促銷中使用及將本人 / 我
們個人資料提供予其他人士。
本人謹此聲明本人明白貴公司或會從保單的給付金額及 / 或貴公司為保單所收金額中，根據適用法定及 / 或規管要求扣除任何逾期金額，包
括保險業監管局收取的徵費。
本人謹此聲明及同意已獲相關人士授權及同意本人作出以上聲明、協議及授權。
如中英文版本的條款有任何分歧，請以英文版本為準。
SIGNATURE 簽署
I/WE ACKNOWLEDGE AND CONFIRM that I/We have carefully read this form and understood the Important Notes.
本人 / 我們確認本人 / 我們已詳細閱讀本表格並明白重要事項。
Signature of Owner* Date (dd/mm/yyyy)
持有人簽署 * 日期 ( 日 / 月 / 年 )

*Please ensure the signature matches with the one provided in the policy file. 簽名式樣須與保單上的記錄相符。
FINANCIAL CONSULTANT’S DETAILS 理財顧問資料
Name Code Contact Number
姓名 編號 聯絡號碼

DOCUMENT CHECKLIST 所需文件指引

Type of service request Documents Required (Please ✓ against the documents you submitted)
服務申請類別 所需文件（請 ✓ 您已提交的文件）
Application of policy value □ Copy of the Owner’s identification proof (if not provided before)
withdrawal/transfer/Application 持有人身份證明文件副本（若之前未曾提交）
for policy loan □ Bank account proof (e.g. bank book, copy of debit card / EPS) which shows account holder name
提取 / 調動保單價值申請 / and account number (if select autopay or telegraphic transfer as payment instruction)
保單借貸申請 銀行�戶證明（例如銀行存摺、提款卡副本 )，而該證明須列有銀行�戶持有人姓名及銀行�號
（如選用自動轉帳或電匯為付款指示）
□ Telegraphic Transfer Request Letter (if select telegraphic transfer as payment instruction)
電匯申請書（如選用電匯為付款指示）
□ Important Facts Statement – Policy Replacement (if applicable)
重要資料聲明書 – 轉保（如適用 )
Application for “Cash” as □ Bank account proof (e.g. bank book, copy of debit card / EPS) which shows account holder name
annuity payment option/ and account number
Change of autopay account 銀行�戶證明 ( 例如銀行存摺、提款卡副本 )，而該證明須列有銀行�戶持有人姓名及銀行�號
for annuity payment
申請年金支付選項為「現金」/
更改年金支付自動轉帳戶口

CONTACT US 聯絡我們
If you have any questions on your request, please reach us at 如果您有任何疑問，請聯絡我們。

(852) 2802 2812 www.axa.com.hk [email protected]

AXA is committed to making your service request process as easy and stress-free as possible.
Thank you for insuring with us. We are always glad to be of service.
安盛致力使您的服務申請過程輕鬆簡單。感謝您與我們投保。我們很高興為您服務。
AXA China Region Insurance Company (Bermuda) Limited (Incorporated in Bermuda with limited liability)/ AXA China Region Insurance Company Limited
安盛保險 ( 百慕達 ) 有限公司 ( 於百慕達註冊成立的有限公司 )/ 安盛金融有限公司

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Customer Service Centre Suite 2001, 20/F, Tower Two, Times Square, 1 Matheson Street, Causeway Bay, Hong Kong
客戶服務中心 香港銅鑼灣勿地臣街 1 號時代廣場 2 座 20 樓 2001 室