Transfer of Policy Ownership Form

保單權益轉讓表格
Please darken the appropriate circle. 請塗黑適當的選項。 Correct form 正確方式為：●
Policy Number 保單號碼 Name of Policyowner
* Please complete the boxes and darken the appropriate numbered circles to 保單持有人姓名
indicate the policy number. 請填寫方格和塗黑適當號碼格，以註明保單號碼。

Name of Life Assured

受保人姓名

0 0 0 0 0 0 0 0 0 0 0 0 Name of Consultant
1 1 1 1 1 1 1 1 1 1 1 1 顧問姓名
2 2 2 2 2 2 2 2 2 2 2 2
Consultant Code
3 3 3 3 3 3 3 3 3 3 3 3
顧問編號
4 4 4 4 4 4 4 4 4 4 4 4
5 5 5 5 5 5 5 5 5 5 5 5 Division Code & Branch Office
6 6 6 6 6 6 6 6 6 6 6 6 分區編號及分行地點
7 7 7 7 7 7 7 7 7 7 7 7
8 8 8 8 8 8 8 8 8 8 8 8 Consultant Contact No.
9 9 9 9 9 9 9 9 9 9 9 9
顧問聯絡電話號碼

Is the policyowner currently a customer in mainland China? 保單持有人現在是否是個中國內地客户？

 Yes 是
(If “Yes”, please tick below box to agree the following statement. If you disagree with this statement, we may not be able to process your request / application.
如「是」，請勾選以下選項以同意下列聲明。如您不同意以下聲明，我們可能無法處理您的指示/申請。)
 By ticking this box, you agree that as an international group company, in order to provide insurance-related products or services,
we may need to store and process your personal information outside of mainland China. Please refer to our Privacy Notice
(https://www.prudential.com.hk/en/china-personal-information-protection-law/) for more information.
勾選此項，表示您同意，我們作為國際集團公司，為提供保險相關產品或服務，可能需要在中國內地境外存儲或處理您的
個人信息。更多資訊，請參閱我們的隱私聲明 (https://www.prudential.com.hk/tc/china-personal-information-protection-law/)。
 No 否

Important Note 重要提示

1. Please complete in BLOCK LETTERS. 請以正楷填寫。
2. This form is NOT applicable for PRURetirement Deferred Annuity Plan. 此表格不適用於保誠「雋逸人生」延期年金計劃。
3. Please return to Prudential Hong Kong Limited (“Prudential”) within 30 days after signing this form. 請於簽署此表格後30天內交回保誠保險有限
公司（「保誠」）處理。
4. Please complete the form in appropriate position as instructed, any information written in non-designated blank spaces will not be processed. Sign on blank
or incomplete form will not be accepted. 請根據此表格之指示於適當的位置填寫資料，任何其他非指定空白位置填寫的資料恕不受理。
在空白表格或尚未填妥的資料上簽署恕不受理。
5. Any changes or amendments in this form must be countersigned by both existing and new Policyowners in full signature. 現有及新保單持有人均須在
此表格內任何更改或修改的地方簽署作實。
6. Both existing and new Policyowners as well as the witness MUST sign and date in Part 9 of this form. 現有及新保單持有人和見證人必須在此表格
第九部分簽署及填寫簽署日期。
7. With effect from 1 January 2018, levy collected by the Insurance Authority has been imposed on relevant policy at the applicable rate. For further
information, please visit www.prudential.com.hk/levy or contact: (852) 2281 1333. 由2018年1月1日起，保險業監管局已按適當的比率於相關保單
徵收徵費。如需更多資訊，請瀏覽www.prudential.com.hk/levy或聯絡：(852) 2281 1333。
8. Prudential shall have the right to reject this form if you fail to fulfill Prudential’s requirements. 若閣下未能符合保誠的有關規定，保誠有權拒絕此表格。
9. Receipt of this form by your Financial Consultant or Broker does not constitute receipt by Prudential. 閣下的理財顧問或經紀收到此表格並不代表保誠亦已收到。
10. In any circumstances, a person who is not a party to the above policy (including but not limited to the Life Assured or the Beneficiary) has no right to enforce
any of the terms of the above policy. 任何不是上述保單某一方的人士或實體（包括但不限於受保人或受益人），在任何情況下均不能強制
執行上述保單的任何條款。
11. If the new Policyowner is a mainlander (holder of either PRC Passport, PRC ID Card or PRC Travel Permit for HKSAR & MSAR) 如新保單持有人為內地
人士（持中國護照，中國居民身份證或往來港澳通行證之人士）
a. you need to complete according to clause 11(b) below and submit "Important Facts Statement for Mainland Policyholder" (IFS-MP) to us before we process
this form. Please contact your Financial Consultant or Broker for the completion of IFS-MP. 在我們處理此表格前，閣下需要按下列條款11(b) 填妥
及遞交「內地人士在港投購人身 / 壽險保單重要資料聲明書」。請與閣下的理財顧問或經紀聯絡以便完成簽署此重要資料聲明書。
b. and if the transfer of policy ownership is made within the first year from the Date of Policy or Commencing Date (whichever the earlier) and if the existing
and new Policyowner are not direct family members (i.e. parent, spouse and children), the new Policyowner is required to sign the IFS-MP physically in
Hong Kong. 而若保單權益轉讓於保單生效日或首期保費日（ 以較前者為準 ）首年內提出，而現有及新保單持有人並非直系親屬
（ 即父母，夫婦及子女 ），新保單持有人需要親身到香港簽署「內地人士在港投購人身 / 壽險保單重要資料聲明書」。

Part 1 第一部分 Details of the New Policyowner 新保單持有人資料

1. Please submit identity document copy for both existing and new Policyowners. 請一併遞交現有及新保單持有人之身份證明文件副本。
2. If the new Policyowner is an Individual, please complete Part 6. If the new Policyowner is a company, please complete the "Supplementary Form for
Business Insurance" and submit the required identity documents which vary according to company type. Please contact your Financial Consultant or
Broker for details. 如新保單持有人為個人，請填寫第六部分。如新保單持有人為公司，必須填妥「商業保險補充表格」並依公司註冊
類別提交所需交件，詳情請與閣下的理財顧問 / 經紀聯絡。
3. All previous designation of beneficiary(ies), trustee, contingent owner, Designated Person appointed under SmartAppoint Service, policyowner's
spouse registered under specific plans, death benefit settlement option, Payor Benefit, Payor Accidental Death Protection and/ or Parental Premium
Waiver Benefit, if any, under the Policy will be revoked automatically upon Prudential accepted the transfer of policy ownership. 保誠接受保單
權益轉讓申請後，於本保單較早前所指定的受益人、信託人、後備持有人、「智安排」預設保單服務下委任指定人士、特定計劃下的
已登記保單持有人配偶、身故賠償支付選擇、投保人保障、投保人意外身故保障及/或親子保費豁免保障（如有）將會被自動撤銷。

00000000
Prudential Hong Kong Limited 保誠保險有限公司
Part of Prudential plc (United Kingdom) 保誠集團成員
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 Part 1 第一部分 Details of the New Policyowner (Continued) 新保單持有人資料（續）
All details in this page are mandatory to be provided. 必須填寫此頁之所有項目。
4. If the policy is a Juvenile Policy (Life Assured under age 18 upon policy issuance), the new policyowner must be the parent, grandparent or legal guardian of
life assured. Please provide relationship proof. 如保單屬兒童保單（即保單繕發時受保人未滿18歲），新保單持有人必須為受保人之父母、
祖父母或合法監護人，並請提供關係證明。
5. Financial Consultant cannot be the new Policyowner unless she / he is the immediate family member of life assured. 理財顧問如非受保人的直系
親屬，不得成為新保單持有人。
6. Person aged below 18 cannot be the new Policyowner. 18 歲以下人士不能成為新保單持有人。
7. Income pay via DDA and death benefit settlement option (if any) will be automatically cancelled upon accepted the transfer of policy ownership, please
re-arrange income payment method and/or death benefit settlement option. 經自動轉賬收取現金入息及身故賠償支付選擇（如有）將於我們
接受保單權益轉讓後自動取消，請重新安排收取現金入息之方法及 / 或身故賠償支付選擇。
8. This form shall not be valid until (i) it is received and recorded by Prudential during the lifetime of both the Policyowner and the life assured of the policy
stated above (the “Policy”), and (ii) it is finally confirmed by Prudential by way of a letter. 此表格需於 (i) 上述保單（「本保單」）之保單持有人
及受保人生存期間獲保誠收到並存檔及 (ii) 最終經保誠以信函確認方為有效。
9. Please return this form with a confirmation of release of collateral assignment if the policy has been assigned. Otherwise the request will not be accepted
by Prudential. 如保單已被抵押，請一併遞交取消抵押轉讓證明，否則此表格將不獲保誠受理。
10. Please read and acknowledge Part 2 to 5 by signing in Part 9. 請細閱及確認第二至第五部分，並於第九部分簽署作實。

