plac-micro-common 1.3.92 → 1.3.93
This diff represents the content of publicly available package versions that have been released to one of the supported registries. The information contained in this diff is provided for informational purposes only and reflects changes between package versions as they appear in their respective public registries.
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"use strict";
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Object.defineProperty(exports, "__esModule", { value: true });
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exports.UW_FORM_TEMPLATE = void 0;
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exports.UW_FORM_TEMPLATE = `
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<!doctype html>
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<html lang="en">
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<head>
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<meta charset="UTF-8" />
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<meta name="viewport" content="width=device-width, initial-scale=1.0" />
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<title>FULL UW APPLICATION FORM</title>
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<link href="https://fonts.googleapis.com/css2?family=Hanuman:wght@100..900&family=Moul&display=swap"
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rel="stylesheet" />
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<script src="https://cdn.tailwindcss.com"></script>
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<style>
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* {
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margin: 0;
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box-sizing: border-box;
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background: none;
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}
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body {
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font-family: "Hanuman", sans-serif;
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margin: 0;
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font-size: 16px;
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}
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.font-moul {
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font-family: "Moul", sans-serif;
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}
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.font-arial {
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font-family: Arial, sans-serif;
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}
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.form-table td {
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border: 1px solid black;
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}
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.no-border td {
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border-top: none !important;
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border-bottom: none !important;
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}
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.form-field-line {
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border-bottom: 1px solid #000;
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min-height: 18px;
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width: 100%;
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display: block;
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margin-top: 4px;
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}
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input[type="checkbox"] {
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width: 18px;
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height: 18px;
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margin-right: 5px;
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vertical-align: middle;
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accent-color: #000;
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}
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@media print {
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@page {
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size: A3 portrait;
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margin: 10mm 10mm 0mm 10mm;
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}
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}
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.page {
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width: 297mm;
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/* A3 portrait width */
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min-height: 420mm;
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/* A3 portrait height */
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padding: 10mm;
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box-sizing: border-box;
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position: relative;
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page-break-after: always;
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break-after: page;
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overflow: hidden;
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}
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.question-row {
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page-break-inside: avoid;
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break-inside: avoid;
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}
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</style>
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</head>
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<% function yesNoCheckbox(value, name) { return '<div class="flex items-center gap-2" style="margin-top:3px;">' + '<input type="checkbox" ' + (value===true ? 'checked' : '') + ' />' + '<span>មាន / Yes</span>' + ' ' + '<input type="checkbox" ' + (value===false ? 'checked' : '') + ' />' + '<span>មិនមាន / No</span>' + '</div>';
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}
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%>
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<% function renderField(value) { const hasValue=value && value.toString().trim(); return '<div style="border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;">' + (hasValue ? '<span style="font-weight:bold;">' + value + '</span>' : ' ') + '</div>';
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} %>
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<% function renderCheck(value, expected) { return value===expected
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? '<span style="font-size:16px; font-weight:bold;">✓</span>' : '' ; } %>
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<body>
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<script>
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document.fonts.ready.then(() => {
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paginateRows();
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});
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function paginateRows() {
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const PAGE_HEIGHT_PX = 1511;
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const wrapper = document.getElementById('pages-wrapper');
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const allRows = Array.from(document.querySelectorAll('.question-row'));
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let currentPage = document.getElementById('main-content');
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let currentTable = currentPage.querySelector('table');
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let currentDiv = currentPage;
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let usedHeight = currentPage.getBoundingClientRect().height;
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let pageNum = 1;
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function createNewPage() {
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pageNum++;
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const newPage = document.createElement('div');
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newPage.className = 'page';
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const newTable = document.createElement('table');
