American Express Home Insurance Plan - Enrollment Form


Please complete and fax this Enrollment Form to us at 2811 3231 before December 31, 2004.

YES, I wish to enroll in the American Express Home Insurance Plan and please charge the premium from my American Express® Card account.

American Express Card Number:

Expiry Date : _____/_______ (MM/YY)

Cardmember's Name

Insured Address:

Gross Floor Area of Insured Premises (in sq. ft.)

Monthly Premium
Below 1,500 sq. feet HK$120
1,501 - 3,000 sq. feet HK$192

Date of Birth ______/______/______(DD/MM/YY)

Sex     Male      Female

HKID Number

Home Tel.

Office Tel.

Mobile Number

E-mail Address

Declaration
  1. I declare that my home is built of bricks, stone or concrete and roofed with concrete. I have not made any claims under this kind of home insurance within the past 12 months and have never had my home insurance refused. I further declare that I/my family members am/are free from any physical impairment or deformity.
  2. I declare that to the best of my knowledge and belief the information on this form is true and complete in every respect. I understand that this form and declaration will form the basis of the contract between me and Zurich Insurance Company (the "Company").
  3. I understand that this proposal will not be in force until it is accepted by the Company and the premium has been paid.
  4. I understand that if I am not satisfied with the American Express Home Insurance Policy ("the Policy"), I can return it within 14 days upon receipt and any premium charged during this period will be refunded in full.
  5. I understand that I shall refer to the Policy for details of the insurance coverage, exclusion clauses and terms and conditions.
  6. I understand that all the personal information collected or held by the Company, howsoever obtained, may be used by or disclosed to any individual or organization within or outside Hong Kong for the following purposes: (i) to assess and service this application (ii) to authorize credit card payment (iii) to provide marketing material of the Company or its associated companies and (iv) to conduct insurance claims or analysis. I understand that I may contact the Company's Personal Data Privacy Officer at Levels 15-17, Cityplaza 3, 14 Taikoo Wan Road, Hong Kong for any request to access to and/or correct any information supplied to the Company.

Signature of Cardmember:


X           Date ______/______/______(DD/MM/YY)  

Exact terms and conditions and exclusion should be referred to the actual policy. Acceptance of this application is subject to the final decision of Zurich Insurance Company.