Name in English
英文姓名
Name in Chinese Sex  Male 男 Nationality
中文姓名 性別  Female 女 國籍
Date of Birth Country of Birth
/ /
出生日期 Day日 Month月 Year年 出生國家
Do you currently file a tax return in the United States? 你現時是否有向美國申報稅項？
(If yes, please provide relevant document(s). 如是，請提供相關文件。)
 No 否  Yes 是
Relationship Relationship with Life Assured 與受保人關係 Relationship with existing Policyowner 與現有保單持有人關係
關係 (Please provide relationship proof if life assured is a juvenile (Please provide relationship proof for direct relationship (i.e. parent,
如受保人為兒童，請提供關係證明 ) spouse, children) 如為直系親屬 ( 即父母，夫婦，子女 )
請提供關係證明 )

Identity Document Identity Document Type Identity Document Number Issuing Country
Number 身份證明文件類別 身份證明文件號碼 簽發國家
身份證明文件號碼 HK Identity Card Hong Kong
(Please submit identity
香港居民身份證 香港
document copy
請遞交身份證明文件 Identity Card
副本 ) 身份證
Chinese Travel Permit China
往來港澳通行證 中國
Passport
護照
Others, please specify
其他，請註明
Reason for Transfer *Juvenile Policy must select “Others” and specify the reason 兒童保單必須選擇「其他」並註明原因
of Policy Ownership  Asset Allocation 資產配置  Gift Offering 餽贈  Others, please specify*
保單權益轉讓之原因  Estate Planning 遺產策劃  Debt Restructuring 債務重組 其他，請註明*
Occupation Details Name of Employer Business Address 公司地址
職業詳情 僱主名稱

Flat / Room 室 Floor 樓 Block 座

Business Nature
業務性質 Building / Estate 大廈 / 屋苑名稱

Street / Road 街道名稱

Occupation & Details

職業及工作性質 District / City / Province 地區 / 城市 / 省

Country 國家 Postal Code

郵政編號

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Part 1 第一部分 Details of the New Policyowner (Continued) 新保單持有人資料（續）
All details in this page are mandatory to be provided. 必須填寫此頁之所有項目。

Residential Address Mobile Number 手提電話

居住地址 Country  HK 香港  China 中國
For Corporate Owner, Name
Flat / Room 室 Floor 樓 Block 座  Others, please specify
Please provide Business 國家名稱 其他，請註明
Address
Telephone
如屬公司為保單持有 Number ( )
Building / Estate 大廈 / 屋苑名稱
人，請提供公司地址 電話號碼
Residential Number 住宅電話
Street / Road 街道名稱 Country  HK 香港  China 中國
Name
 Others, please specify
國家名稱 其他，請註明
District / City / Province 地區 / 城市 / 省
Telephone
Number ( )
電話號碼
Country 國家 Postal Code
Email Address 電郵地址
郵政編號

Correspondence Address Correspondence Address 通訊地址 Permanent Address 永久地址

& Permanent Address
(If the correspondence
or permanent address is
the same as residential Flat / Room 室 Floor 樓 Block 座 Flat / Room 室 Floor 樓 Block 座
address, please skip this
question.)
通訊地址及永久地址 Building / Estate 大廈 / 屋苑名稱 Building / Estate 大廈 / 屋苑名稱
(如通訊地址或永久地
址與居住地址相同，
則無須回答此問題。) Street / Road 街道名稱 Street / Road 街道名稱

District / City / Province 地區 / 城市 / 省 District / City / Province 地區 / 城市 / 省

Country 國家 Postal Code Country 國家 Postal Code

郵政編號 郵政編號

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Part 2 第二部分 Declaration by the Existing Policyowner 現有保單持有人聲明
I / We, the existing Policyowner(s), hereby give notice that I / we have transferred all my / our rights, claims and interests in and obligations under the Policy to
the new Policyowner stated above. I / We understand and agree that this notice is not valid until it is confirmed by Prudential Hong Kong Limited in writing. I
/ We understand that such transfer of ownership will automatically revoke the existing designation of revocable beneficiary(ies), trustee(s), contingent owner,
policyowner's spouse registered under specific plans and death benefit settlement option and terminate the existing Payor Benefit, Payor Accidental Death
Protection and / or Parental Premium Waiver Benefit (if any) on the Policy. 本人 / 吾等，作為現有保單持有人，現通知本人 / 吾等已將上述本保單
轄下本人 / 吾等的權利、賠償、利益及責任，轉讓予上述新保單 持有人。本人 / 吾等明白並同意此通知於保誠保險有限公司書面確認
後方為有效。本人 / 吾等明白該擁有權轉讓將自動撤換現時指定的可撤換受益人、信託人、後備持有人、特定計劃下的已登記保單持有人
配偶及身故賠償支付選擇及終止保單現時之投保人保障、投保人意外身故保障及 / 或親子保費豁免保障（如適用）。

Part 3 第三部分 Declaration by the New Policyowner 新保單持有人聲明

I / We, the new Policyowner(s), understand that the Mobile Phone Number I / we provided in this form will be saved in policy record. In the future when I / we use
myPrudential, while identity authentication is required, system will issue Identity Verification Code through SMS message to this mobile phone number.
For Individual Policyowner(s)
I / We, the new Policyowner(s), hereby confirm that I am / we are the ultimate beneficial owner(s) of the Policy and can exercise ultimate effective control over the
Policy. I / We shall immediately inform Prudential Hong Kong Limited of any change in the ultimate beneficial ownership or control under the Policy, and provide
such relevant information as may be required for identifying the ultimate beneficial owner(s) of the Policy.
For Corporate Policyowner
I / We, the authorized person(s) of the new Policyowner, hereby confirm that all principal shareholder(s)* of the new Policyowner are the ultimate beneficial
owner(s) of the Policy and can exercise ultimate effective control over the new Policyowner. I / We shall immediately inform Prudential Hong Kong Limited of any
change in the ultimate beneficiary ownership or control of the new Policyowner, and provide such relevant information as may be required for identifying the
ultimate principal beneficial owner(s) of the new Policyowner.
* “principal shareholder” refers to an individual person entitled to exercise or control the exercise of 10% or more of the voting rights of the new Policyowner.
For Juvenile Policy (Life Assured under age 18 upon policy issuance)
I / We, the new Policyowner(s), hereby declare and consent to act as trustee of the Policy subject to the following terms and conditions:
(1) All benefits payable under the Policy shall belong to the life assured who shall constitute the irrevocable beneficiary and shall be paid through me until the
ownership of the Policy has been transferred to the life assured;
(2) I / We shall have the right to exercise every option, benefit and privilege under the Policy in my / our capacity as trustee until the ownership of the Policy has
been transferred to the life assured;
(3) I / We and the life assured may jointly apply for transfer of the ownership of the Policy to the life assured who has attained age 18 by signing the required form(s); and
(4) Only applicable to the policy issued prior to 1 April 2014:
a) Upon the life assured attaining age 21, the life assured shall automatically become the new owner of the Policy;
b) Upon the transfer of policy ownership to the life assured either automatically when the life assured attains age 21 or pursuant to clause (3) above, all
my/our rights entitlements and powers in relation to the Policy shall automatically cease.
本人 / 吾等，作為新保單持有人，明白在此表格所提供的手提電話號碼將會保存到保單紀錄中。日後當本人 / 吾等使用 myPrudential 時，
如有需要進行身份核實，系統將會以手機短訊形式發送身份驗證碼到這個手提電話號碼。
適用於個人保單持有人
本人 / 吾等，作為新保單持有人，現確認本人 / 吾等是保單最終實益擁有人，並可以對本保單行使最終有效控制權。本人 / 吾等將立即通知
保誠保險有限公司有關本保單的最終實益擁有權或控制權的任何變動及提供所需的資料，作為對本保單的最終實益擁有人進行身份核實。
適用於公司保單持有人
本人 / 吾等，作為新保單持有人之授權人，現確認新保單持有人的所有主要股東* 是新保單持有人的最終實益擁有人，並可以對新保單
持有人行使最終有效控制權。本人 / 吾等將立即通知保誠保險有限公司有關新保單持有人的最終實益擁有權或控制權的任何變動及提供
其所需的資料，作為對新保單持有人的最終實益擁有人進行身份核實。
*「主要股東」指有權行使或控制行使新保單持有人 10% 或以上投票權之人士。
適用於兒童保單(即保單繕發時受保人未滿 18 歲之保單)
本人 / 吾等，作為新保單持有人，現聲明及同意依據下列條款及條件擔任本保單的信託人：
(1) 本保單之所有保障利益將屬於受保人，受保人為本保單之不可撤換受益人，而所有本保單之保障利益將由本人 / 吾等代受保人託管，
直至本保單之持有權轉予受保人；
(2) 本人 / 吾等可以信託人身份行使本保單之任何選擇權、利益及特權，直至本保單之持有權轉予受保人；
(3) 本人 / 吾等及受保人可共同簽署所需表格，以申請將保單持有權轉予已年滿十八歲之受保人；及
(4) 只適用於2014年4月1日前已繕發的保單 :
a) 當受保人年滿廿一歲時，受保人將自動成為本保單的新保單持有人；
b) 當保單持有權於受保人年滿廿一歲時自動轉予受保人或根據上述 (3) 條轉予受保人後，本人 / 吾等於本保單之所有權利、權益及
權力將自動終止。