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newTable.className = 'table w-full table-fixed border-collapse form-table';
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newTable.setAttribute('cellpadding', '20');
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newPage.appendChild(newTable);
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wrapper.appendChild(newPage);
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currentTable = newTable;
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currentDiv = newPage;
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usedHeight = 0;
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}
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for (const row of allRows) {
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const isDeclaration = row.classList.contains('declaration-header');
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const isTr = row.tagName === 'TR';
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const container = isTr ? currentTable : currentDiv;
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// Measure
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row.style.visibility = 'hidden';
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container.appendChild(row);
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const rowH = row.getBoundingClientRect().height;
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container.removeChild(row);
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row.style.visibility = '';
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const remaining = PAGE_HEIGHT_PX - usedHeight;
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if (usedHeight + rowH > PAGE_HEIGHT_PX || (isDeclaration && remaining < 300)) {
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createNewPage();
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}
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const target = row.tagName === 'TR' ? currentTable : currentDiv;
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target.appendChild(row);
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usedHeight += rowH;
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}
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}
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</script>
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<div id="pages-wrapper">
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<div class="page">
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<div id="first-off-page">
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<div class="space-y-3">
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<table width="100%" cellpadding="20">
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<colgroup>
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<col style="width: 20%" />
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<col style="width: 80%" />
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</colgroup>
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<tr style="text-align:center;">
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<th style="background:#ebebeb; border:1px solid;">
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<img src="data:image/png;base64,<%= logo_base64 %>" alt="Logo" class="title-logo" width="200px" />
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</th>
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<th style="background:#dddddd; border:1px solid;" class="space-y-2">
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<p class="font-moul text-2xl">
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ពាក្យសេី្នសុំធានារ៉ាប់រងអាយុជីវិត
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</p>
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<p class="text-lg">
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LIFE ASSURANCE APPLICATION FORM
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</p>
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</th>
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</tr>
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</table>
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<div class="space-y-2 text-align">
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<p>សូមផ្តល់ព័ត៌មានមកក្រុមហ៊ុនឱ្យបានគ្រប់គ្រាន់ និងត្រឹមត្រូវ។ ការផ្តល់ព័ត៌មានមិនត្រឹមត្រូវ ឬក្លែងបន្លំ
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នាំឱ្យបណ្ណសន្យារ៉ាប់រងមោឃភាព ឬត្រូវលុបចោល។</p>
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<p>Please provide us with complete and accurate information. Providing wrong or false information may
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result
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in
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the policy issued being cancelled or voided.</p>
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</div>
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<table class="table w-full table-fixed border-collapse form-table" cellpadding="10">
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<colgroup>
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<col style="width: 17%">
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<col style="width: 17%">
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<col style="width: 8%">
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<col style="width: 8%">
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<col style="width: 17%">
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<col style="width: 17%">
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<col style="width: 8%">
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<col style="width: 8%">
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</colgroup>
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<thead>
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<tr>
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<th colspan="4" class="w-1/2 border border-black">
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<p>ផ្នែកទី១: ព័ត៌មានអំពីម្ចាស់បណ្ណសន្យារ៉ាប់រង</p>
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<p>Part 1: INFORMATION ABOUT THE POLICYHOLDER</p>
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</th>
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<th colspan="4" class="w-1/2 border border-black">
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<p>ផ្នែកទី១: ព័ត៌មានអំពីអ្នកត្រូវបានធានារ៉ាប់រង</p>
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<p>( ប្រសិនបេីខុសពីម្ចាស់បណ្ណសន្យារ៉ាប់រង )</p>
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<p>Part 1: INFORMATION ABOUT THE LIFE ASSURED</p>
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<p>( if different from the policyholder )</p>
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</th>
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</tr>
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<!-- Full Name Value -->
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<tr>
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<td colspan="4">
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<p>ឈ្មេាះពេញដូចបង្ហាញនៅក្នុងអត្តសញ្ញាណបណ្ណ / លិខិតឆ្លងដែន / សំបុត្រកំណេីត / ប័ណ្ណប៉ាតង់
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(ជាភាសាខ្មែរ និងអង់គ្លេស)</p>
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<p class=" ">Full name as shown in ID card / Passport / Birth Certificate / Patent Tax (Khmer
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and
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English)</p>
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</td>
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<td colspan="4">
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<p>ឈ្មេាះពេញដូចបង្ហាញនៅក្នុងអត្តសញ្ញាណបណ្ណ / លិខិតឆ្លងដែន / សំបុត្រកំណេីត (ជាភាសាខ្មែរ
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និងអង់គ្លេស)</p>
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<p class=" ">Full name as shown in ID card / Passport / Birth Certificate (Khmer and English)
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</p>
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</td>
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</tr>
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<tr>
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<td colspan="4">
