リタイヤメントO-Aビザ適格保険お申込書
ご記入方法などを詳しくご説明した和訳版は秋山までお問い合わせください

LIFESTYLE SERIES APPLICATIONA New Lifestyle for a New Generation

Experience Mattersリタイヤメント(O-A)ビザ申請用の場合はココ余白箇所に"Retirement Visa" と明記してください。

รายละเอี ย ดผู  ข อเอาประกั น ภั ย (ตามที ่ ร ะบุ ในบั ตรประจำตั ว ประชาชนหรอหนั ง สื อ เดิ น ทาง)Applicant’s Details (as stated on ID Card or Passport): Mr.
ง : Mrs.
กช : Masterก ง : Ms.
ช ขก: Family Name
ช : First NameงPCHI ID No.

: Miss: Other.........................................................

ข จ
ชช / งID / Passport No.

ง:............................................................................................
ช ก ง : Middle Name: Expiry Dateก: Genderช : Male

ご記入不要____- ____ - ______

ご記入不要: Policy Commencement Date ____
- ____ - ______DD MM YYYY
: Marital Statusง : Female: Single: Married: Age ...........................

ช: Nationality ................................................................

/ ก (ค. .) : Date of Birth ____ - ____ - ______DD MM YYYY
ช : Occupation ............................................................................

DD MM YYYY
: Widowed: Divorcedก (กก.) :Weight (kg.)ง ( .) :Height (cm.)( .) :Waist (cm.)................................

................................

................................

/( กกกช)(If リタイヤされている場合は最終職業
retired please specify your last occupation)

จจง : Positionก..............................................................................

ง: Type of Work...............................................................................

: Current Address .............................................................................................................................................................................................................................................................................

......................................................................................................................................................................................................................................................................................................................................................
ชง : Company Name, Work Address ........................................................................................................................................................................................................
......................................................................................................................................................................................................................................................................................................................................................
郵送先:会社をお勧めしงก() : Contact Address (Please identify)
ます: Mobile No.

จจ: Telephone No.

: Current Addressง: Work Address: E-mail Address.................................................................................
.................................................................................
......................................................................................................................................
ข ชจ: Bank Account Details for the Payment of Claims
銀行口座情報。保険金振り込みの場合
ค : Bank .....................................................................................................................
ช ช : Account Name .......................................................................................................................
銀行名
ข : Branch .....................................................................................................................
ข ช : Account No. .......................................................................................................................
支店名รายละเอีย ดผู  ร ั บ ประโยชน (ตามที ่ ระบุ ใ นบั ต รประจำตั ว ประชาชนหรอหนั ง สื อ เดิ น ทาง)死亡保険金受取人(ご家族に限る）
Beneficiary Details and Relation ship to Insured (as stated on ID Card or Passport): Mr.
ง : Mrs.
: Masterก ง : Ms.
ชช 1 : Bene ciary Name 1
ก : Family Name
ช : First Nameกชคง: Miss: Other.........................................................

ช ก ง : Middle Nameก ข:Spouseก: Relationship to the Applicant:Child:Other........................................

: Genderช : Maleก ข:Spouseก: Relationship to the Applicant:Child:Other........................................

: Genderช : Maleข จชช / ง
ง:ID / Passport No.
.................................................................................................
// ก (ค. .) :ช :Date of Birth
Nationality____ - ____ - ______DD MM YYYY .......................................

: Contact Phone No.
ง : Female .................................................................................................
: E-mail Address
ช : Bene ciary Full Address.................................................................................................................................................................................................................................................... .................................................................................................
ข จ
ชช / ง
ง:: Mr.
ง : Mrs.
ง : Miss
ID / Passport No.
กช : Masterก ง : Ms.
: Other.........................................................
.................................................................................................
ชช 2 : Bene ciary Name 2// ก (ค. .) :ช :
ก : Family Name
Date of BirthNationality
ช : First Nameช ก ง : Middle Name____ - ____ - ______DD MM YYYY .......................................
คค: Contact Phone No.
ง : Female .................................................................................................
: E-mail Address
ช : Bene ciary Full Address.................................................................................................................................................................................................................................................... .................................................................................................
คApplication Form Rev. October/201901

เบี้ ยมาตรฐาน (Base Premium)保障プラン
1. เลือกแผนความคุ ม ครอง (Select your Protection Plan) O-Aビザ適格プランはスタンダードエキストラ以上のプランにチェックしてください。
บาท/Baht

Standard
ビサ不適格StandardPlus
ビサ不適格Standard Extra

PremierPremier Plus

MaximaMaxima Plus

UltimaUltima Plus保険料欄の数字記入は不要です。
お見積り書をお送りします。

2. เลื อ กส ว นลดเบี ้ ย ประกั น ภั ย (Premium Discount Options) ビザ申請用保険では下記の特約割引は不適格となります。