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Part 4 第四部分 Legal, Jurisdiction and Tax Statement 法律，司法管轄權及稅務聲明
You acknowledge that the legal and/or tax consequences arising from your decision to make any proposal for assurance to Prudential Hong Kong Limited (referred
to as “our, “we” or “us” in this Part IV entitled “Legal, Jurisdiction and Tax Statement”) (including any legal and tax reporting or compliance obligations to any
applicable tax authorities on your part) depend on your personal circumstances. You are reminded that it is your sole responsibility to seek independent legal
and/or tax advice on any such legal and/or tax consequences (in all applicable jurisdictions) before making any proposal for assurance to us.
You understand that foreign exchange control and currency transfer laws and regulations may apply to your proposal, policy and related premium payments and
agree that you are responsible for ensuring compliance with those laws and regulations and that the application of, or changes in, such laws or regulations may
adversely affect you, your policy or benefits thereunder. You acknowledge and confirm that neither we nor anyone on our behalf has given you any assurances in
that regard.
You acknowledge that we may change premium payment arrangements at any time without prior notice.
You understand and agree that the legal contract and policy between you and the Company for the proposed assurance shall be governed by and
construed in accordance with the laws of Hong Kong Special Administrative Region of the People’s Republic of China (“Hong Kong”) and be subject to
the exclusive jurisdiction of the Hong Kong courts.
閣下承認向保誠保險有限公司 ( 在第四部分「法律，司法管轄權及稅務聲明」，簡稱「我們的」或「我們」) 申請人壽保險之決定而引起
之法律及 / 或稅務後果（包括就閣下適用之稅務機構之任何法律及稅務報告或遵從的責任）取決於閣下個人情況。閣下須注意在向我們
申請人壽保險前，閣下須全權負責就任何此法律及 / 或稅務後果（在所有適用的管轄範圍）尋求獨立法律及 / 或稅務諮詢。
閣下明白外匯管制及貨幣轉移法律和法規可能適用於閣下的保險申請，保單及保費繳付，並同意就該等法律和法規的合規負責，閣下
明白因應該等法律和法規的應用或更改，閣下本人，閣下的保單或保單下的利益可能受到不良的影響。閣下知悉及確認我們或我們的
任何代表均沒有向閣下在這方面提供任何保證。
閣下承認我們可能於任何時間在沒有事先通知的情況下更改保費繳款安排。
閣下明白及同意閣下向我們所申請保險有關的法律合約及保單受中華人民共和國香港特別行政區（[ 香港 ]）法律管轄及闡釋並遵從香港
法院的專有司法裁判權。

Part 5 第五部分 Notice and Agreement relating to Foreign Account Tax Compliance Act and other Applicable Laws
有關《外國帳戶稅務合規法》和其他適用法律的聲明和協定
1. Customer acknowledgement regarding compliance with Foreign Account Tax Compliance Act and other Applicable Laws
You acknowledge that Prudential Hong Kong Limited (referred to as “our”, “we”, or “us” in this Part 5 entitled “Notice and Agreement relating to Foreign
Account Tax Compliance Act and other Applicable Laws”) may be obliged to comply with, observe or fulfill the requirements of the laws, regulations, orders,
guidelines, codes, and requirements including the applicable requirements under the Foreign Account Tax Compliance Act of or agreements with any public,
judicial, taxation, governmental and/or other regulatory authorities, including without limitation, the Internal Revenue Service of the United States of America
(the “Authorities” and each an “Authority”) in various jurisdictions as promulgated and amended from time to time (the “Applicable Requirements”). In this
connection, you agree that we may disclose your particulars to any Authority, or withhold payments otherwise payable to you, in each case in circumstances
as specified in this form, for the purpose of ensuring our compliance or adherence with the Applicable Requirements.
2. Customer consent to disclose information to third parties / waiver of data privacy rights
You agree that we may disclose your particulars or any information to any Authority in connection or adherence with the Applicable Requirements. Such
disclosure may be effected directly or sent through any of our Head Office(s) or other affiliates of Prudential plc. For the purposes of the foregoing and
notwithstanding anything contained in this form or any other agreements between us, we may need you to provide us with further information as may be
required for disclosure to any Authority and you shall provide the same to us within such time as may be reasonably required.
3. Updating of customer information about nationality, tax status and others
Notwithstanding anything contained in this form or any other agreements between us, you agree to provide us with such assistance as may be necessary to enable
us to comply with our obligations under all Applicable Requirements concerning you or your policies with us.
You agree to update us in a timely manner of any change of any of the details previously provided to us whether at time of application or at any other times. In
particular, it is very important that you notify us immediately if, where you are an individual, your personal identification numbers, addresses, telephone numbers,
nationality, tax status or tax residency changes or if you become tax resident in more than one country, or, where you are a corporation or any other type of entity,
your registered address, address of your place of business, substantial shareholders, legal and beneficial owners or controllers (who own or control more than 10% of
your shares or ownership interest or control), tax status, tax residency changes or if you become tax resident in more than one country. If any of these changes occurs
or if any other information comes to light concerning such changes, we may need to request certain documents or information from you. Such information and
documents include but are not limited to duly completed and/or executed (and, if necessary, notarized) tax declarations or forms.
If you do not provide us with the information or documents requested in a timely manner or if any information or documents provided are not up-to-date,
accurate or complete you agree that we may, in order to ensure our ongoing compliance or adherence with the Applicable Requirements, withhold payment of
any amount due to you or your personal representatives under your policy in compliance with the Applicable Requirements and/or pay the same to any relevant
Authority as the relevant Authority may require.
1. 客戶確認符合《外國帳戶稅務合規法》和其他適用法律
閣下承認保誠保險有限公司（在此第五部分「 有關《外國帳戶稅務合規法》和其他適用法律的聲明和協定」，簡稱為「我們的」或
「我們」）須遵從，遵守或履行法律，法規，命令，指引，守則和包括《外國帳戶稅務合規法》適用規定的要求，或任何公眾，司法，
稅務，政府和 / 或其他監管機構協定的要求，包括但不限於美國的稅務局（以下簡稱「監管機構 」）在不同的司法管轄區（以下簡稱
「適用規定 」）不時頒布及修訂的協定。在這方面，閣下同意我們可以根據此表格列明的每種情況，向任何監管機構透露閣下的個人
資料或扣留任何支付給閣下的款項，以確保我們遵行適用規定。
2. 客戶同意向第三方披露資料 / 放棄資料的私隱權
閣下同意我們可能會根據適用規定的要求，向任何監管機構披露閣下的個人資料或任何資料。此等披露可以由我們直接或通過我們的總
公司或英國保誠集團的其它成員進行。基於前述的原因，以及儘管在此表格或我們之間的任何其他協議所載的任何內容，我們可能需要
閣下向我們提供進一步資料，以便向任何監管機構透露，而閣下必須在合理要求的時間內，向我們提供相關的資料。
3. 更新客戶有關國籍，稅務狀況的資料及其他資料
儘管載於此表格或我們之間其他任何協議所包含的任何內容，閣下同意向我們提供協助，使我們能夠就閣下或閣下向我們購買的保險
計劃，遵行我們在適用規定下的義務。
就閣下任何在申請時或其他時間向我們提供的任何資料，閣下同意及時向我們提供更新資料。尤其重要的是閣下立即通知我們下列的
更新：若閣下是個體，閣下的個人身份號碼，地址，電話，國籍，稅務狀況或稅籍所在地的變動；閣下擁有多於一個國家的稅籍；若
閣下是法團法人或任何其他類型的實體，閣下的註冊地址，業務營運地址，主要股東，法定及實際受益人或管理人（擁有或控制 10% 以
上股份或所有權或管理權的人士），稅務狀況，稅籍所在地的變動，或若閣下擁有多於一個國家的稅籍。若發生這些變動，或若任何
這種變動的其他資料已為大家所知，我們可能會要求閣下提供某些文件或資料。此等資料和文件包括但不限於正式完成及 / 或簽署（並且
如有需要，由公證人作出公證）的稅務申報或表格。
如果閣下未能及時向我們提供資料或文件，或閣下所提供所需的資料或文件並非最新，準確或完整，為確定我們持續遵從適用規定，閣下
同意我們可以按適用規定的要求，就我們於閣下保單應支付閣下或閣下的個人代表的任何款項中作出扣留，並 / 或按相關監管機構的要求，
向相關監管機構支付所扣留的款項。