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<span class="font-bold text-md">
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<%= ph.full_name %>
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</span>
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</td>
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<td colspan="4">
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<span class="font-bold text-md">
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<%= la.full_name %>
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</span>
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</td>
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</tr>
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<!-- Present Address Label -->
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<tr>
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<td colspan="4">
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<span class="">អាសយដ្ឋានបច្ចុប្បន្ន /</span>
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<span class=" ">Present Address</span>
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</td>
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<td colspan="4">
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<span class="">អាសយដ្ឋានបច្ចុប្បន្ន /</span>
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<span class=" ">Present Address</span>
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</td>
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</tr>
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<tr>
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<td colspan="4">
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<span class="font-bold">
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<%= ph.present_address %>
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</span>
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</td>
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<td colspan="4">
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<span class="font-bold">
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<%= la.present_address %>
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</span>
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</td>
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</tr>
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<!-- Phone / Relationship Label -->
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<tr>
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<td colspan="4">
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<ol class="list-decimal pl-5">
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<li>
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<span>លេខទូរស័ព្ទផ្ទាល់ខ្លួន / អុីម៉ែល /</span>
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<span>Phone Number / Email</span>
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</li>
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<li>
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<span>ទំនាក់ទំនងជាមួយអ្នកត្រូវបានធានារ៉ាប់រង /</span>
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<span>Relationship to Life Assured</span>
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</li>
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</ol>
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</td>
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<td colspan="4">
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<ol class="list-decimal pl-5">
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<li>
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<span>លេខទូរស័ព្ទផ្ទាល់ខ្លួន / អុីម៉ែល /</span>
|
|
292
|
+
<span>Phone Number / Email</span>
|
|
293
|
+
</li>
|
|
294
|
+
<li>
|
|
295
|
+
<span>ទំនាក់ទំនងជាមួយម្ចាស់បណ្ណសន្យារ៉ាប់រង /</span>
|
|
296
|
+
<span>Relationship to Policyholder</span>
|
|
297
|
+
</li>
|
|
298
|
+
</ol>
|
|
299
|
+
</td>
|
|
300
|
+
</tr>
|
|
301
|
+
|
|
302
|
+
<tr class="font-bold">
|
|
303
|
+
<td colspan="4">
|
|
304
|
+
<ol class="list-decimal pl-5">
|
|
305
|
+
<li>
|
|
306
|
+
<span>Primary Contact: <%= ph.contact_info %> </span>
|
|
307
|
+
</li>
|
|
308
|
+
<li>
|
|
309
|
+
<span>
|
|
310
|
+
<%= ph.ph_la_relationship %>
|
|
311
|
+
</span>
|
|
312
|
+
</li>
|
|
313
|
+
</ol>
|
|
314
|
+
</td>
|
|
315
|
+
|
|
316
|
+
<td colspan="4">
|
|
317
|
+
<ol class="list-decimal pl-5">
|
|
318
|
+
<li>
|
|
319
|
+
<span>Primary Contact: <%= la.contact_info %> </span>
|
|
320
|
+
</li>
|
|
321
|
+
<li>
|
|
322
|
+
<span>
|
|
323
|
+
<%= la.ph_la_relationship %>
|
|
324
|
+
</span>
|
|
325
|
+
</li>
|
|
326
|
+
</ol>
|
|
327
|
+
</td>
|
|
328
|
+
</tr>
|
|
329
|
+
|
|
330
|
+
<!-- PH = LA / PH ≠ LA -->
|
|
331
|
+
<tr>
|
|
332
|
+
<td colspan="4">
|
|
333
|
+
<div class="flex items-center gap-2">
|
|
334
|
+
<input type="checkbox" <%=isphla_same_person ? 'checked' : '' %> />
|
|
335
|
+
<span>ម្ចាស់បណ្ណសន្យារ៉ាប់រង = អ្នកត្រូវបានធានារ៉ាប់រង</span>
|
|
336
|
+
<span>/</span>
|
|
337
|
+
<span>PH = LA</span>
|
|
338
|
+
</div>
|
|
339
|
+
</td>
|
|
340
|
+
<td colspan="4">
|
|
341
|
+
<div class="flex items-center gap-2">
|
|
342
|
+
<input type="checkbox" <%=!isphla_same_person ? 'checked' : '' %> />
|
|
343
|
+
<span>ម្ចាស់បណ្ណសន្យារ៉ាប់រង </span> ≠ <span>អ្នកត្រូវបានធានារ៉ាប់រង</span>
|
|
344
|
+
<span>/</span>
|
|
345
|
+
<span>PH ≠ LA</span>
|
|
346
|
+
</div>
|
|
347
|
+
</td>
|
|
348
|
+
</tr>
|
|
349
|
+
|
|
350
|
+
<!-- Nationality / ID / Gender / Age Labels -->
|
|
351
|
+
<% const headers=[ { kh: "សញ្ជាតិ" , en: "Nationality" }, { kh: "លេខអត្តសញ្ញាណប័ណ្ណ/លិខិតឆ្លងដែន" ,
|
|
352
|
+
en: "ID / Passport Number" }, { kh: "ភេទ" , en: "Gender" }, { kh: "អាយុ" , en: "Age" } ]; %>
|
|
353
|
+
|
|
354
|
+
<tr>
|
|
355
|
+
<% for (let i=0; i < 2; i++) { %>
|
|
356
|
+
<% headers.forEach((h, idx)=> { %>
|
|
357
|
+
|
|
358
|
+
<td class="align-top <%= idx === headers.length - 1 ? 'text-center' : 'text-start' %>">
|
|
359
|
+
<div class="flex flex-col justify-center h-full">
|
|
360
|
+
<p class="text-sm">
|
|
361
|
+
<%= h.kh %>
|
|
362
|
+
</p>
|
|
363
|
+
<p class="text-sm">
|
|
364
|
+
<%= h.en %>
|
|
365
|
+
</p>
|
|
366
|
+
</div>
|
|
367
|
+
</td>
|
|
368
|
+
|
|
369
|
+
<% }) %>
|
|
370
|
+
<% } %>
|
|
371
|
+
</tr>
|
|
372
|
+
|
|
373
|
+
<!-- Nationality / ID / Gender / Age Values -->
|
|
374
|
+
<tr>
|
|
375
|
+
<td class="text-start-top">
|
|
376
|
+
<p class="font-bold">
|
|
377
|
+
<%= ph.nationality %>
|
|
378
|
+
</p>
|
|
379
|
+
</td>
|
|
380
|
+
<td class="text-start-top">
|
|
381
|
+
<p class="font-bold">
|
|
382
|
+
<%= ph.identifier_no %>
|
|
383
|
+
</p>
|
|
384
|
+
</td>
|
|
385
|
+
<td class="text-start-top">
|
|
386
|
+
<p class="font-bold">
|
|
387
|
+
<%= ph.gender %>
|
|
388
|
+
</p>
|
|
389
|
+
</td>
|
|
390
|
+
<td class="text-start-top text-center">
|
|
391
|
+
<span class="font-bold">
|
|
392
|
+
<%= ph.age %>
|
|
393
|
+
</span>
|
|
394
|
+
</td>
|
|
395
|
+
|
|
396
|
+
<td class="text-start-top">
|
|
397
|
+
<p class="font-bold">
|
|
398
|
+
<%= la.nationality %>
|
|
399
|
+
</p>
|
|
400
|
+
</td>
|
|
401
|
+
<td class="text-start-top">
|
|
402
|
+
<p class=" font-bold">
|
|
403
|
+
<%= la.identifier_no %>
|
|
404
|
+
</p>
|
|
405
|
+
</td>
|
|
406
|
+
<td class="text-start-top">
|
|
407
|
+
<p class="font-bold">
|
|
408
|
+
<%= la.gender %>
|
|
409
|
+
</p>
|
|
410
|
+
</td>
|
|
411
|
+
<td class="text-start-top text-center">
|
|
412
|
+
<span class="font-bold ">
|
|
413
|
+
<%= la.age %>
|
|
414
|
+
</span>
|
|
415
|
+
</td>
|
|
416
|
+
</tr>
|
|
417
|
+
|
|
418
|
+
<!-- DOB / Marital / Children Labels -->
|
|
419
|
+
<% const fields=[ { kh: "ថ្ងៃខែឆ្នាំ និងទីកន្លែងកំណើត" , en: "Date and Place of Birth" , colspan: 1 }, {
|
|
420
|
+
kh: "នៅលីវ / រៀបការរួច / លែងលះ / ពោះម៉ាយ ឬមេម៉ាយ" , en: "Single / Married / Divorced / Widowed" , colspan: 1 }, {
|
|
421
|
+
kh: "ចំនួនកូន" , en: "Number of Children" , colspan: 2 } ]; %>
|
|
422
|
+
|
|
423
|
+
<tr>
|
|
424
|
+
<% for (let i=0; i < 2; i++) { %>
|
|
425
|
+
<% fields.forEach(field=> { %>
|
|
426
|
+
|
|
427
|
+
<td colspan="<%= field.colspan %>" class="text-start-top align-top">
|
|
428
|
+
<p class="text-sm">
|
|
429
|
+
<%= field.kh %>
|
|
430
|
+
</p>
|
|
431
|
+
<p class="text-sm">
|
|
432
|
+
<%= field.en %>
|
|
433
|
+
</p>
|
|
434
|
+
</td>
|
|
435
|
+
|
|
436
|
+
<% }) %>
|
|
437
|
+
<% } %>
|
|
438
|
+
</tr>
|
|
439
|
+
|
|
440
|
+
<tr>
|
|
441
|
+
<td class="text-start-top" style="line-height:1.7">
|
|
442
|
+
