ENDOEX FORM 13/F DCH Commercial Centre

25 Westlands Road , Quarry Bay, Hong Kong

Tel : (852) 2892 3888
Fax: (852) 2572 8071

Policyholder:
ENDOEX 表格 附屬公司
Website: www.libertyinternational.com.hk

保單持有者 Under Armour Asia Limited Affiliated Company Name :

Policy Number: 附屬公司保單號碼
保單號碼 Sub-policy Number :
Report Date:
申報日期 Panel Credit Facility (L/UMP) (To be filled out by Liberty) : LB01 LB03
Eligiblity : 福 利 計 劃 醫療卡福利 (由利寶內部填寫)
參加資格 Benefit scheme Hospital Outpatient SMM Maternity Dental Life AD&D TP&D
住院 門診 附加重症 懷孕 牙科 人壽 意外死亡或傷殘 完全及永久性傷殘

Name of Employee Name of Dependent Date of Last Date of Bank Account No. 銀行戶口號碼
Date of Date of Birth HKID No. ＃ Effective Date Employment
Cert. No. Plan
僱員姓名 家屬姓名 Marital Marriage Email Address ＃ Dept. Code Section. Code Employment Monthly
(Same as HKID/ (Same as Sex 出生日期 生效日期 最後 Salary/Sum Remark備註
Code Status 結婚日期 電子郵件地 部門號 分部門號 僱用日期
編號 計劃 性別 (mm/dd/yy) 身份証號碼 ＃ (mm/dd/yy) 受僱日期 Bank Branch
Passport) HKID/Passport) 婚姻狀況 (mm/dd/yy) 址 ＃ 碼 碼 (mm/dd/yy) - - Account No. Assured月薪/保額
月/日/年 (e.g: A123456(7)) 月/日/年 (mm/dd/yy) Code Code
(Surname First) (Surname First) 月/日/年 月/日/年
月/日/年

N/A

N/A

N/A

N/A

N/A - -

N/A - -

N/A - -

N/A - -

N/A - -

＃ To* Enjoy Free 'E-services', HKID No. and Email must be provided. 閣下必須同時提供身份証號碼及電郵地址以享用免費電子服務

Legend
AE = Addition of employee 新投保僱員
AD = Addition of dependent 增加投保僱員家屬
TE = Termination of employee 終止個別僱員之投保
TD = Termination of dependent 終止個別僱員家屬之投保
CP = Change Plan 更改投保計劃
CMS = Change salary 更改月薪
CA = Change bank A/C. 更改銀行戶口資料
CB = Change date of birth 更改出生日期
CE = Change employee name 更改僱員姓名
CD = Change dependent name 更改家屬姓名
CED = Change effective date 更改投保生效日期
CS = Change sex 更改性別

Note: 1) Please note that member addition and changes should be submitted within 31 days from date of eligibility and no back date of more than 31 days from our received date would be allowed. Otherwise, coverage will be subject to satisfactory underwriting.
注意 僱員/家屬投保申請及資料/保障更改通知需於生效日前31日內申報；而有關申請或資料更改通知最早生效日只可追溯至本公司收訖日前31日為限。逾期者之申請或資料更改需通過核保才可生效。
2) Please kindly send this completed form via email to the following email addresses: group.admin@libertymutual.com.hk
請將完整表格傳送至以下電郵地址: group.admin@libertymutual.com.hk。