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Part 6 第六部分 Individual Tax Residence Self-Certification 個人稅務居住地自我申報證明書
Important Notes 重要提示：
• This part is a self-certification provided by New Policyowner, who may be Individual Account Holder, to a reporting financial institution for the
purpose of automatic exchange of financial account information. The data collected may be transmitted by the reporting financial institution to
the Inland Revenue Department for transfer to the tax authority of another jurisdiction. 本部分是新保單持有人（可能作為個人帳戶持有人）
向申報財務機構提供的自我證明，以作自動交換財務帳戶資料用途。申報財務機構可把收集所得的資料交給稅務局，稅務局會將
資料轉交到另一稅務管轄區的稅務當局。
• Account Holder should report all changes in his / her tax residency status to the reporting financial institution. 如帳戶持有人的稅務居民身分有
所改變，應盡快將所有變更通知申報財務機構。
• Please read instruction and glossary in below websites before completing the form: 填表前請先細閱以下連結之指引及定義摘要：
http://www.ird.gov.hk/eng/tax/aeoi/self_cert.htm
A. Identification of Individual New Policyowner 個人新保單持有人身分識別資料
The New Policyowner’s Full Name, Identity Document No., Date of Birth, Country of Birth, Residential Address and Correspondence Address as
completed in Part I will be considered as part of your self-certification. 新保單持有人在第一部分填寫的姓名，身份證明文件號碼，出生日期，
出生國家，居住地址及通訊地址將被視為閣下的自我申報證明書一部分。
B. Jurisdiction of Residence and Taxpayer Identification Number or its Functional Equivalent (“TIN”)
居留司法管轄區及稅務編號或具有等同功能的識辨編號（以下簡稱「稅務編號」）
Complete the following table indicating 提供以下資料，列明
a) the jurisdiction of residence (including Hong Kong) where the new Policyowner is a resident for tax purposes and
新保單持有人的居留司法管轄區，亦即新保單持有人的稅務管轄區（香港包括在內）及
b) the new Policyowner ‘s TIN for each jurisdiction indicated.
該居留司法管 轄區發給新保單持有人的稅務編號。
Indicate all (not restricted to five) jurisdictions of residence. 列出所有（不限於 5 個）居留司法管轄區。
If a TIN is unavailable, provide the appropriate reason A, B or C: 如沒有提供稅務編號，必須填寫合適的理由：
Reason 理由 A - The jurisdiction where the new Policyowner is a resident for tax purposes does not issue TINs to its residents.
新保單持有人的居留司法稅務管轄區並沒有向其居民發出稅務編號。
Reason 理由 B - The new Policyowner is unable to obtain a TIN. Explain why the new Policyowner is unable to obtain a TIN if you have selected this reason.
新保單持有人不能取得稅務編號。如選取這一理由，解釋新保單持有人不能取得稅務編號的原因。
Reason 理由 C - TIN is not required. Select this reason only if the authorities of the jurisdiction of residence do not require the TIN to be disclosed.
新保單持有人毋須提供稅務編號。居留司法管轄區的主管機關不需要新保單持有人披露稅務編號。
Enter Reason A, B or C
Jurisdiction of Residence TIN# if no TIN is available
居留司法管轄區 稅務編號 # 如沒有提供稅務編號，
填寫理由 A、B 或 C

Explain why the Proposer / Policyowner is unable to obtain a TIN if you have selected Reason B in corresponding line.
如選擇理由 B，請於相對的欄位解釋新保單持有人不能取得稅務編號的原因。

#
If the new Policyowner is a tax resident of Hong Kong, the TIN is the Hong Kong Identity Card Number.
如新保單持有人為香港稅務居民，稅務編號是其香港身份證號。
If the new Policyowner is a tax resident of China, the TIN is the China Identity Card Number.
如新保單持有人為中國稅務居民，稅務編號是其中國身份證號。
If the new Policyowner is a U.S. citizen, permanent resident (“Green Card” holder), or otherwise a U.S. tax residen, U.S. social security number is equivalent to TIN.
如果新保單持有人為美國公民，永久居民 (“綠咭”持有人 ) ，或美國稅務居民，稅務編號是其美國社會福利保障號碼。