<p class="font-bold text-sm">
|
|
443
|
+
<%= ph.dob_and_pob || '' %>
|
|
444
|
+
</p>
|
|
445
|
+
</td>
|
|
446
|
+
<td class="text-start-top text-center">
|
|
447
|
+
<p class="font-bold">
|
|
448
|
+
<%= ph.martial_status %>
|
|
449
|
+
</p>
|
|
450
|
+
</td>
|
|
451
|
+
<td colspan="2" class="text-start-top text-center">
|
|
452
|
+
<p class=" font-bold">
|
|
453
|
+
<%= ph.number_of_children %>
|
|
454
|
+
</p>
|
|
455
|
+
</td>
|
|
456
|
+
|
|
457
|
+
<td class="text-start-top" style="line-height:1.7">
|
|
458
|
+
<p class="font-bold text-sm">
|
|
459
|
+
<%= la.dob_and_pob || '' %>
|
|
460
|
+
</p>
|
|
461
|
+
</td>
|
|
462
|
+
<td class="text-start-top text-center">
|
|
463
|
+
<p class=" font-bold">
|
|
464
|
+
<%= la.martial_status %>
|
|
465
|
+
</p>
|
|
466
|
+
</td>
|
|
467
|
+
<td colspan="2" class="text-start-top text-center">
|
|
468
|
+
<p class=" font-bold">
|
|
469
|
+
<%= la.number_of_children %>
|
|
470
|
+
</p>
|
|
471
|
+
</td>
|
|
472
|
+
</tr>
|
|
473
|
+
|
|
474
|
+
<!-- Employer Name Label -->
|
|
475
|
+
<tr>
|
|
476
|
+
<td colspan="4">
|
|
477
|
+
<span>ឈ្មោះ និងអាសយដ្ឋានរបស់និយោជក /</span>
|
|
478
|
+
<span>Name and Address of Employer</span>
|
|
479
|
+
</td>
|
|
480
|
+
<td colspan="4">
|
|
481
|
+
<span>ឈ្មោះ និងអាសយដ្ឋានរបស់និយោជក /</span>
|
|
482
|
+
<span>Name and Address of Employer</span>
|
|
483
|
+
</td>
|
|
484
|
+
</tr>
|
|
485
|
+
|
|
486
|
+
<!-- Employer Name Value -->
|
|
487
|
+
<tr>
|
|
488
|
+
<td colspan="4">
|
|
489
|
+
<span class="font-khmer font-bold">
|
|
490
|
+
<%= ph.name_and_address_of_employer || 'N/A' %>
|
|
491
|
+
</span>
|
|
492
|
+
</td>
|
|
493
|
+
<td colspan="4">
|
|
494
|
+
<span class="font-khmer font-bold">
|
|
495
|
+
<%= la.name_and_address_of_employer || 'N/A' %>
|
|
496
|
+
</span>
|
|
497
|
+
</td>
|
|
498
|
+
</tr>
|
|
499
|
+
|
|
500
|
+
<!-- Job Title / Salary Labels -->
|
|
501
|
+
<% const jobFields=[ { kh: "តួនាទី និងប្រភេទនៃការងារ" , en: "Job Title and Nature of Work" , colspan: 2 }, {
|
|
502
|
+
kh: "ប្រាក់បៀវត្សប្រចំាឆ្នាំ" , en: "Annual Salary" , colspan: 2 } ]; %>
|
|
503
|
+
<tr>
|
|
504
|
+
<% for (let i=0; i < 2; i++) { %>
|
|
505
|
+
<% jobFields.forEach(field=> { %>
|
|
506
|
+
<td colspan="<%= field.colspan %>">
|
|
507
|
+
<p>
|
|
508
|
+
<%= field.kh %>
|
|
509
|
+
</p>
|
|
510
|
+
<p>
|
|
511
|
+
<%= field.en %>
|
|
512
|
+
</p>
|
|
513
|
+
</td>
|
|
514
|
+
<% }) %>
|
|
515
|
+
<% } %>
|
|
516
|
+
</tr>
|
|
517
|
+
|
|
518
|
+
<!-- Job Title / Salary Values -->
|
|
519
|
+
<tr>
|
|
520
|
+
<td colspan="2"><span class="font-khmer font-bold">
|
|
521
|
+
<%= ph.job_title %>
|
|
522
|
+
</span></td>
|
|
523
|
+
<td colspan="2"><span class="font-khmer font-bold">
|
|
524
|
+
<%= ph.annual_salary %>
|
|
525
|
+
</span></td>
|
|
526
|
+
|
|
527
|
+
<td colspan="2"><span class="font-khmer font-bold">
|
|
528
|
+
<%= la.job_title %>
|
|
529
|
+
</span></td>
|
|
530
|
+
<td colspan="2"><span class="font-khmer font-bold">
|
|
531
|
+
<%= la.annual_salary %>
|
|
532
|
+
</span></td>
|
|
533
|
+
</tr>
|
|
534
|
+
<!-- USA Green Card -->
|
|
535
|
+
<tr>
|
|
536
|
+
<td colspan="8">
|
|
537
|
+
<span>ម្ចាស់បណ្ណសន្យារ៉ាប់រងមិនមែនជាពលរដ្ឋអាមេរិក ឬ ជាប់ពន្ធស្នាក់នៅអាមេរិក ឬ
|
|
538
|
+
មានសិទ្ធិកាន់</span>
|
|
539
|
+
<span> Green Card </span>
|
|
540
|
+
<span>នោះទេ។ </span>
|
|
541
|
+
<p>
|
|
542
|
+
<span>The Policyholder is not USA citizen / USA resident for tax purpose or holding
|
|
543
|
+
Green
|
|
544
|
+
Card.</span>
|
|
545
|
+
</p>
|
|
546
|
+
<%- yesNoCheckbox(ph_is_not_us_citizen) %>
|
|
547
|
+
</td>
|
|
548
|
+
</tr>
|
|
549
|
+
</thead>
|
|
550
|
+
</table>
|
|
551
|
+
</div>
|
|
552
|
+
|
|
553
|
+
<!-- page break -->
|
|
554
|
+
<div style="page-break-after: always;"></div>
|
|
555
|
+
<!-- table 2 question -->
|
|
556
|
+
<table class="table w-full table-fixed border-collapse form-table" cellpadding="10">
|
|
557
|
+
<colgroup>
|
|
558
|
+
<col style="width: 40%">
|
|
559
|
+
<col style="width: 30%">
|
|
560
|
+
<col style="width: 30%">
|
|
561
|
+
</colgroup>
|
|
562
|
+
<!-- Only Life Assured Notice -->
|
|
563
|
+
<tr>
|
|
564
|
+
<td colspan="3" class="text-lg font-bold" style="text-align:center;">
|
|
565
|
+
<h5>
|
|
566
|
+
អ្នកត្រូវបានធានារ៉ាប់រងតែប៉ុណ្ណោះដែលតម្រូវឱ្យបំពេញផ្នែកដែលនៅសល់នៃទម្រង់ពាក្យស្នើសុំនេះ</h5>
|
|
567
|
+
<h5>ONLY THE LIFE ASSURED'S INFORMATION IS REQUIRED FOR THE REMAINDER OF THIS
|
|
568
|
+
APPLICATION FORM</h5>
|
|
569
|
+
</td>
|
|
570
|
+
</tr>
|
|
571
|
+
|
|
572
|
+
<tr>
|
|
573
|
+
<td colspan="3">
|
|
574
|
+
<span>ព័ត៌មានអំពីរបៀបរស់នៅ និងហានិភ័យ</span> / <span>Lifestyle and Risk Information</span>
|
|
575
|
+
</td>
|
|
576
|
+
</tr>
|
|
577
|
+
|
|
578
|
+
<!-- Dangerous Activities -->
|
|
579
|
+
|
|
580
|
+
<!-- Military Flying -->
|
|
581
|
+
<tr class="no-border">
|
|
582
|
+
<td colspan="3">
|
|
583
|
+
<p>តើលោកអ្នកកំពុង ឬមានគម្រោងធ្វើការហោះហើរជាលក្ខណៈយោធា ឬឯកជន
|
|
584
|
+
ក្រៅពីអ្នកដំណើរតាមក្រុមហ៊ុនអាកាសចរណ៍ធម្មតាដែរឬទេ?</p>
|
|
585
|
+
|
|
586
|
+
<p>Do you take part in or do you plan to take part in military or private flying other
|
|
587
|
+
than as a passenger on a regular airline?</p>
|
|
588
|
+
|
|
589
|
+
<%- yesNoCheckbox(la_lifestyle.military_or_flying) %>
|
|
590
|
+
</td>
|
|
591
|
+
</tr>
|
|
592
|
+
|
|
593
|
+
<!-- Dangerous Occupations Header -->
|
|
594
|
+
<tr class="no-border">
|
|
595
|
+
<td colspan="3">
|
|
596
|
+
<p>តើលោកអ្នកកំពុង ឬមានគម្រោងនឹងមានអាជីព
|
|
597
|
+
ឬធ្វើសកម្មភាពគ្រោះថ្នាក់ដូចមានរៀបរាប់នៅខាងក្រោមនេះដែរឬទេ?</p>
|
|
598
|
+
<p>Do you take part in, or plan to take part in any of these listed dangerous occupations or
|
|
599
|
+
pursuits?</p>
|
|
600
|
+
</td>
|
|
601
|
+
</tr>
|
|
602
|
+
|
|
603
|
+
<!-- Scuba / Rock Climbing -->
|
|
604
|
+
<tr class="no-border">
|
|
605
|
+
<td colspan="3">
|
|
606
|
+
<span>ជ្រមុជទឹកគ្រប់ប្រភេទ ឡើងថ្ម ឬឡើងភ្នំ / Scuba Skin diving Mountain or rock climbing</span>
|
|
607
|
+
<%- yesNoCheckbox(la_lifestyle.diving_or_climbing) %>
|
|
608
|
+
</td>
|
|
609
|
+
</tr>
|
|
610
|
+
|
|
611
|
+
<!-- Parachuting / Motor Racing -->
|
|
612
|
+
<tr class="no-border">
|
|
613
|
+
<td colspan="3">
|
|
614
|
+
<span>លោតឆ័ត្រយោង ប្រណាំងម៉ូតូ / Free fall parachuting Motor racing</span>
|
|
615
|
+
<%- yesNoCheckbox(la_lifestyle.parachuting_or_racing) %>
|
|
616
|
+
</td>
|
|
617
|
+
</tr>
|
|
618
|
+
|
|
619
|
+
<!-- Other -->
|
|
620
|
+
<tr class="no-border">
|
|
621
|
+
<td colspan="3">
|
|
622
|
+
<span>ផ្សេងៗទៀត ប្រសិនបើមានសូមបញ្ជាក់ / Other if yes please provide more details : <%-
|
|
623
|
+
renderField(la_lifestyle.activity_detail_desc) %></span>
|
|
624
|
+
</td>
|
|
625
|
+
</tr>
|
|
626
|
+
|
|
627
|
+
<!-- Travel Abroad -->
|
|
628
|
+
<tr class="no-border border-t border-black">
|
|
629
|
+
<td colspan="3">
|
|
630
|
+
<p>តើលោកអ្នកស្នាក់នៅ ឬ មានគម្រោងស្នាក់នៅក្រៅប្រទេសលើសពីរយៈពេល៣ខែ ក្នុង១ឆ្នាំដែរឬទេ?</p>
|
|
631
|
+
<p>Do you plan to reside or travel abroad for more than three months a year?</p>
|
|
632
|
+
<%- yesNoCheckbox(la_lifestyle.reside_or_travel_abroad) %>
|
|
633
|
+
</td>
|
|
634
|
+
</tr>
|
|
635
|
+
<tr class="no-border">
|
|
636
|
+
<td colspan="3">
|
|
637
|
+
<p>ប្រសិនបើមានសូមផ្តល់ព័ត៌មានលម្អិតអំពីអាសយដ្ឋានរបស់ប្រទេសដែលលោកអ្នកស្នាក់នៅ ឬ
|
|
638
|
+
មានគម្រោងស្នាក់នៅ ឬធ្វើដំណើរដូចខាងក្រោម:</p>
|
|
639
|
+
<p class="mb-3">
|
|
640
|
+
If yes, please provide detail information about address of country that reside / travel as
|
|
641
|
+
following :
|
|
642
|
+
</p>
|
|
643
|
+
<span> <%- renderField(la_lifestyle.travel_detail_desc) %></span>
|
|
644
|
+
</td>
|
|
645
|
+
</tr>
|
|
646
|
+
|
|
647
|
+
|
|
648
|
+
<tr class="width-100" cellpadding="10">
|
|
649
|
+
<td colspan="3" style="text-align:center;" class="text-lg font-bold">
|
|
650
|
+
<h5>ផ្នែកទី ២: ព័ត៌មានអំពីបណ្ណសន្យារ៉ាប់រង</h5>
|
|
651
|
+
<h5>Part 2: INFORMATION ABOUT THE POLICY</h5>
|
|
652
|
+
</td>
|
|
653
|
+
</tr>
|
|
654
|
+
|
|
655
|
+
<!-- Policy Info Labels -->
|
|
656
|
+
<tr>
|
|
657
|
+
<td style="width:45%;">
|
|
658
|
+
<p>ប្រភេទបណ្ណសន្យារ៉ាប់រង និងរយៈពេលធានា</p>
|
|
659
|
+
<p>Type of Policy and Length of Cover</p>
|
|
660
|
+
</td>
|
|
661
|
+
<td>
|
|
662
|
+
<p>ទឹកប្រាក់ត្រូវបានធានា</p>
|
|
663
|
+
<p>(ដុល្លារអាមេរិក)</p>
|
|
664
|
+
<p>Sum Assured (USD)</p>
|
|
665
|
+
</td>
|
|
666
|
+
<td>
|
|
667
|
+
<p>បុព្វលាភធានារ៉ាប់រងដែលត្រូវបង់</p>
|
|
668
|
+
<p>(ដុល្លារអាមេរិក)</p>
|
|
669
|
+
<p>Premium Payable (USD)</p>
|
|
670
|
+
</td>
|
|
671
|
+
</tr>
|
|
672
|
+
|
|
673
|
+
<!-- Policy Info Values -->
|
|
674
|
+
<% policy_info.products.forEach(product=> { %>