ค ค ค งก (OPD Bene t)คชก/ค /(Deductible/Person/Policy Year)ค ค ง

ก (Exclusion of Outpatient Bene t)20%คชก 20,000(THB 20,000 Deductible)15%คชก 40,000(THB 40,000 Deductible)
25%******
คช
ก 100,000(THB 100,000 Deductible) 32.5%
Standard & Standard Plusกคชก 200,000(THB 200,000 Deductible)40%*** Remark ***คชก 300,000(THB 300,000 Deductible)
50%
Deductible options are not available for
the Standard and Standard Plus Plansกค ค (Family Discount)5%กจ กคข จกกก( )Sub-Total
These premium discounts are to be applied progressively from the base premium above (Where applicable)เบี้ยมาตรฐาน / Base Premium
保険料ご記入不要
บาท/Baht

3. เลื อกความคุ  มครองเพิ ่ มเติ ม (Additional Benefits)******ค ค ค ง ง ก /Dental Bene tค ค ง/Coverค ค ง/Not CoverStandard Plansกกค ค ค ง งจก /Vision Bene tค ค ง/Coverค ค ง/Not Coverค ค ค ง
傷害補償額の増額希望の場合กคค / Buy More Personal Accident (PA)...................................Baht
กจก(Insert Amount)

希望増額金額を点線上に記入*** Remark ***ก145ค ค ค ง 100,000
Dental and Vision Bene ts Additional Premium THB 145/ THB 100,000
are not available for allจงจ ก งงก
ก
types of Standard Plans The amount bought is to be added to existing amount within the selected planงง ค ค ค งงงจกกกThis coverage is in addition to the selected insurance plan amount.
*ข งจ จง ข
*The Insurer reserves the right to accept, limit or decline this request.

4. ค าเบี ้ ยประกั นภั ยรายป (Annual Premium) 半年払いご希望の場合は大きくกกIm portan tNoteก(Net Premium Sub-Total)

Semi-Annualとお書きください

お見積り書をお送りしますので保険料などご記入不要です。

0.4% (Stamp Duty 0.4%)(Total Premium)*กกข กกกงกง งค กช จ จข งจ จง ขกกข กกจก งกข คชจค ค ค ง*Elective Treatment in North America, Japan, Hong Kong, Singapore, EU Countries and Switzerland.
This Bene t is permitted only on a case by case basis with no guarantee of acceptance by the Insurer.
All other Elective Treatments in other countries require Pre - Approval.

(: Baht)((: Baht): Baht)

แบบสอบถาม (Medical Questions)กคงกขช/ ค กชขง งค กกจก จกจจขก ข งข 8Kindly answer the questions below. For each Yes answer please identify provider s name (hospital or clinic) and address,injury or illness condition, date of treatment, current clinical and other relevant information. Please specify in Question 8

ช/ คYesช/ คNo1. ขค ค ค งจ กกก ข? (กกกงกก )Are you currently covered by any other Health Insurance policy? (If Yes, please enclose a copy of the policy and bene t schedule)2.

ค กกกกง ข ก ก ก ขก ช?
กค กHave you ever had any Health or Life Insurance policy declined, postponed, rate adjusted, restricted or cancelled?
If yes, please clarify.
....................................................................................................................................................................................................................................................................................................................

Application Form Rev. October/201902ช/ คYes
3.
10ค
กค
ก
จฉ
ก ก ก ก ค ง?
ขชIn the past 10 years, have you ever had symptoms of, or been made aware of, or diagnosed with, or treated for any of the following?
Please underline the speci c condition.
3.1 - กก (Headaches, Migraines)- คง (Cerebrovascular Disease or Disorders)-คกข ง(Any other Disease or Disorders of Neurological System)- จก ค จ (Chest Pain / Heart Disease)- จ (Palpitations)- จก (Arrhythmia s)-คก ข งจ
(Any Disorders of Lungs, Heart or Blood Circulation System)ข (Varicose Veins)(Diabetes)-คง (Hypertension)ขก (Dyslipidemia)- คง ข ง งก (Blood Disease, Hormonal or Glandular Disease)
3.2 ง
จ (Respiratory System)- งง ง (Emphysema)กง (COPD)(Asthma)งก(Bronchial Hyper responsiveness)งจ (Respiratory Allergy)กจ(Any other Breathing Problems, please specify)แบบสอบถาม – ต อ เนื ่ อ ง (Medical Questions – Continued)กช/ คNoค…………………………………………………….……………………………………………..………………………………………………….………………………………………………………………..............……………………………..
3.3 - คจ (Psychosis)- จ ช (Psychiatric Disorders)- คกกง(Stress, Anxiety, Insomnia)(Mood Disorder)ก (Panic Disorders)(Depression)
3.4- ชก-(Seizures or Epilepsy)(Fainting or Black-out Spells)