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 C. Declaration 聲明
I, the new Policowner, acknowledge and agree that (a) the information contained in this form is collected and may be kept by the financial institution for the
purpose of automatic exchange of financial account information, and (b) such information and information regarding the new Policyowner and any reportable
account(s) may be reported by the financial institution to the Inland Revenue Department of the Government of the Hong Kong Special Administrative Region
and exchanged with the tax authorities of another jurisdiction or jurisdictions in which the new Policyowner may be resident for tax purposes, pursuant to the
legal provisions for exchange of financial account information provided under the Inland Revenue Ordinance (Cap.112).
I, the new Polocyowner, am reminded that it is my sole responsibility to seek independent legal and / or tax advice on any such legal and / or tax consequences
(in all applicable jurisdictions) before making this self-certification to Prudential Hong Kong Limited. I acknowledge and confirm that neither Prudential Hong
Kong Limited nor anyone on the behalf of Prudential Hong Kong Limited has given me any legal and / or tax advice in that regard.
I, the new Policyowner certify that I am the new Policyowner or I am authorized to sign for the new Policyowner of all the account(s) to which this form relates.
I, the new Policyowner, undertake to advise Prudential Hong Kong Limited of any change in circumstances which affects the tax residency status of the
individual identified in Part I of this form or causes the information contained herein to become incorrect, and to Prudential Hong Kong Limited with a suitably
updated self-certification form within 30 days of such change in circumstances.
I, the new Policyowner, declare that the information given and statements made in this form are, to the best of my knowledge and belief, true,
correct and complete.
本人作為新保單持人知悉及同意，財務機構可根據《稅務條例》（第 112 章）有關交換財務帳戶資料的法律條文，(a) 收集本表格
所載資料並可備存作自動交換財務帳戶資料用途及 (b) 把該等資料和關於新保單持有人及任何須申報帳戶的資料向香港特別行政區
政府稅務局申報，從而把資料轉交到投保人 / 保單持有人的居留司法管轄區的稅務當局。
本人，作為新保單持有人，知悉在向保誠保險有限公司提交自我申報證明書前，本人須全權負責就任何此法律及 / 或稅務後果（在
所有適用的管轄範圍）尋求獨立法律及 / 或稅務諮詢。本人承認保誠保險有限公司或保誠保險有限公司的任何代表均沒有向本人在
這方面提供任何法律及 / 或稅務諮詢。
本人，作為新保單持有人，證明，就與本表格所有相關的帳戶，本人是新保單持有人或本人獲新保單持有人授權簽署本表格。
本人，作為新保單持有人，承諾，如情況有所改變，以致影響本表格第一部所述的個人的稅務居民身分，或引致本表格所載的資料
不正確，本人會通知保誠保險有限公司，並會在情況發生改變後 30 日內，向保誠保險有限公司提交一份已適當更新的自我證明表格。
本人，作為新保單持有人，聲明就本人所知所信，本表格內所填報的所有資料和聲明均屬真實、正確和完備。

/ /
Day 日 Month 月 Year 年 Signature of New Policyowner
新保單持有人簽署
Name of New Policyowner
新保單持有人姓名
Note: Please indicate the capacity if you are not the individual identified in Part I. If signing under a power of attorney, attach a certified copy of the power
of attorney.)
註： 如閣下不是第一部所述的個人，請說明閣下的身分。如果閣下是以 授權人身份簽署這份表格，須夾附該授權書的核證副本。
Capacity in which declaration is made 以下列身分作出聲明 :

WARNING: It is an offence under section 80(2E) of the Inland Revenue Ordinance if any person, in making a self-certification, makes a
statement that is misleading, false or incorrect in a material particular AND knows, or is reckless as to whether, the statement is misleading,
false or incorrect in a material particular. A person who commits the offence is liable on conviction to a fine at level 3 (i.e.$10,000).
警告 : 根據《稅務條例》第 80(2E) 條，如任何人在作出自我證明時，在明知一項陳述在要項上屬具誤導性、虛假或不正確，或罔
顧一項陳述是否在要項上屬具誤導性、虛假或不正確下，作出該項陳述，即屬犯罪。一經定罪，可處第 3 級 ( 即 $10,000) 罰款。

Part 7 第七部分 Revocation and Appointment of Beneficiary(ies) 撤銷及委任受益人

1. This form is only applicable to beneficiary policies and subject to the terms and conditions of the Policy. To change beneficiary for trust policies, please
complete Form D2 instead. Please contact your Financial Consultant or Broker for details. 此表格只適用於受益人保單並根據本保單之條款發出。
如欲更改信託保單之受益人，請填寫 D2 表格。詳情請與閣下的理財顧問 / 經紀聯絡。
2. Once Prudential have accepted your request for appointment of beneficiary(ies) and / or trustee(s), this form will form part of the Policy. Such change will
be effective from the date when you signed this form, whether or not the Life Assured is alive at the time when we endorsed such change. All previous
designation of beneficiary(ies) and trustee(s) under the Policy shall be revoked. All death benefit thereafter shall be paid and allocated to the beneficiary(ies)
and / or trustee(s) listed below in Part 7. 有關受益人及 / 或信託人委任一經保誠接納，則會成為本保單的一部分。不論受保人當時是否
在生，有關更改即於閣下簽署此表格日期起生效。所有於較早前在本保單下委任的受益人及信託人將被取替。此後，一切身故賠償將
根據此表格第七部分所列之受益人及 / 或信託人作出支付及分配。
3. The total share for each group of beneficiary(ies) must be 100% (to share equally according to Prudential’s guideline unless otherwise stated). 每組受益人
獲分配的百分比總和必須為 100%（如沒有特別聲明，賠償則會按保誠的守則平均分配）。
4. To appoint secondary beneficiary, primary beneficiary must be appointed in advance. The designation of secondary beneficiary(ies) will only be effective if all primary
beneficiaries are deceased. 如需委任候補受益人，必須先委任基本受益人。候補受益人的委任必須於所有基本受益人身故後方才生效。
5. If the beneficiary is NOT an immediate family member (including spouse, parent, children, siblings, or grandparent) of the life assured, it is a MUST to
provide identity document / passport number of the beneficiary in this form. 如受益人並非受保人之直系親屬（包括配偶 / 父母 / 子女 / 兄弟姊妹 /
祖父母），必須於此表格提供受益人之身份證 / 護照號碼。
6. Financial Consultant cannot be the beneficiary, unless she / he is the immediate family member of life assured. 理財顧問如非受保人的直系親屬，不得
成為受益人。
7. There is no restriction on the age of beneficiary(ies), but payment of benefit to any minors shall be subject to the provisions of the Policy (if applicable).
受益人的年齡不受限制，但向未成年人士支付的利益將受本保單的條款限制（如適用）。
8. Appointment of beneficiary under a juvenile policy is not allowed. 兒童保單不接受委任受益人。