|
|
675
|
+
<tr class="text-md">
|
|
676
|
+
<td>
|
|
677
|
+
<b>
|
|
678
|
+
<%= product.product %>
|
|
679
|
+
</b>
|
|
680
|
+
</td>
|
|
681
|
+
<td>
|
|
682
|
+
<b>
|
|
683
|
+
<%= product.sum_assured %>
|
|
684
|
+
</b>
|
|
685
|
+
</td>
|
|
686
|
+
<td>
|
|
687
|
+
<b>
|
|
688
|
+
<%= product.premium %>
|
|
689
|
+
</b>
|
|
690
|
+
</td>
|
|
691
|
+
</tr>
|
|
692
|
+
<% }) %>
|
|
693
|
+
|
|
694
|
+
<!-- Rider Details -->
|
|
695
|
+
|
|
696
|
+
<tr>
|
|
697
|
+
<td>
|
|
698
|
+
<p>
|
|
699
|
+
<span>អំពីគម្រោងបន្ថែម / Details of Rider: </span>
|
|
700
|
+
</p>
|
|
701
|
+
<p class="text-md font-bold">
|
|
702
|
+
<%= policy_info.rider.product || 'N/A' %>
|
|
703
|
+
</p>
|
|
704
|
+
</td>
|
|
705
|
+
<td class="text-md">
|
|
706
|
+
<b>
|
|
707
|
+
<%= policy_info.rider.sum_assured || '-' %>
|
|
708
|
+
</b>
|
|
709
|
+
</td>
|
|
710
|
+
<td class="text-md">
|
|
711
|
+
<b>
|
|
712
|
+
<%= policy_info.rider.premium || '-' %>
|
|
713
|
+
</b>
|
|
714
|
+
</td>
|
|
715
|
+
</tr>
|
|
716
|
+
<!-- Total Premium -->
|
|
717
|
+
<tr>
|
|
718
|
+
<td colspan="2" style="text-align:right;">
|
|
719
|
+
<p class="font-bold text-md">
|
|
720
|
+
បុព្វលាភធានារ៉ាប់រងសរុប(ដុល្លារអាមេរិក) / Total Premium (USD)
|
|
721
|
+
</p>
|
|
722
|
+
</td>
|
|
723
|
+
<td class="text-md">
|
|
724
|
+
<b>
|
|
725
|
+
<%= policy_info.total_premium %>
|
|
726
|
+
</b>
|
|
727
|
+
</td>
|
|
728
|
+
</tr>
|
|
729
|
+
</table>
|
|
730
|
+
<!-- table 3 payment -->
|
|
731
|
+
<table class="width-100 form-table" style="margin-top:10px;" cellpadding="10">
|
|
732
|
+
<tr>
|
|
733
|
+
|
|
734
|
+
<!-- Premium Payment Label -->
|
|
735
|
+
<td style="vertical-align:top;width:15%;">
|
|
736
|
+
<p>បុព្វលាភធានារ៉ាប់រងដែលត្រូវបង់ (ជ្រើសរើស)</p>
|
|
737
|
+
<p>Premium Payment (select):</p>
|
|
738
|
+
</td>
|
|
739
|
+
|
|
740
|
+
<!-- Premium Payment Options -->
|
|
741
|
+
<td style="vertical-align:top;width:18%;">
|
|
742
|
+
|
|
743
|
+
<!-- Single Premium -->
|
|
744
|
+
<div style="display:flex;align-items:flex-start;gap:6px;margin-top:4px;">
|
|
745
|
+
<input type="checkbox" <%=policy_info.payment_mode==='Single' ? 'checked' : '' %>
|
|
746
|
+
style="margin-top:3px;flex-shrink:0;" />
|
|
747
|
+
<span>បុព្វលាភធានារ៉ាប់រងបង់មួយលើក / Single Premium</span>
|
|
748
|
+
</div>
|
|
749
|
+
|
|
750
|
+
<!-- Annually -->
|
|
751
|
+
<div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
|
|
752
|
+
<input type="checkbox" <%=policy_info.payment_mode==='Annually' ? 'checked' : '' %>
|
|
753
|
+
style="margin-top:3px;flex-shrink:0;" />
|
|
754
|
+
<span>ប្រចាំឆ្នាំ / Annually</span>
|
|
755
|
+
</div>
|
|
756
|
+
|
|
757
|
+
<!-- Semi-Annually -->
|
|
758
|
+
<div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
|
|
759
|
+
<input type="checkbox" <%=policy_info.payment_mode==='Semi-Annually' ? 'checked' : '' %>
|
|
760
|
+
style="margin-top:3px;flex-shrink:0;" />
|
|
761
|
+
<span>ប្រចាំឆមាស / Semi-Annually</span>
|
|
762
|
+
</div>
|
|
763
|
+
|
|
764
|
+
<!-- Quarterly -->
|
|
765
|
+
<div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
|
|
766
|
+
<input type="checkbox" <%=policy_info.payment_mode==='Quarterly' ? 'checked' : '' %>
|
|
767
|
+
style="margin-top:3px;flex-shrink:0;" />
|
|
768
|
+
<span>ប្រចាំត្រីមាស / <span>Quarterly</span></span>
|
|
769
|
+
</div>
|
|
770
|
+
|
|
771
|
+
<!-- Monthly -->
|
|
772
|
+
<div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
|
|
773
|
+
<input type="checkbox" <%=policy_info.payment_mode==='Monthly' ? 'checked' : '' %>
|
|
774
|
+
style="margin-top:3px;flex-shrink:0;" />
|
|
775
|
+
<span>ប្រចាំខែ / Monthly</span>
|
|
776
|
+
</div>
|
|
777
|
+
|
|
778
|
+
</td>
|
|
779
|
+
|
|
780
|
+
<!-- Method of Payment Label -->
|
|
781
|
+
<td style="vertical-align:top;width:12.7%;">
|
|
782
|
+
<p>របៀបនៃការបង់ (ជ្រើសរើស)</p>
|
|
783
|
+
<p>Method of Payment (select)</p>
|
|
784
|
+
</td>
|
|
785
|
+
|
|
786
|
+
<!-- Method of Payment Options -->
|
|
787
|
+
<td style="vertical-align:top;text-align:left;width:20%;">
|
|
788
|
+
|
|
789
|
+
<!-- Direct Debit -->
|
|
790
|
+
<div style="display:flex;align-items:flex-start;gap:6px;margin-top:4px;">
|
|
791
|
+
<input type="checkbox" <%=policy_info.payment_method==='Direct Debit' ? 'checked' : '' %>
|
|
792
|
+
style="margin-top:3px;flex-shrink:0;" />
|
|
793
|
+
<span>ឥណពន្ធផ្ទាល់ / <span>Direct Debit</span></span>
|
|
794
|
+
</div>
|
|
795
|
+
|
|
796
|
+
<!-- Bank Transfer -->
|
|
797
|
+
<div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
|
|
798
|
+
<input type="checkbox" <%=policy_info.payment_method==='Bank Transfer' ? 'checked' : '' %>
|
|
799
|
+
style="margin-top:3px;flex-shrink:0;" />
|
|
800
|
+
<span>ផ្ទេរតាមរយៈធនាគារ / <span>Bank Transfer</span></span>
|
|
801
|
+
</div>
|
|
802
|
+
|
|
803
|
+
<!-- Cheque -->
|
|
804
|
+
<div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
|
|
805
|
+
<input type="checkbox" <%=policy_info.payment_method==='Cheque' ? 'checked' : '' %>
|
|
806
|
+
style="margin-top:3px;flex-shrink:0;" />
|
|
807
|
+
<span>មូលប្បទានប័ត្រ / <span>Cheque</span></span>
|
|
808
|
+
</div>
|
|
809
|
+
|
|
810
|
+
<!-- Cash -->
|
|
811
|
+
<div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
|
|
812
|
+
<input type="checkbox" <%=policy_info.payment_method==='Cash' ? 'checked' : '' %>
|
|
813
|
+
style="margin-top:3px;flex-shrink:0;" />
|
|
814
|
+
<span>សាច់ប្រាក់ / <span>Cash</span></span>
|
|
815
|
+
</div>
|
|
816
|
+
|
|
817
|
+
<!-- Credit Card -->
|
|
818
|
+
<div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
|
|
819
|
+
<input type="checkbox" <%=policy_info.payment_method==='Credit Card' ? 'checked' : '' %>
|
|
820
|
+
style="margin-top:3px;flex-shrink:0;" />
|
|
821
|
+
<span>ប័ណ្ណឥណទាន / <span>Credit Card</span></span>
|
|
822
|
+
</div>
|
|
823
|
+
|
|
824
|
+
<!-- Other -->
|
|
825
|
+
<div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
|
|
826
|
+
<input type="checkbox" <%=policy_info.payment_method==='Other' ? 'checked' : '' %>
|
|
827
|
+
style="margin-top:3px;flex-shrink:0;" />
|
|
828
|
+
<span>ផ្សេងៗ / Other</span>
|
|
829
|
+
</div>
|
|
830
|
+
|
|
831
|
+
</td>
|
|
832
|
+
|
|
833
|
+
<!-- Direct Debit / Cheque / Credit Card Details -->
|
|
834
|
+
<td colspan="4" style="vertical-align:top;">
|
|
835
|
+
|
|
836
|
+
<!-- Direct Debit and Cheques -->
|
|
837
|
+
<div>
|
|
838
|
+
<p>ឥណពន្ធផ្ទាល់ និងមូលប្បទានប័ត្រ /</p>
|
|
839
|
+
<p>Direct Debit and Cheques:</p>
|
|
840
|
+
</div>
|
|
841
|
+
|
|
842
|
+
<!-- Bank Name / Cheque No -->
|
|
843
|
+
<div style="margin-top:4px;">
|
|
844
|
+
<p>សូមផ្តល់ឈ្មោះធនាគារ និងសាខាធនាគារ / លេខមូលប្បទានប័ត្រ</p>
|
|
845
|
+
<p>Please provide bank name and branch / cheque no.</p>
|
|
846
|
+
<%- policy_info.cheque_info ? '<p><u><b>' + policy_info.cheque_info + '</b></u></p>'
|
|
847
|
+
: '<div style="border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;"></div>'
|
|
848
|
+
%>
|
|
849
|
+
</div>
|
|
850
|
+
|
|
851
|
+
<!-- Credit Card Number -->
|
|
852
|
+
<div style="margin-top:4px;">
|
|
853
|
+
<p>ប័ណ្ណឥណទាន សូមផ្តល់លេខប័ណ្ណឥណទាន</p>
|
|
854
|
+
<p>Credit card please provide card number</p>
|
|
855
|
+
<%- policy_info.credit_card_info ? '<p><u><b>' + policy_info.credit_card_info + '</b></u></p>'
|
|
856
|
+
: '<div style="border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;"></div>'
|
|
857
|
+
%>
|
|
858
|
+
</div>
|
|
859
|
+
|
|
860
|
+
<!-- Card Type -->
|
|
861
|
+
<div style="display:flex;align-items:center;gap:12px;margin-top:4px;flex-wrap:wrap;">
|
|
862
|
+
<div style="display:flex;align-items:center;gap:6px;">
|
|
863
|
+
<input type="checkbox" <%=policy_info.credit_card_type==='Visa' ? 'checked' : '' %>
|
|
864
|
+
style="flex-shrink:0;"
|
|
865
|
+
/>
|
|
866
|
+
<span>Visa</span>
|
|
867
|
+
</div>
|
|
868
|
+
<div style="display:flex;align-items:center;gap:6px;">
|
|
869
|
+
<input type="checkbox" <%=policy_info.credit_card_type==='Master' ? 'checked' : '' %>
|
|
870
|
+
style="flex-shrink:0;"
|
|
871
|
+
/>
|
|
872
|
+
<span>Master</span>
|
|
873
|
+
</div>
|
|
874
|
+
<div style="display:flex;align-items:center;gap:6px;">
|
|
875
|
+
<input type="checkbox" <%=policy_info.credit_card_type==='American Express' ? 'checked' : '' %>
|
|
876
|
+
style="flex-shrink:0;" />
|
|
877
|
+
<span>American Express</span>
|
|
878
|
+
</div>
|
|
879
|
+
</div>
|
|
880
|
+
|
|
881
|
+
<!-- Expiry Date -->
|
|
882
|
+
<div style="margin-top:4px;">
|
|
883
|
+
<span>ថ្ងៃផុតកំណត់ /</span>
|
|
884
|
+
<span> Expiry Date:</span>
|
|
885
|
+