3.5 - คก ข งง
(Gastrointestinal Problems)-ก(GERD - Acid Re ux)
กกง(Stomach or Intestinal Ulcers, Gastrointestinal Bleeding)กค ง งข ง(IBS, In ammatory Bowel Disease (IBD), Diverticular Disease)กกขก (Pancreatitis, Hepatitis, Fatty Liver)- คข ง งงง(Gallbladder Disease, Gallstones, Bile Duct Disease)จ ง (Anemia),
ง (Hernias, Hemorrhoid)(Food Allergy)-คกข งก(Other Disorders of Stomach, Liver or Intestines)
3.6 - คก ข งก กง(Disorders of Prostate or Genitourinary Tract)-คก ข ง(Disorders of Kidneys, Ureters)(Kidney Stones)-คก ข งก(Disorders of Bladder)ค ก ก ง (Immune System Disease)- ชกก ก ข งกค
ง(HIV, AIDS, AIDS Related Complex)
3.7 - คง(Neck, Back or Shoulder Pain)- คกกก(Fibromyalgia)-กกกง (Myofascial Pain Syndrome)งก กงก
(Bulging or Herniated Discs)
3.8 - คคกกก ก ก กขก ก (Muscle, Joint or Bone Disease or Condition)- กข ข ก ข(Joint Pain, Arthritis, Rheumatoid)- ค
ง (Auto-Immune Disorders)-กก คข ง งก (Any Degenerative Disorders or Diseases)- คง คก ข งงง(Any Skin Condition, Atopic Dermatitis, Urticaria, Moles, Lumps, Rash)
3.9 - ก คก ก กจ ก งค (Disorders of the Eyes, Ears, Nose, Sinuses or Throat)ก จกจกง(Pterygium, Cataracts, Glaucoma, Retina Disorders, Blindness or Visual Loss)

Application Form Rev. October/201903

ช/ คYesแบบสอบถาม – ต อ เนื ่ อ ง (Medical Questions – Continued)
3.10

ช/ คNoคง ง ก งคกจ จฉกก ข งกงง ก?
คDo you have any history of cancer, tumors or cysts, or been investigated or treated for suspected cancers or tumors?
If yes, please specify.
………………………………………………….……………………………………………..……………………….....……………….………………………………………………………………..............……………………………..

3.11 ขก งก กคข ง? ชAre you currently having any treatment or medications recommended or has been prescribed by a physician?
If yes, please specify.
………………………………………………….……………………………………………..……………………….....……………….………………………………………………………………..............……………………………..
410
ค ข ก
ง
ชก ค กก?
ชชข งกจ /ก จข กก
Have you ever been admitted to or been treated at a hospital, medical center, clinic or sanitarium in the past 10 years? If yes,please give the name and address of the hospit al, the illness or injury, date of treatment and for how long you were hospitalized?

//กช
Treatment Date (DD/MM/YYYY) (Name of Healthcare Provider)(FOR WOMEN ONLY) : 女性の方のみ,

5. ฉ
5.1

ค จฉ ค(Diagnosis)

５．１

ก ก(Result of Treatment)

５．２

５．３

10
ก

ค

งคคง

คคค
ค

ง
Yesก

ก ก กกงคก งขกช/ คNoงข ก กจ จฉ/จกก?
ชIn the past 10 years, have you had any diseases or disorders of the breast, uterus, ovaries, fallopian tubes, cervix,
menstruation, reproductive system, abortion, miscarriage or have been dia gnosed and treated for infertility or not?
If yes, please specify.
女性のみ…………………………………………………….……………………………………………..………………………………………………….………………………………………………………………..............……………………………..
5.3

ก คช/ คYes
女性のみก ง งค? ชค
Are you pregnant? If yes, please specify number of weeks of the pregnancy. ........
/ Weeks5.2

ก ก คง(Latest Follow-up date)ก? Have you had a prior child delivery?
ง Surgical Delivery/C-Section?
No: year. ........

女性のみ

男性ー女性

6คคจ จฉจ ขกกจกขง? ชHave you ever been advised to have any medical test, medical check-up or procedure other than as noted above?
If yes, please specify.
....................................................................................................................................................................................................................................................................................................................

6.1

จจก? ชจก?
. ........
Do you currently smoke a pipe, cigars or cigarettes? How many sticks do you smoke per day?