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Part 7 第七部分 Revocation and Appointment of Beneficiary(ies) (Continued) 撤銷及委任受益人（續）
9. If the intended beneficiary is a business entity / trust fund / trust company, it is required to submit along with this form (i) Business Registration number of
the party concerned; and (ii) a copy of Business Registration Certificate or Certificate of Incorporation; and (iii) a copy of latest Annual Return. 如欲委任的
受益人為一商業實體 / 信託基金 / 信託公司，必須連同此表格一併遞交 (i) 其商業登記號碼，及 (ii) 商業登記證或公司註冊證明書之副本
及 (iii) 最新的周年申報表之副本。
10. To name a Charitable Institution as the Beneficiary (policy donation) with over 50% of policy benefit or an amount more than HK$1 Million, a written
declaration signed by the Policyowner should be provided. 如捐贈 50% 以上保單利益或其金額超過一百萬港元予慈善團體，保單持有人必須
提供已簽署書面聲明。
11. If your application of Transfer of Policy Ownership in Part 1 of this form is not accepted by Prudential due to whatever reason, your request for beneficiary
appointment made in this part of the form will not be processed. 若保誠因任何原因未能接納閣下於此表格第一部分的保單權益轉讓申請，閣下
於此表格本部分內的委任受益人要求將不獲處理。
^ IMPORTANT NOTES FOR APPOINTMENT OF TRUSTEE FOR MINOR BENEFICIARY ^ 委任未成年受益人的信託人之重要資料
1. If the beneficiary of an insurance policy is a minor (below the age of majority as defined under the Age of Majority (Related Provisions) Ordinance as then
inforce) at the time when the benefit proceeds is paid, the benefit proceeds will be paid to the legal guardian of the minor beneficiary. If you wish to appoint
an individual as trustee of any benefit proceeds payable to a minor beneficiary during his / her minority, you may make a request to appoint a trustee for
a minor beneficiary by using this form. The final decision on the validity of this form remains with Prudential. 凡保單的受益人於保單利益給付時為
未成年人士（即當時有效的《成年歲數（有關條文）條例》定義下為未達法定的成年歲數），保單的利益將會支付給未成年受益人的
法定監護人。如閣下欲委任個人作為未成年受益人於未成年期間應得之保單利益的信託人，可填妥及遞交此表格以確定有關之委任。
保誠對此表格的有效性擁有最終的決定權。
2. The appointment of trustee(s) for minor beneficiary(ies) will be revoked automatically when: (i) the beneficiary attains the age of majority by the time
the benefit proceeds is paid and the benefit proceeds shall be paid directly to the beneficiary; or (ii) the trustee(s) do(es) not submit a claim for the benefit
proceeds within 180 calendar days of the date of death of the life assured; or (iii) if the trustee is not living at the date of death of the life assured. 未成年
受益人的信託人委任將於以下情況被自動撤銷： (i) 於保單利益給付時，受益人已達法定的成年歲數，保單利益將直接支付給受益人；
或 (ii) 未成年受益人的信託人沒有於受保人身故後的 180 曆日內提出保單利益的索償；或 (iii) 信託人於受保人身故時已去世。
3. You have the right to change designated trustee(s) without his/her consent from time to time by submitting a request using the latest version of the Prudential’s
prescribed form. Any previously appointed beneficiary(ies) and trustee(s) will be revoked when beneficiary is changed. 閣下有權更改已委任之信託人而不需取
得已委任的信託人的同意，但需填妥及遞交保誠最新的表格。當更改受益人時，所有之前已委任的受益人及信託人將被自動撤銷。
4. The Policyowner hereby declares that any trustee designated in the table below (“Trustee”) shall be appointed as trustee to receive any benefit proceeds
under the Policy for the beneficiary named on and in accordance with the percentage proportion as shown in the same row before such beneficiary attains
the age of majority. 保單持有人謹此聲明，當受益人年滿法定的成年歲數前，於下表內指定之信託人 (「信託人」) 將以信託人身份代表
受益人根據下表內同一行所示之百分比收取本保單的保單利益。
5. Prudential only accepts individual who attains the age of majority being appointed as the trustee for minor beneficiary. 保誠只接受委任已達法定的成
年歲數之個人作為未成年受益人的信託人。
6. Naming minor beneficiary(ies) and appointing trustee(s) for minor beneficiary(ies) hereunder without a separate trust document may have important legal
consequence at the time of claim for benefit proceeds and receipt of the benefit proceeds. You should check with your legal advisor before making such an
appointment. 在此沒有獨立之信託文件下指定未成年人士為受益人及委任未成年受益人的信託人可能於保單利益索償及收取保單利益時
涉及重要的法律後果。閣下應於作出此委任前先諮詢閣下的法律顧問。
7. The Policyowner hereby declares that the trustee(s) designated below have been notified and the trustee(s) has / have consented to act as trustee. Any
failure by the Policyowner to do so may affect the validity of the appointment for which Prudential shall not assume any responsibility or liability. 保單持有
人謹此聲明已通知下表內委任的信託人並已取得其同意擔任信託人。若保單持有人未能通知信託人及取得其同意將可能影響信託人
委任的有效性，惟保誠對此不承擔任何責任。
8. The receipt of the benefit proceeds by the Trustee shall be a full discharge of the liability of Prudential under the Policy. Prudential shall not be responsible for
the application or disposition of the benefit proceeds by the Trustee. 當信託人收取保單利益後，保誠已完全履行本保單上的所有法律責任。保
誠就信託人對保單利益的運用及處置概不負責。
9. Financial Consultant cannot be the trustee, unless she / he is the immediate family member of the minor beneficiary. 理財顧問如非未成年受益人的直系
親屬，不得成為信託人。

Primary Beneficiary(ies) 基本受益人

^ ONLY APPLICABLE TO MINOR BENEFICIARY
^ 只適用於未成年受益人
Trustee
Beneficiary Name
Relationship with Identity Document / Share % Relationship with Identity Document /
(English / Chinese) Name of Trustee
受益人姓名
Life Assured Passport Number 分配 Beneficiary Passport Number
與受保人之關係 身份證 / 護照號碼 信託人姓名 與受益人之關係 信託人身份證 /
（英文 /中文） (百分比)
護照號碼
1

Total 總額 100%

Secondary Beneficiary(ies) 候補受益人

^ ONLY APPLICABLE TO MINOR BENEFICIARY
^ 只適用於未成年受益人
Trustee
Beneficiary Name
Relationship with Identity Document / Share % Relationship with Identity Document /
(English / Chinese) Name of Trustee
受益人姓名
Life Assured Passport Number 分配 Beneficiary Passport Number
與受保人之關係 身份證 / 護照號碼 信託人姓名 與受益人之關係 信託人身份證 /
（英文 /中文） (百分比)
護照號碼
1

