Prudential General Insurance Hong Kong Limited 保誠財險有限公司

(A member of Prudential plc group) (英國保誠集團成員)

3/F, Berkshire House, 25 Westlands Road 香港鰂魚涌華蘭路25號
Quarry Bay, Hong Kong 栢克大廈3樓
Tel : (852) 2977 3888 電話：(852) 2977 3888
Fax : (852) 2977 1266 傳真：(852) 2977 1266

EMPLOYEES' COMPENSATION INSURANCE

僱員補償保險
PREMIUM ADJUSTMENT & DECLARATION OF EARNINGS FORM
保費調整及薪金申報表
N.B. PLEASE SEE OVERLEAF FOR GUIDELINES FOR COMPLETING THIS FORM
注意：在填寫本表格時，請留意背頁所列指引。

The Insured 投保人 Policy Number 保單號碼

When you are confirming the renewal of the policy, please complete the following information and provide a copy of latest wageroll (e.g. latest MPF
contribution records, financial statements, tax returns or other relevant documents) of employee(s):
確認保單續保時，請填寫以下資料及提供最近期的僱員薪酬紀錄副本（例如：強積金供款紀錄、財務報表、報稅表或其他相關文件）：

Current Year(a) 本年度(a) Renewal Year 續保年度

Description of Number of Total Earnings(c) Estimated Number Estimated
Occupations(b) Employees (HK$) of Employees Total Earnings
職業類別(b) 僱員人數 總薪金(c)(港幣） 僱員人數估計 總薪金估計

Description of Number of Part-time Total Earnings(c) Estimated Number of Estimated

Occupations(b) Employees (HK$) Part-time Employees Total Earnings
職業類別(b) 兼職僱員人數 總薪金(c)(港幣） 兼職僱員人數估計 總薪金估計
GI3/FR00114B/P01 (10/20)

TOTAL合計
 PLEASE COMPLETE THE FOLLOWING IF THIS POLICY IS TO PROTECT EMPLOYEES OF CONTRACTOR(S)/ SUBCONTRACTOR(S)(d).
如本保單涉及為承辦商/ 次承辦商(d)的僱員提供保障，請填寫下列資料。

Name of Contractor(s)/ Nature of Works sub-contracted Total Amount Paid/ Payable to Contractor(s)/
Sub-contractor(s) 外判工程的性質 Sub-contractor(s) for the Period of Insurance
承辦商/ 次承辦商名稱 保障期內已支付及將支付予承辦商/ 次承辦商的金額

TOTAL合計

Pursuant to the Insurance Premium Clause of the above mentioned Policy, I/ we affirm that the above amount of all earnings paid by me/ us to every
employee in my/ our employment during the said Period of Insurance is true and correct to the best of my/ our knowledge.
承上述保單保險費條款所要求，以上所列乃在有關保障期內，所有獲本人/ 吾等聘用的每位僱員所支取全部薪金的資料，本人/ 吾等確認一切均
為正確無誤，及以本人/ 吾等所知悉範圍內提供。

Authorised Signature 授權簽署 Name & title of person signing 簽署人姓名及職位

company chop (where applicable)公司蓋印（如適用）

Date日期

IMPORTANT NOTICE
重要事項

(1) Any employer who fails to insure himself in accordance with Section 40(1) of the Employees' Compensation Ordinance (Chapter 282) shall be
guilty of an offence and shall be liable on conviction to a maximum fine of HK$100,000 and imprisonment for two years.
任何僱主如未有依僱員補償條例(282章)40條(1)所要求投保，即屬違法，最高將被罰款港幣100,000元及監禁2年。
(2) You are required under the policy conditions to furnish the Premium Adjustment & Declaration of Earnings Form to your Insurance Company
within the stipulated time (see Guidelines (e) below), stating the actual Earnings of Employees and provide the relevant supporting
documents during the Period of Insurance. The actual Earnings of Employees declared shall be taken as the Estimated Earnings of the
Employees employed during the next period of insurance immediately subsequent to this renewal.
在本保單的條款下，您必須在指定時間內(詳情見下述指引(e)所示)，提交載有保障期內僱員實際薪金資料的「保費調整及薪金申報
表」予您的保險公司，並提供有關約支持文件。所申報的僱員實際薪金資料，將用作計算在本續保後下一個保障期的僱員預期薪金。

GUIDELINES FOR COMPLETING THE

PREMIUM ADJUSTMENT & DECLARATION OF EARNINGS FORM
填寫保費調整及薪金申報表指引

(a) Current Year 本年度

The Current Period of Insurance as shown on the Renewal Notice with which this Form is presented.
隨本申報表一併發出的續保通知書上所載有的現有保障期。
(b) Description of Occupations 職業類別
Each category of occupation is to be shown separately e.g. Clerical Staff, Sales/ Marketing, Messenger, Lorry Driver, Welder etc.
請將各職業類別逐一列舉出來，如文職人員、銷售/ 市場推廣、信差、貨車司機、焊工等。
(c) Total Earnings (As more fully defined under Section 3 of the Employees' Compensation Ordinance (Chapter 282)
總薪金（在僱員補償條例（282章）3條中有更詳細解釋）
Please declare the actual total gross earnings for the period of insurance.
請申報在保障期內的實際總薪金。
(d) Contractors & Sub-contractor's Employees 承辦商/ 次承辦商的僱員
If you contract out any of the work in connection with your business, please provide particulars as specified therein.
如您就業務將工程外判，請詳細列明。
(e) Submission of this Form 交回本表
You have to complete the Premium Adjustment & Declaration of Earnings Form and submit it after the expiry or termination of the policy
together with the following:
您必須在本保單到期日或被中止日後，填寫本保費調整及薪金申報表，並連同下列各項－併交回：
i) Signature of an authorised officer
獲授權人土簽署
ii) Latest MPF contribution records, financial statements, tax returns or other relevant documents for the Period of Insurance (stating of
each employee).
就保障期最近期的強積金供款紀錄、財務報表、報稅表或其他相關文件(需列明每名僱員)。