<%- policy_info.credit_card_expiry_date ? '<p><u><b>' + policy_info.credit_card_expiry_date + '</b></u></p>'
|
|
886
|
+
: '<div style="border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;"></div>'
|
|
887
|
+
%>
|
|
888
|
+
</div>
|
|
889
|
+
|
|
890
|
+
<!-- Other Method -->
|
|
891
|
+
<div style="margin-top:4px;">
|
|
892
|
+
<span>ផ្សេងទៀត សូមបញ្ជាក់វិធីបង់ប្រាក់ /</span>
|
|
893
|
+
<span> Other indicate method of payment:</span>
|
|
894
|
+
<%- policy_info.other_payment_method_desc ? '<p><u><b>' + policy_info.other_payment_method_desc + '</b></u></p>'
|
|
895
|
+
: '<div style="border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;"></div>'
|
|
896
|
+
%>
|
|
897
|
+
</div>
|
|
898
|
+
</td>
|
|
899
|
+
</tr>
|
|
900
|
+
</table>
|
|
901
|
+
<!-- page break -->
|
|
902
|
+
<div style="page-break-after: always;"></div>
|
|
903
|
+
|
|
904
|
+
<!-- table 4 beneficiaries -->
|
|
905
|
+
<table class="width-100 form-table" style="margin-top:10px;" cellpadding="10">
|
|
906
|
+
<colgroup>
|
|
907
|
+
<col style="width: 25%;" />
|
|
908
|
+
<col style="width: 5%;" />
|
|
909
|
+
<col style="width: 20%;" />
|
|
910
|
+
<col style="width: 35%;" />
|
|
911
|
+
<col style="width: 15%;" />
|
|
912
|
+
</colgroup>
|
|
913
|
+
|
|
914
|
+
<tr class="width-100" cellpadding="10">
|
|
915
|
+
<td colspan="5" style="text-align:center;" class="text-lg font-bold">
|
|
916
|
+
<h5>ផ្នែកទី៣: ព័ត៌មានរបស់អ្នកទទួលផល</h5>
|
|
917
|
+
<h5>Part 3: BENEFICIARIES DETAILS</h5>
|
|
918
|
+
</td>
|
|
919
|
+
</tr>
|
|
920
|
+
|
|
921
|
+
<tr class="text-start">
|
|
922
|
+
<td style="vertical-align: top;">
|
|
923
|
+
<p>
|
|
924
|
+
ឈ្មោះពេញរបស់អ្នកទទួលផលជាភាសាខ្មែរ និងអង់គ្លេស
|
|
925
|
+
</p>
|
|
926
|
+
<p>
|
|
927
|
+
Beneficiary's Full Name in Khmer and English
|
|
928
|
+
</p>
|
|
929
|
+
</td>
|
|
930
|
+
|
|
931
|
+
<td style="vertical-align: top;">
|
|
932
|
+
<p>អាយុ</p>
|
|
933
|
+
<p>Age</p>
|
|
934
|
+
</td>
|
|
935
|
+
|
|
936
|
+
<td style="vertical-align: top;">
|
|
937
|
+
<p>ទំនាក់ទំនង</p>
|
|
938
|
+
<p>Relationship</p>
|
|
939
|
+
</td>
|
|
940
|
+
|
|
941
|
+
<td style="vertical-align: top;">
|
|
942
|
+
<p>
|
|
943
|
+
លេខអត្តសញ្ញាណប័ណ្ណ/លិខិតឆ្លងដែន/សំបុត្រកំណើត
|
|
944
|
+
</p>
|
|
945
|
+
<p>
|
|
946
|
+
ID, Passport, Birth Certificate Number
|
|
947
|
+
</p>
|
|
948
|
+
</td>
|
|
949
|
+
|
|
950
|
+
<td style="vertical-align: top;">
|
|
951
|
+
<p>% នៃការបែងចែក</p>
|
|
952
|
+
<p>% of Share</p>
|
|
953
|
+
</td>
|
|
954
|
+
</tr>
|
|
955
|
+
|
|
956
|
+
<% beneficiaries.forEach(benefactor=> { %>
|
|
957
|
+
<tr>
|
|
958
|
+
<td>
|
|
959
|
+
<p> <span><b>
|
|
960
|
+
<%= benefactor.full_name %>
|
|
961
|
+
</b></span> </p>
|
|
962
|
+
</td>
|
|
963
|
+
<td>
|
|
964
|
+
<p> <span><b>
|
|
965
|
+
<%= benefactor.age %>
|
|
966
|
+
</b></span> </p>
|
|
967
|
+
</td>
|
|
968
|
+
<td>
|
|
969
|
+
<p> <span><b>
|
|
970
|
+
<%= benefactor.relationship %>
|
|
971
|
+
</b></span> </p>
|
|
972
|
+
</td>
|
|
973
|
+
<td>
|
|
974
|
+
<p> <span><b>
|
|
975
|
+
<%= benefactor.identifier_and_birth_info %>
|
|
976
|
+
</b></span> </p>
|
|
977
|
+
</td>
|
|
978
|
+
<td>
|
|
979
|
+
<p> <span><b>
|
|
980
|
+
<%= benefactor.percentage %>
|
|
981
|
+
</b></span> </p>
|
|
982
|
+
</td>
|
|
983
|
+
</tr>
|
|
984
|
+
<% }) %>
|
|
985
|
+
|
|
986
|
+
<tr>
|
|
987
|
+
<td colspan="4" style="text-align:right">
|
|
988
|
+
<span>% សរុប /</span>
|
|
989
|
+
<span>Total %</span>
|
|
990
|
+
</td>
|
|
991
|
+
<td> <b>100%</b> </td>
|
|
992
|
+
</tr>
|
|
993
|
+
|
|
994
|
+
<tr>
|
|
995
|
+
<td colspan="5">
|
|
996
|
+
<p>
|
|
997
|
+
<span>
|
|
998
|
+
កំណត់សម្គាល់៖ ប្រសិនបើភាគរយមិនបានបញ្ជាក់ចំនួនទឹកប្រាក់នឹងត្រូវចែកស្មើៗគ្នា /
|
|
999
|
+
</span>
|
|
1000
|
+
<span>
|
|
1001
|
+
Note: If the percentage is not specified the amount will be shared equally
|
|
1002
|
+
</span>
|
|
1003
|
+
</p>
|
|
1004
|
+
</td>
|
|
1005
|
+
</tr>
|
|
1006
|
+
</table>
|
|
1007
|
+
<!-- table 5 existing insurance -->
|
|
1008
|
+
<table class="width-100 form-table" style="margin-top:10px;" cellpadding="10">
|
|
1009
|
+
<colgroup>
|
|
1010
|
+
<col style="width: 60%;" />
|
|
1011
|
+
<col style="width: 20%;" />
|
|
1012
|
+
<col style="width: 20%;" />
|
|
1013
|
+
</colgroup>
|
|
1014
|
+
<tr class="width-100" cellpadding="10">
|
|
1015
|
+
<td colspan="3" style="text-align:center;" class="text-lg font-bold">
|
|
1016
|
+
<h5>សេចក្ដីប្រកាសអំពីបណ្ណសន្យារ៉ាប់រងដែលមាន</h5>
|
|
1017
|
+
<h5>DECLARATION OF ANY EXISTING INSURANCE POLICIES</h5>
|
|
1018
|
+
</td>
|
|
1019
|
+
</tr>
|
|
1020
|
+
|
|
1021
|
+
<tr>
|
|
1022
|
+
<td colspan="3">
|
|
1023
|
+
<p class="mb-2">
|
|
1024
|
+
<span>
|
|
1025
|
+
តើលោកអ្នកមានបណ្ណសន្យារ៉ាប់រងដែរឬទេ / Do you have any existing insurance policies?
|
|
1026
|
+
</span>
|
|
1027
|
+
<%- yesNoCheckbox(existing_insurance_info.has_existing_insurance) %>
|
|
1028
|
+
</p>
|
|
1029
|
+
<p class="mt-2">
|
|
1030
|
+
<span>
|
|
1031
|
+
ប្រសិនបើមាន សូមផ្ដល់ព័ត៍មានដូចខាងក្រោម / If yes, please provide the following information:
|
|
1032
|
+
<!-- <div class="form-field-line"> -->
|
|
1033
|
+
</span>
|
|
1034
|
+
</p>
|
|
1035
|
+
</td>
|
|
1036
|
+
</tr>
|
|
1037
|
+
|
|
1038
|
+
<tr>
|
|
1039
|
+
<td style="vertical-align: top;">
|
|
1040
|
+
<p>
|
|
1041
|
+
ឈ្មោះរបស់ក្រុមហ៊ុនធានារ៉ាប់រង
|
|
1042
|
+
</p>
|
|
1043
|
+
<p>
|
|
1044
|
+
Name of Insurance Company
|
|
1045
|
+
</p>
|
|
1046
|
+
</td>
|
|
1047
|
+
<td style="vertical-align: top;">
|
|
1048
|
+
<p>
|
|
1049
|
+
ប្រភេទបណ្ណសន្យារ៉ាប់រងដែលលោកអ្នកមាន
|
|
1050
|
+
</p>
|
|
1051
|
+
<p>
|
|
1052
|
+
Type of Policy You Currently Have
|
|
1053
|
+
</p>
|
|
1054
|
+
</td>
|
|
1055
|
+
<td style="vertical-align: top;">
|
|
1056
|
+
<p>
|
|
1057
|
+
ទឹកប្រាក់ត្រូវបានធានាសរុប
|
|
1058
|
+
</p>
|
|
1059
|
+
<p>
|
|
1060
|
+
The Total Amount Insured (USD)
|
|
1061
|
+
</p>
|
|
1062
|
+
</td>
|
|
1063
|
+
</tr>
|
|
1064
|
+
|
|
1065
|
+
<% existing_insurance_info.existing_policy_info.forEach(exist_pilicy=> { %>
|
|
1066
|
+
<tr>
|
|
1067
|
+
<td><b>
|
|
1068
|
+
<%= exist_pilicy.insurance_company %>
|
|
1069
|
+
</b></td>
|
|
1070
|
+
<td><b>
|
|
1071
|
+
<%= exist_pilicy.type_of_policy %>
|
|
1072
|
+
</b></td>
|
|
1073
|
+
<td><b>
|
|
1074
|
+
<%= exist_pilicy.sum_assured %>
|
|
1075
|
+
</b></td>
|
|
1076
|
+
</tr>
|
|
1077
|
+
<% }) %>
|
|
1078
|
+
|
|
1079
|
+
<% if (existing_insurance_info.existing_policy_info.length===0) { %>
|
|
1080
|
+
<tr>
|
|
1081
|
+
<td class="height-25"> </td>
|
|
1082
|
+
<td> </td>
|
|
1083
|
+
<td> </td>
|
|
1084
|
+
</tr>
|
|
1085
|
+
<tr>
|
|
1086
|
+
<td class="height-25"> </td>
|
|
1087
|
+
<td> </td>
|
|
1088
|
+
<td> </td>
|
|
1089
|
+
</tr>
|
|
1090
|
+
<% } %>
|
|
1091
|
+
|
|
1092
|
+
</tbody>
|
|
1093
|
+
</table>
|
|
1094
|
+
<!-- iMPORTANT Remark-->
|
|
1095
|
+
<h4 class="font-bold text-lg mt-5 underline">ចំណាំ / IMPORTANT ៖</h4>
|
|
1096
|
+
|
|
1097
|
+
<div class="my-2 space-y-2">
|
|
1098
|
+
<p>
|
|
1099
|
+
យើងខ្ញុំសូមណែនាំលោកអ្នកមិនគួរផ្លាស់ប្តូរបណ្ណសន្យារ៉ាប់រងអាយុជីវិតដែលមានស្រាប់ជាមួយនឹងបណ្ណសន្យារ៉ាប់រងថ្មី។
|
|
1100
|
+
គុណវិបត្តិមួយចំនួនគឺ៖
|
|
1101
|
+
</p>
|
|
1102
|
+
<p>
|
|
1103
|
+
We advise you not to replace an existing life insurance policy with a new one. Some disadvantages are:
|
|
1104
|
+
</p>
|
|
1105
|
+
|
|
1106
|
+
<ol style="list-style-type: decimal; padding-left: 30px; margin: 0;">
|
|
1107
|
+
<li style="margin-bottom: 6px;">
|
|
1108
|
+
លោកអ្នកអាចនឹងមិនទទួលបានការធានារ៉ាប់រងតាមលក្ខខណ្ឌទូទៅ /
|
|
1109
|
+
You may not be insurable on standard terms
|
|
1110
|
+
</li>
|
|
1111
|
+
|
|
1112
|
+
<li style="margin-bottom: 6px;">
|
|
1113
|
+
លោកអ្នកអាចនឹងត្រូវបង់បុព្វលាភធានារ៉ាប់រងខ្ពស់ជាងបច្ចុប្បន្នដោយសារពេលនេះអ្នកមានអាយុច្រើនជាងមុន /
|
|
1114
|
+
You may have to pay a higher premium as you are now older
|
|
1115
|
+
</li>
|
|
1116
|
+
|
|
1117
|
+
<li>
|
|
1118
|
+
លោកអ្នកអាចនឹងបាត់បង់កំណើនអត្ថប្រយោជន៍ហិរញ្ញវត្ថុដែលមានក្នុងឆ្នាំកន្លងមក /
|
|
1119
|
+
You may lose financial benefits built up over the years
|
|
1120
|
+
</li>
|
|
1121
|
+
</ol>
|
|
1122
|
+
<p>
|
|
1123
|
+
សូមពិគ្រោះជាមួយក្រុមហ៊ុនធានារ៉ាប់រងបច្ចុប្បន្នរបស់លោកអ្នក មុននឹងធ្វើការសម្រេចចិត្ត។
|
|
1124
|
+
សូមធ្វើការប្រៀបធៀបដោយប្រុងប្រយ័ត្នដើម្បីប្រាកដថាលោកអ្នកកំពុងធ្វើការ
|
|
1125
|
+
សម្រេចចិត្តដែលល្អបំផុតសម្រាប់អត្ថប្រយោជន៍របស់លោកអ្នក។
|
|
1126
|
+
</p>
|
|
1127
|
+
<p>
|
|
1128
|
+
Please consult your current insurer before making a final decision. Make a careful comparison so that
|
|
1129
|
+
you
|
|
1130
|
+
can be sure you are making a decision that is in your best interest.