Total 總額 100%

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Part 8 第八部分 Personal Information Collection Statement (“PICS”) 收集個人資料聲明 (「收集個人資料聲明」)
Prudential Hong Kong Limited (referred to as “Company”, “our”, “we”, or “us”) take the privacy and protection of your personal information seriously. We collect
personal information from you that is necessary or helpful for us to either provide you with the product or service you have requested or to comply with statutory
or contractual requirements (including the purposes mentioned below), or even for security purpose. We may collect personal information including, but not limited
to, full name, address, contact details, contact details history, date of birth, gender, nationality, family members, beneficiaries, identity card copy and details, travel
document information, health/medical records, credit information, product history, claims history, biometric data including but not limited to your voice pattern,
fingerprint and facial images, your location information based on your device, financial and medical information ("Personal Information") to provide you with the
insurance or financial products or services. “Personal information” shall also include, but not be limited to, the personal information relating to your beneficiaries
(or any other person designated or entitled to receive any benefits under an insurance policy), dependents, authorised representatives, company staff, and other
individuals in relation to which you have provided personal information. If you provide personal information about another person to us, you confirm that you are
either their parent or guardian or you have obtained that person's consent to provide such personal information for use and transfer by the Company for the purposes
set out in this PICS. We may also collect Personal Information about you from third parties such as other insurance companies, agents, credit reference/reporting
agencies, vendors, financial institutions, fraud prevention agencies, government agencies, medical personnel, courts or public record.
China Personal Information Protection Law (PIPL)
The PIPL Addendum supplements the Personal Information Collection Statement and applies to you if you are located in Mainland China. The PIPL Addendum is
available on our website at https://www.prudential.com.hk/en/china-personal-information-protection-law/
1. Purpose of Collection
We may use your Personal Information for the following purposes: (a) the administration of our products and services, including to provide any relevant services
as discussed with you prior to any purchase of a product or service; (b) to process your application; (c) to administer and process insurance policies, insurance
claims, medical, security and underwriting checks; (d) to process payment instructions; (e) to verify your eligibility for insurance, financial or wealth management
products and services; (f) to design and provide you with insurance, financial and related products and services; (g) to communicate with you; (h) to comply with
any regulatory or other legal requirements or other internal business requirements (whether imposed on us or any third parties in Section 2 below), including but
not limited to anti-money laundering and Know-Your-Client obligations; (i) to investigate and settle claims and detect and prevent fraud (whether or not relating
to the policy issued in respect of this application) and/or other illegal activity, or security or technical issues; (j) to carry out checks using agencies including credit
reference agencies, tracing companies or publicly available information; (k) to provide customer services; (l) to perform automated decision-making or profiling; (m)
to perform a policy review or needs analysis; (n) to conduct research and statistical analysis (including use of new technologies); (o) to administer lucky draws and
other contests; (p) to enable us to perform our obligations to you; (q) to keep your information on record and carry out other internal business administration;
(r) with your specific consent where required for direct marketing as explained in Section 3 below, personalise and tailor, customised promotions, messages and
suggestions to you; and (s) any other purpose directly relating to any of the above purposes. With your consent, we may also use your personal data to send you
marketing communications, as described in Section 3 below.
Some of the purposes above are necessary to allow us to perform our contractual obligations to you and to enable us to comply with applicable laws and
regulation. We may also use and share your Personal Information for the purposes described above to improve our products and services. Your Personal
Information will be stored either for as long as you (or your joint policyholder) are our customer, or longer if required by law or as is otherwise necessary.
2. Classes of Transferees
We may disclose your Personal Information to the group of companies including the Company and those of other entities whose ultimate parent company is
Prudential plc including but not limited to Prudential General Insurance Hong Kong Limited ("companies within the Prudential Group”) and their respective
insurance agents, and to our financial/medical/wellness/health business partners. We may also disclose your Personal Information to the following third parties
(within or outside Hong Kong) for the purposes outlined at Section 1 above: (a) insurance agents; (b) insurance brokers; (c) re-insurance companies; (d) claims
investigation companies; (e) organisations that consolidate claims and underwriting information for the insurance industry, fraud prevention organisations,
other insurance companies (whether directly or through fraud prevention organisations or other persons named in this paragraph) and databases or registers
(and their operators) used by the insurance industry to analyse and check information provided against existing information; (f) third party service providers who
provide administrative, telecommunications, computer, information technology, data processing and storage, customer satisfaction analysis, payment, printing,
redemption or other services to us to enable us to operate our business (including without limitation other insurers, lawyers, bankers, accountants, professional
advisors, financial institutions and trustees, auditors, IT service and platform providers, insurance intermediaries, investment managers, agents, pension trustees
(and other stakeholders), scheme advisors, introducers, and selected third party financial and insurance product providers); (g) industry associations and
federations; (h) medical bill review companies; (i) your joint policy or investment holder; (j) researchers; (k) credit reference agencies; (l) debt collection agencies;
(m) partnering financial institutions and partnerships; and (n) financial crime prevention agencies, any legal, regulatory, law enforcement or government bodies
and the courts. We may also disclose your Personal Information to an actual or proposed assignee or participant in connection with a transaction with another
company which affects the control, governance, structure and/or management of all or a substantial part of our business, or if required to satisfy applicable legal
or regulatory requirements. With your consent, we may also disclose your personal data to third parties to allow them to send you marketing communications, as
described below.
3. Use and Transfer of Personal Data for Direct Marketing Purposes
With your consent, we intend to use your name and contact details for promotional and marketing purpose including sending marketing communications and
conducting direct marketing to you by electronic and non-electronic means including by post, in relation to the following products, services and subjects, and we
require your consent in order to do so: insurance; annuities; retirement schemes; pensions; wealth and financial management; estate management; investment;
financial; medical/wellness/health related products, reward/loyalty programme services and subjects ("Classes of Marketing Subjects").
We also intend to transfer your name and contact details to our insurance agents, other companies within the Prudential Group and their respective insurance
agents, our Business Partners, and our Marketing Partners, to enable them to market any of the Classes of Marketing Subjects to you, and your written consent is
required in order for us to do so. We may provide your personal data to such transferees for gain.
If you change your mind, and / or you would like to opt-out of receiving direct marketing, you can advise our Data Protection Officer at service@prudential.com.hk.
4. Consequence of failing to provide Personal Information
Unless otherwise specified by us, it is mandatory for you to provide the Personal Information requested by us. If you do not provide such Personal Information, we
may not be able to provide you the product or service that you’ve requested.
5. Access and Correction Rights
Under the Personal Data (Privacy) Ordinance (the "Ordinance"), you have the right to request access to and correction of any Personal Information that you provide
to us. If want to exercise your rights, or if you require any other information, you can advise our Data Protection Officer at service@prudential.com.hk or contact
us using the details on “Contact Us” section of the Company website (https://www.prudential.com.hk/scws/pages/en/contact-us/contact-us-home/index.html)
or our Privacy Notice.
If you move/moved to a European Union (“EU”) jurisdiction, we may be required to provide you with further information, and you may have additional rights,
under the EU General Data Protection Regulation. This information and these rights are set out in the Privacy Notice on our Company website.
We update our Privacy Notice from time to time. We encourage you to familiarise yourself with the Privacy Notice on our Company website. The Privacy Notice is
available on our Company website at https://www.prudential.com.hk/scws/pages/en/privacy-policy/index.html. By completing and progressing with this form, you
confirm that you have read and understood this PICS.
Business Partners means our service providers who provide administrative, telecommunications, computer, information technology, data processing and storage,
customer satisfaction analysis, payment, printing, redemption or other services to us to enable us to operate our business, accountants, auditors, IT service and
platform providers, insurance intermediaries, reinsurers, investment managers, agents, pension trustees (and other stakeholders), scheme advisors, introducers,
selected third party financial and insurance product providers, and our legal advisers.
Marketing Partners means our service providers who provide administrative, telecommunications, computer, payment, printing, third-party rewards/loyalty/
privileges programs, medical/health/wellness related products, redemption or other services to us to enable us to operate our business, insurance intermediaries,
pension trustees (and other stakeholders), scheme advisors, introducers and selected third party financial and insurance product providers.