. ........ Sticks

6.2

ค งก
? ช(จฉ)Do you drink alcohol? If yes, please specify (average units per week consumed)…………………………………………………….……………………………………………..………………………………………………….………………………………………………………………..............……………………………..

7.

คก
จ
(ชก )ก
กงกช กงก ง จคกกจ
จHave you ever had any special medical examination (such as MRI, CT Scan) any surgical, or procedures e.g. endoscopy?
If yes, for what? When? And the result s?
....................................................................................................................................................................................................................................................................................................................

8.

ช/ คคกข ข ง ข ข งกช ง งงกWhen you answered Yes to any question in this form, please give details in the space below or put on additional paper.
..............................................................................................................................................................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................................................................................................................................................

Application Form Rev. October/201904

งข งกข จ คก ก ข งขคจง ก กง งขคขกขคขกก/จขงชก(ข จ ข จชข จค ค ข งข จ) จ กงข ก ขง ขจ ข จ คข จ/กกขจกจ ก ขจก กกจก กกง ก ก ข จคคก ขจก ( ช )จ ข/ ขข ข งขข ข งข จ จจขจจ ก ชกง ค ก ก ก กง กก กกกจ กก ขข

จจ กจ

จก
ข ง กก

ขชกชข งข จข จจ ง ก ก ข ข งข จกจ ก(ค .)งจ กก จ งกช งกกงขงกฉก
ค กงก

งคกก
ช

All the above statements are true and have been completed to the best of my knowledge and belief, and I understand that The Company,believing them to be such, will rely upon them. I further understand that the premium quoted above or elsewhere, unless otherwise advised by Paci c
Cross Health Insurance PCL are quoted in respect of me and my family being residents of Thailand. I do understand that the quoted premium in thisdocument and/or other documents (if any) may be loaded in regard to my health information and/or health record.
I do hereby give my consent to Paci c Cross Health Insurance PCL or its representative to request copies of any kind of information regarding
my health records or health condition from any physician, healthcare provider, or any organization until completion. A photocopy of this statement shallbe as e ective and valid as the original.
I hereby give my consent to Paci c Cross Health Insurance PCL to collect, use and disclose information pertaining to my health and any otherin formation to insurance company or reinsurance companies or the O ce of Insurance Commission (OIC) or legal authorities or medical professional
personnel for the purpose of Insurance Business Compliance or The Company s underwriting decision or bene t payment decision or medical use.

保険料を所得税控除申請するための証明書発行依頼

สิ ทธิ ข อยกเว นภาษีเง� นได (Tax Deduction)ขกงคจ ช ข กงกกWould you like to claim for Personal Income Tax Deduction with this health insurance premium?
控除申請に必要な証明書を発行依頼します。

คกงคกงข ก กกกกงคกกกขกชงช (Non-Thai Resident) งงงกข จจ กกก
ข : ......................................................................................
Yes, and I permit the insurer to send and reveal the information about this insurance premium to the Revenue Department.
as long as the policy remains in force. If the applicant is a non-Thai resident, please enter the taxpayer ID Number givenby the Revenue Department : . ................................ ............................................. 納税者番号ご記入くだ. ............................................................... ...............................................
ขก
Applicant s Signature. ..............................................................................................................
ชช(กขกง)Guardian s Signature(Applicant on behalf of a Minor)

お申込者サイン（２０才以上の場合のみ）

ข ง

กง คค

งขงก งก

さい。

คงค / No不要です。

คกกก

ก กกง

ค
ก

กก

จ ง กขกกกกจก ข คช

งก

. ............................... ...............................................................
日付け//Date/Month/Year(ค .)จง865งข คจจกกฆWARNING BY OFFICE OF INSURANCE COMMISSION (OIC)The applicant must truthfully answer all questions. Any concealment or misrepresentation of the truth may result in the insurance contract
becoming void under Clause 865 of the Civil and Commercial Code resulting in the cancellation of the policy.

กง Directก
Agentก
Brokerข
License No. ................................... ................ . ............................................... ...................
Broker/Agent Code ....................................................................................................

บร�ษัท แปซิฟค ครอส ประกันสุขภาพ จำกัด (มหาชน)152 ค ชค ช 21

ง 21-01ขงขง กก ง10500

Pacific Cross Health Insurance PCL

152 Chartered Square Buildin g, 21 st Floor, Room 21-01, North Sathorn Road, Silom, Bangrak, Bangkok 10500
T: +66 2 401 9189 | F: +66 2 401 9187 | E: contactus@th.paci ccrosshealth.com | www.paci ccrosshealth.com

Application Form Rev. October/201905