|
|
1131
|
+
</p>
|
|
1132
|
+
|
|
1133
|
+
<p>
|
|
1134
|
+
តើមានធានារ៉ាប់រងណាមួយដែលលោកអ្នកកំពុងស្នើសុំដើម្បីជំនួស
|
|
1135
|
+
ឬមានបំណងជំនួសដូចបានរៀបរាប់ខាងលើដែរឬទេ?
|
|
1136
|
+
</p>
|
|
1137
|
+
<p>
|
|
1138
|
+
Is the insurance you are applying for to replace, or intended to replace, any of the policies listed
|
|
1139
|
+
above?
|
|
1140
|
+
</p>
|
|
1141
|
+
<%- yesNoCheckbox(existing_insurance_info.is_intended_to_replace) %>
|
|
1142
|
+
|
|
1143
|
+
<p>ប្រសិនបើមាន មួយណា? / If yes, which one?
|
|
1144
|
+
</p>
|
|
1145
|
+
|
|
1146
|
+
<%- renderField(existing_insurance_info.replacement_detail_desc ) %>
|
|
1147
|
+
|
|
1148
|
+
<p>
|
|
1149
|
+
<span>យើងខ្ញុំត្រូវការព័ត៌មាននេះដើម្បីផ្តល់ដំណឹងដល់ក្រុមហ៊ុនធានារ៉ាប់រងបច្ចុប្បន្នរបស់លោកអ្នក(ប្រសិនបើមាន)ថាលោកអ្នកអាចនឹងសម្រេចចិត្តផ្លាស់ប្តូរបណ្ណសន្យារ៉ាប់រង។</span>
|
|
1150
|
+
<span>
|
|
1151
|
+
We need this information as we are required to inform your existing insurer-if you have one-that
|
|
1152
|
+
you
|
|
1153
|
+
may be
|
|
1154
|
+
replacing
|
|
1155
|
+
the policy.
|
|
1156
|
+
</span>
|
|
1157
|
+
</p>
|
|
1158
|
+
<span>
|
|
1159
|
+
តើលោកអ្នកមានការស្នើសុំ
|
|
1160
|
+
ឬពាក្យស្នើសុំការធានារ៉ាប់រងអាយុជីវិតណាមួយដែលត្រូវបានបដិសេធ ពន្យារពេល
|
|
1161
|
+
ឬទទួលយកក្រោមលក្ខខណ្ឌពិសេសដោយក្រុមហ៊ុនធានារ៉ាប់រងណាមួយផ្សេងទៀតដែរឬទេ?
|
|
1162
|
+
ប្រសិនបើមានសូមផ្តល់ព័ត៌មានលម្អិតដូចខាងក្រោម
|
|
1163
|
+
</span>
|
|
1164
|
+
|
|
1165
|
+
<%- yesNoCheckbox(existing_insurance_info.is_rejected_by_other_insurer) %>
|
|
1166
|
+
|
|
1167
|
+
<p>
|
|
1168
|
+
Has any proposal or application for a Life Insurance policy of any kind ever been refused,
|
|
1169
|
+
postponed,
|
|
1170
|
+
or accepted at special terms by any other insurer? If yes, please provide details below:
|
|
1171
|
+
</p>
|
|
1172
|
+
</div>
|
|
1173
|
+
|
|
1174
|
+
<table style="width:100%; table-layout:fixed; border-collapse:collapse;" cellpadding="10" class="form-table">
|
|
1175
|
+
<colgroup>
|
|
1176
|
+
<col style="width: 25%;" />
|
|
1177
|
+
<col style="width: 25%;" />
|
|
1178
|
+
<col style="width: 25%;" />
|
|
1179
|
+
<col style="width: 25%;" />
|
|
1180
|
+
</colgroup>
|
|
1181
|
+
<tr>
|
|
1182
|
+
<td>
|
|
1183
|
+
<p>ឈ្មោះរបស់ក្រុមហ៊ុនធានារ៉ាប់រង</p>
|
|
1184
|
+
<p>Name of Insurance Company</p>
|
|
1185
|
+
</td>
|
|
1186
|
+
|
|
1187
|
+
<td class="td-width-100">
|
|
1188
|
+
<p>
|
|
1189
|
+
<b>
|
|
1190
|
+
<%= existing_insurance_info.rejected_insurance_company %>
|
|
1191
|
+
</b>
|
|
1192
|
+
</p>
|
|
1193
|
+
</td>
|
|
1194
|
+
|
|
1195
|
+
<td>
|
|
1196
|
+
<p>ប្រភេទបណ្ណសន្យារ៉ាប់រង</p>
|
|
1197
|
+
<p>Type of Policy</p>
|
|
1198
|
+
</td>
|
|
1199
|
+
|
|
1200
|
+
<td class="td-width-100">
|
|
1201
|
+
<p>
|
|
1202
|
+
<b>
|
|
1203
|
+
<%= existing_insurance_info.rejected_policy_type %>
|
|
1204
|
+
</b>
|
|
1205
|
+
</p>
|
|
1206
|
+
</td>
|
|
1207
|
+
</tr>
|
|
1208
|
+
|
|
1209
|
+
<tr>
|
|
1210
|
+
<td>
|
|
1211
|
+
<span>មូលហេតុ </span>
|
|
1212
|
+
<span>Reasons Given</span>
|
|
1213
|
+
</td>
|
|
1214
|
+
|
|
1215
|
+
<td colspan="3">
|
|
1216
|
+
<p>
|
|
1217
|
+
<b>
|
|
1218
|
+
<%= existing_insurance_info.rejected_reason %>
|
|
1219
|
+
</b>
|
|
1220
|
+
</p>
|
|
1221
|
+
</td>
|
|
1222
|
+
</tr>
|
|
1223
|
+
</table>
|
|
1224
|
+
<!-- page break -->
|
|
1225
|
+
<div style="page-break-after: always;"></div>
|
|
1226
|
+
|
|
1227
|
+
<!-- Part 7 Health Questions-->
|
|
1228
|
+
<table class="width-100 form-table" style="margin-top:10px;" cellpadding="10">
|
|
1229
|
+
|
|
1230
|
+
<tr class="width-100" cellpadding="10">
|
|
1231
|
+
<td colspan="3" style="text-align:center;" class="text-lg font-bold">
|
|
1232
|
+
<h5>ផ្នែកទី៤: ព័ត៌មានពាក់ព័ន្ធនឹងសុខភាព</h5>
|
|
1233
|
+
<h5>Part 4: HEALTH-RELATED QUESTIONS</h5>
|
|
1234
|
+
</td>
|
|
1235
|
+
</tr>
|
|
1236
|
+
|
|
1237
|
+
<tr>
|
|
1238
|
+
<td style="width:35%;" class="align-top">
|
|
1239
|
+
<table style="border-collapse: collapse; width: 100%; border: none;">
|
|
1240
|
+
<colgroup>
|
|
1241
|
+
<col style="width: 40%;" />
|
|
1242
|
+
<col style="width: 60%;" />
|
|
1243
|
+
</colgroup>
|
|
1244
|
+
<tr>
|
|
1245
|
+
<td style="white-space: nowrap; border: none;">
|
|
1246
|
+
<span>កម្ពស់ / Height:</span>
|
|
1247
|
+
</td>
|
|
1248
|
+
<td style="border: none;">
|
|
1249
|
+
<b>
|
|
1250
|
+
<u>
|
|
1251
|
+
<span class="font-eng font-bold">
|
|
1252
|
+
<%= health_info.height %> ស.ម / cm
|
|
1253
|
+
</span>
|
|
1254
|
+
</u>
|
|
1255
|
+
</b>
|
|
1256
|
+
</td>
|
|
1257
|
+
</tr>
|
|
1258
|
+
<tr>
|
|
1259
|
+
<td style="white-space: nowrap; border: none;">
|
|
1260
|
+
<span>ទម្ងន់ / Weight:</span>
|
|
1261
|
+
</td>
|
|
1262
|
+
<td style="border: none;">
|
|
1263
|
+
<b><u>
|
|
1264
|
+
<span class="font-eng font-bold">
|
|
1265
|
+
<%= health_info.weight %>
|
|
1266
|
+
</span>
|
|
1267
|
+
<span> គ.ក្រ / kg</span>
|
|
1268
|
+
</u></b>
|
|
1269
|
+
</td>
|
|
1270
|
+
</tr>
|
|
1271
|
+
</table>
|
|
1272
|
+
</td>
|
|
1273
|
+
|
|
1274
|
+
<td class="align-top">
|
|
1275
|
+
<p>
|
|
1276
|
+
<span>
|
|
1277
|
+
តើមានការផ្លាស់ប្តូរទម្ងន់ក្នុងកំឡុងពេល ៦ ខែឬទេ? / Any weight changes during the past 6 month?
|
|
1278
|
+
</span>
|
|
1279
|
+
<%- yesNoCheckbox( health_info.is_weight_changed) %>
|
|
1280
|
+
</p>
|
|
1281
|
+
</td>
|
|
1282
|
+
</tr>
|
|
1283
|
+
|
|
1284
|
+
<tr>
|
|
1285
|
+
<td class="align-top">
|
|
1286
|
+
<p>
|
|
1287
|
+
តើលោកអ្នកពិសារបារីដែរឬទេ? / Do you smoke?