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Part 8 第八部分 Personal Information Collection Statement (“PICS”) (Continued) 收集個人資料聲明 (「收集個人資料聲明」)（續）
保誠保險有限公司（簡稱「本公司」或「我們」）認真對待閣下個人資料的私隱及保護。為使我們可以向閣下提供閣下要求的產品或服務，
或為遵守法定及合約要求，我們會向閣下收集必要或有幫助的個人資料。為向閣下提供保險或金融產品或服務 , 遵守法定或合同要求（以
下概述的其他目的），及保安目的，我們可能會向閣下收集個人資料，包括但不限於全名、地址、聯絡資料、過往聯絡資料、出生日期、
性別、國籍、家庭成員、受益人、身分證副本及資料、旅遊證件資料、健康 / 醫療紀錄、信貸資料、過往產品紀錄、過往索償紀錄、生
物辨識資料，包括但不限於閣下的聲音模式、指紋及面部圖像、基於閣下的流動或其他電子裝置收集閣下的位置資料、財務及醫療資料
（「個人資料」）。「個人資料」將包括但不限於與有關以下人士的個人資料：閣下的受益人（或任何其他根據保單被指定或有權獲得
任何利益的人）、收養人、授權代表、公司職員和閣下曾提供其個人資料的其他人士。如閣下向我們提供其他人士的個人資料，即表示
閣下確認閣下是該人的父母或監護人或閣下已取得該人士的同意以提供個人資料供本公司按此收集個人資料聲明的目的使用和轉移。
我們亦可能會從第三方，如其他保險公司、代理、信貸資料服務 / 報告機構、供應商、金融機構、防欺詐機構、政府機構、醫務人員、
法院或公開紀錄，收集關於閣下的個人資料。
《中華人民共和國個人信息保護法》
中 國 內 地 補 充 內 容 是 對 本 個 人 信 息 收 集 聲 明 的 補 充， 如 果 您 在 中 國 內 地 則 適 用 此 補 充 內 容。 您 可 在 本 網 站
https://www.prudential.com.hk/tc/china-personal-information-protection-law/ 查閱中國內地補充內容。
1. 收集資料之目的
我們可能會使用閣下的個人資料作下列目的︰ (a) 管理我們的產品和服務，包括在購買產品或服務之前提供已與閣下討論的任何相關服務；
(b) 處理閣下的申請；(c) 管理和處理保單、保險索償、醫療、抵押和承保檢查；(d) 處理付款指示；(e) 核實閣下申請保險、金融或財富
管理產品及服務的資格；(f) 設計及為閣下提供保險、金融及相關的產品和服務；(g) 與閣下進行通訊；(h) 遵守任何監管或其他法律規定
或其他內部業務規定（不論是向我們或下述第 2 部分所列的任何第三方實施），包括但不限於打擊洗錢和認識你的客戶（KYC）義務；
(i) 就索償進行調查及和解，以及偵查及防止欺詐（不論是否有關就本申請簽發的保單）及 / 或其他非法行為或安全 / 技術問題；(j) 使用
代理機構（包括信貸資料服務機構）、追蹤公司或公開可得資料以執行核查；(k) 提供客戶服務；(l) 執行自動決策或資料剖析；(m) 進行
保單審查或需求分析；(n) 進行研究和統計分析（包括使用新科技）；(o) 進行管理幸運抽獎和其他比賽；(p) 使我們能夠履行對閣下的
義務；(q) 保持閣下的資料記錄並執行其他內部業務管理；(r) 為直接市場推廣需要並在有需要時經閣下的特定同意下，如以下第 3 部分所述，
為閣下量身訂製個性化的促銷、消息和建議；及 (s) 與上述任何目的直接相關的任何其他目的。經閣下同意，我們亦可能會按照以下述
第 3 部分所列使用閣下的個人資料以向閣下發出促銷通訊。
為履行對閣下的合約責任及至使我們能夠遵守適用法律及法規，上述部分目的屬必要的。我們亦可能會為上述所列的目的使用及分享
閣下的個人資料以改善我們的產品及服務。只要閣下（或閣下的聯名保單持有人）仍為我們的客戶，我們將一直保存閣下的個人資料，
或如法律有所規定或因其他原因而為必要，我們則將其保存更長時間。
2. 被資料轉交者的類別
我們可能會向該公司集團，包括本公司以及其他母公司為英國保誠集團的實體包括但不限於保誠財險有限公司（「保誠集團內的公司」）
及他們各自的保險代理，及我們的金融 / 醫療 / 保健 / 健康業務夥伴，透露閣下的個人資料。為達到上述第一部分所列明之目的，我們
亦可能會向下列第三方（在香港境內或境外）透露閣下的個人資料︰ (a) 保險代理；(b) 保險經紀；(c) 再保險公司；(d) 索償調查公司；
(e) 為保險業整合索償及承保資料的組織、防欺詐組織、其他保險公司（不論直接或透過防欺詐組織或本段指名的其他人士），及保險
業用作分析及核查現有資料與及後提供的資料而使用的數據庫或登記冊（及其營運商）；(f) 提供行政、電訊、電腦、信息技術、數據
處理及儲存、客戶滿意度分析、付款、印刷、贖回或其他服務以令我們的業務可以運作的第三方服務供應商（包括但不限於其他保險公司、
律師、銀行家、會計師、專業顧問、金融機構及受託人、審計師、IT 服務及平台供應商、保險中介、投資經理、代理、退休金受託人
（及其他持份者）、計劃顧問、介紹人及選定的第三方金融和保險產品供應商）；(g) 行業協會及聯會；(h) 醫療賬單審查公司；(i) 閣下
的聯名保單或投資持有人；(j) 研究人員；(k) 信貸資料服務機構；(l) 收賬代理；(m) 夥伴金融機構及合作夥伴；及 (n) 預防金融罪案機構、
任何法律、監管和執法機構或政府機構及法院。在有關影響到我們全部或重大部分業務的控制權、治理、結構及 / 或管理的與另一公司的
交易時，或在必須符合適用的法律或監管要求下，我們亦可能會透露閣下的個人資料予該等的實在或擬議受讓人或參與人。經閣下同意，
我們亦會向第三方透露閣下的個人資料以讓該等第三方向閣下發出促銷通訊（如下文所述）。
3. 使用及轉移個人資料作直接促銷用途
經閣下的同意，我們擬使用閣下的姓名和聯絡資料，用於宣傳和市場推廣用途，包括通過電子和非電子方式（包括郵寄）向閣下發送
市場推廣通訊和進行直接促銷，就以下產品、服務和目的，我們需要閣下的同意才可以這樣做 : 保險；年金；退休計劃；退休金；財富和
財務管理；遺產管理；投資；金融；醫療 / 保健 / 健康相關產品；獎賞／優惠計劃服務及目的（「促銷標的類別」）。
我們亦擬將閣下的姓名和聯絡資料轉移給我們的保險代理人、保誠集團內的其他公司及其保險代理人、我們的業務合作夥伴和營銷合作
夥伴，以使他們能夠向閣下推銷任何促銷標的類別，並且需要閣下的書面同意才能這樣做。 我們可能因向此類受讓人提供閣下的個人
資料而獲得利益。
如閣下改變主意，及 / 或閣下想選擇不接受直接市場推廣，可以與我們的資料保護主任聯絡 (service@prudential.com.hk)。
4. 未能提供個人資料的影響
除非我們另有規定，否則閣下必須提供我們要求的個人資料。若閣下未提供有關個人資料，我們可能無法為閣下提供所要求的產品或服務。
5. 查閱和更正的權利
根 據《 個 人 資 料（ 私 隱 ） 條 例 》（「 條 例 」）， 閣 下 有 權 要 求 查 閱 及 更 正 任 何 閣 下 提 供 給 我 們 的 個 人 資 料。 閣 下 如 欲 行 使
閣 下 的 權 利， 或 如 閣 下 需 要 任 何 其 他 資 料， 請 聯 絡 我 們， 閣 下 可 以 發 送 電 郵 至 service@prudential.com.hk 或 使 用 本 公 司 網 站
(https://www.prudential.com.hk/scws/pages/tc/contact-us/contact-us-home/index.html) 或我們的私隱通知中「聯絡我們」部分所列的資料與我們的資料
保護主任聯絡。
如閣下搬遷／已搬遷至歐洲聯盟（「歐盟」）司法管轄區，我們可能需要向閣下提供進一步資料，且閣下可能在歐盟《通用數據保障條例》
下享有額外權利。此類資料及此等權利均載於本公司網站上的私隱通知中。
我 們 會 不 時 更 新 我 們 的 私 隱 通 知， 並 建 議 閣 下 瀏 覽 本 公 司 網 站 以 了 解 該 私 隱 通 知。 該 私 隱 通 知 可 在 本 公 司 網 站
〔https://www.prudential.com.hk/scws/pages/tc/privacy-policy/index.html〕上查閱 。閣下填妥並繼續提交本表格，即表示閣下確認已閱讀並理解本
收集個人資料聲明。
業務合作夥伴指我們的服務供應商、提供行政、電信、電腦、信息技術、數據處理及儲存、客戶滿意度分析、支付、印刷、贖回或其他
服務予我們，以使我們能夠經營我們業務，會計師、審計師、IT 服務和平台供應商、保險中介機構、再保險承保人、投資經理、代理、
退休金受託人（和其他持分者）、計劃顧問、介紹人、核准的第三方金融和保險產品供應商以及我們的法律顧問。
營銷合作夥伴指我們的服務供應商提供行政、電信、電腦、支付、印刷、第三方獎賞 / 會員 / 優惠計劃、醫療 / 健康 / 保健相關產品、
贖回或其他服務，以使我們能夠經營我們業務、保險中介、退休金受託人（和其他持分者）、計劃顧問、介紹人和核准的第三方金融和
保險產品供應商。
Opting-out to Marketing Communications and Materials 拒絕市場推廣通訊及資料
 If you do not agree to receive marketing communications and materials from the Company, please check this opt-out box.
If you do not check the opt-out box and sign below, you agree to the provision and use of your personal data by the Company for direct marketing
purposes in accordance with Section 3 of the PICS.
如果你不同意接收本公司的市場推廣通訊及資料，請選擇此拒絕方格。
如果你沒有選擇此拒絕方格，並在下方簽署，則代表你同意本公司根據收集個人資料聲明第三部分，使用及轉移你的個人資料
作直接促銷用途。

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Part 9 第九部分 Signature 簽署
If the signatory is a Company / Partnership / Sole Proprietorship, its authorized signatories should sign and chop. 如簽署方為公司 / 合夥 /
獨資經營持有，須由公司授權人員簽署及蓋章。

/ /
Day Month Year Signature of Existing Policyowner Signature of New Policyowner Signature of Irrevocable Beneficiary /
日 月 年 現有保單持有人簽署 新保單持有人簽署 Irrevocable Trustee (if applicable)
(It must be consistent with that in our 不可撤換受益人 /
record 保單持有人的簽署必須與 不可撤換信託人簽署 (如適用)
本公司的記錄相符)
The witness must be an individual third party aged 18 or above who is not the beneficiary named herein or existing beneficiary or trustee
designated herein or existing trustee or existing contingent owner. If the Policyowner uses signature chop or fingerprint, two witnesses are
required. The personal particulars of the witness(es) will only be used for the purpose of verification and confirmation of the identity(ies) of the
signatory(ies) of this form. 見證人必須為年滿 18 歲或以上之非受益人、非信託人及非後備持有人的第三者。若保單持有人以圖章蓋印或
指紋簽署，必須有兩位見證人。見證人之個人資料只會用於處理本申請及確認此表格簽署人的身份之用。

Signature of Witness Name and Identity Document Signature of Witness Name and Identity Document
見證人簽署 Number of Witness 見證人簽署 Number of Witness
見證人姓名及身份證明文件號碼 見證人姓名及身份證明文件號碼

Please DO NOT sign on BLANK form. 請勿在空白表格上簽署。

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