|
|
1288
|
+
</p>
|
|
1289
|
+
<%- yesNoCheckbox(health_info.is_smoke) %>
|
|
1290
|
+
</td>
|
|
1291
|
+
|
|
1292
|
+
<td class="align-top">
|
|
1293
|
+
<p>
|
|
1294
|
+
ប្រសិនបើមាន តើប៉ុន្មានដើមក្នុងមួយថ្ងៃ? / If yes, How many cigarettes per day?
|
|
1295
|
+
</p>
|
|
1296
|
+
<%- renderField(health_info.smoke_detail) %>
|
|
1297
|
+
</td>
|
|
1298
|
+
</tr>
|
|
1299
|
+
|
|
1300
|
+
<tr>
|
|
1301
|
+
<td class="align-top">
|
|
1302
|
+
<p>
|
|
1303
|
+
Have you ever taken any kind of addictive substance/drugs?
|
|
1304
|
+
តើអ្នកធ្លាប់ប្រើប្រាស់សារធាតុញៀន ឬថ្នាំញៀនដែរឬទេ? /
|
|
1305
|
+
</p>
|
|
1306
|
+
<%- yesNoCheckbox(health_info.is_drug_or_substance) %>
|
|
1307
|
+
</td>
|
|
1308
|
+
|
|
1309
|
+
<td class="align-top space-y-3">
|
|
1310
|
+
<p>
|
|
1311
|
+
If yes, please state:
|
|
1312
|
+
ប្រសិនបើមាន សូមបញ្ជាក់ដូចខាងក្រោម /
|
|
1313
|
+
</p>
|
|
1314
|
+
|
|
1315
|
+
<p>
|
|
1316
|
+
<span>
|
|
1317
|
+
(ក). ប្រភេទថ្នាំ / Type of drug
|
|
1318
|
+
<%- renderField(health_info.drug_type) %>
|
|
1319
|
+
</span>
|
|
1320
|
+
</p>
|
|
1321
|
+
|
|
1322
|
+
<p>
|
|
1323
|
+
<span>
|
|
1324
|
+
(ខ). រយៈពេលប្រើប្រាស់ / For how long?
|
|
1325
|
+
<%- renderField(health_info.drug_duration) %>
|
|
1326
|
+
</span>
|
|
1327
|
+
</p>
|
|
1328
|
+
|
|
1329
|
+
<p>
|
|
1330
|
+
<span>
|
|
1331
|
+
(គ). តើលោកអ្នកបានឈប់ប្រើប្រាស់ហើយឬនៅ? / Have you stopped?
|
|
1332
|
+
<%- renderField(health_info.drug_stopped) %>
|
|
1333
|
+
</span>
|
|
1334
|
+
</p>
|
|
1335
|
+
|
|
1336
|
+
</td>
|
|
1337
|
+
</tr>
|
|
1338
|
+
|
|
1339
|
+
<tr>
|
|
1340
|
+
<td class="align-top">
|
|
1341
|
+
<p>
|
|
1342
|
+
តើលោកអ្នកពិសារគ្រឿងស្រវឹងដែរឬទេ? / Do you drink alcohol?
|
|
1343
|
+
</p>
|
|
1344
|
+
<%- yesNoCheckbox(health_info.is_alcohol) %>
|
|
1345
|
+
</td>
|
|
1346
|
+
|
|
1347
|
+
<td>
|
|
1348
|
+
<p>
|
|
1349
|
+
ប្រសិនបើមាន តើញឹកញាប់ដែរឬទេ? / If yes, how often?
|
|
1350
|
+
</p>
|
|
1351
|
+
<p>
|
|
1352
|
+
សូមបញ្ជាក់បរិមាណដែលបានពិសារក្នុងមួយសប្តាហ៍ / Please specify amount of drink per week.
|
|
1353
|
+
<%- renderField(health_info.alcohol_detail) %>
|
|
1354
|
+
</p>
|
|
1355
|
+
</td>
|
|
1356
|
+
</tr>
|
|
1357
|
+
</table>
|
|
1358
|
+
<div class="space-y-2 my-3">
|
|
1359
|
+
<p class="text-justify">តើលោកអ្នកមានឪពុកម្តាយ ឬបងប្អូនបង្កើត មានជំងឺ ឬទទួលមរណភាពដោយសារ៖ ជំងឺវង្វេង
|
|
1360
|
+
(Alzheimer's
|
|
1361
|
+
disease) ជំងឺមហារីក
|
|
1362
|
+
(Cancer) ជំងឺជាលិកាមហារីកមិនទាន់រាលដាល (Carcinoma in situ) ជំងឺផ្លូវចិត្ត (Mental illness)
|
|
1363
|
+
ជំងឺទឹកនោមផ្អែម
|
|
1364
|
+
(Diabetes) ជំងឺតម្រងនោម (polycystic kidney disease) ជំងឺដាច់សរសៃឈាមខួរក្បាល (Stroke)
|
|
1365
|
+
ការឡើងសម្ពាធឈាមខ្ពស់
|
|
1366
|
+
(High
|
|
1367
|
+
blood pressure) ជំងឺបេះដូង (Heart Disease) ឬជំងឺតំណពូជដទៃទៀត (Hereditary disease) ដែរឬទេ?</p>
|
|
1368
|
+
|
|
1369
|
+
<p class="text-justify">Have any of your biological parents or siblings been diagnosed with or passed
|
|
1370
|
+
away as
|
|
1371
|
+
a
|
|
1372
|
+
result
|
|
1373
|
+
of: Alzheimer's
|
|
1374
|
+
disease, cancer, carcinoma in situ, mental illness, diabetes, polycystic kidney disease, stroke, high
|
|
1375
|
+
blood
|
|
1376
|
+
pressure, heart disease, or any other hereditary disease?</p>
|
|
1377
|
+
|
|
1378
|
+
<%- yesNoCheckbox(health_info.is_hereditary_disease) %>
|
|
1379
|
+
|
|
1380
|
+
<p class="mb-3">ប្រសិនបើមាន សូមផ្ដល់ព័ត៌មានលម្អិតដូចខាងក្រោម / If yes, please provide details below:
|
|
1381
|
+
</p>
|
|
1382
|
+
</div>
|
|
1383
|
+
|
|
1384
|
+
<table style="width:100%; table-layout:fixed; border-collapse:collapse;" cellpadding="10" class="form-table">
|
|
1385
|
+
<colgroup>
|
|
1386
|
+
<col style="width: 25%;" />
|
|
1387
|
+
<col style="width: 25%;" />
|
|
1388
|
+
<col style="width: 25%;" />
|
|
1389
|
+
<col style="width: 25%;" />
|
|
1390
|
+
</colgroup>
|
|
1391
|
+
<tr>
|
|
1392
|
+
<td>
|
|
1393
|
+
<p>ឈ្មោះរបស់សាច់ញាតិ</p>
|
|
1394
|
+
<p>Name of Relative</p>
|
|
1395
|
+
</td>
|
|
1396
|
+
|
|
1397
|
+
<td>
|
|
1398
|
+
<p>ទំនាក់ទំនងជាមួយលោកអ្នក</p>
|
|
1399
|
+
<p>Relationship to you</p>
|
|
1400
|
+
</td>
|
|
1401
|
+
|
|
1402
|
+
<td>
|
|
1403
|
+
<p>ជម្ងឺ</p>
|
|
1404
|
+
<p>Illness</p>
|
|
1405
|
+
</td>
|
|
1406
|
+
|
|
1407
|
+
<td>
|
|
1408
|
+
<p>រស់នៅ ឬទទួលមរណៈភាព</p>
|
|
1409
|
+
<p>Living or Deceased?</p>
|
|
1410
|
+
</td>
|
|
1411
|
+
</tr>
|
|
1412
|
+
|
|
1413
|
+
<% health_info.hereditary_relative_info.forEach(hereditary=> { %>
|
|
1414
|
+
<tr>
|
|
1415
|
+
<td><b>
|
|
1416
|
+
<%= hereditary.full_name %>
|
|
1417
|
+
</b></td>
|
|
1418
|
+
<td><b>
|
|
1419
|
+
<%= hereditary.relationship %>
|
|
1420
|
+
</b></td>
|
|
1421
|
+
<td><b>
|
|
1422
|
+
<%= hereditary.illness %>
|
|
1423
|
+
</b></td>
|
|
1424
|
+
<td><b>
|
|
1425
|
+
<%= hereditary.living_or_deceased %>
|
|
1426
|
+
</b></td>
|
|
1427
|
+
</tr>
|
|
1428
|
+
<% }) %>
|
|
1429
|
+
|
|
1430
|
+
<% if (health_info.hereditary_relative_info.length===0) { %>
|
|
1431
|
+
<tr>
|
|
1432
|
+
<td class="height-25"> </td>
|
|
1433
|
+
<td> </td>
|
|
1434
|
+
<td> </td>
|
|
1435
|
+
<td> </td>
|
|
1436
|
+
</tr>
|
|
1437
|
+
<% } %>
|
|
1438
|
+
</table>
|
|
1439
|
+
</div>
|
|
1440
|
+
|
|
1441
|
+
<div id="questions-source">
|
|
1442
|
+
<!-- Additional Questions-->
|
|
1443
|
+
<table class="table w-full table-fixed border-collapse form-table" cellpadding="10">
|
|
1444
|
+
|
|
1445
|
+
<colgroup>
|
|
1446
|
+
<col style="width: 45%;" />
|
|
1447
|
+
<col style="width: 10%;" />
|
|
1448
|
+
<col style="width: 10%;" />
|
|
1449
|
+
<col style="width: 35%;" />
|
|
1450
|
+
</colgroup>
|
|
1451
|
+
|
|
1452
|
+
<!-- Header -->
|
|
1453
|
+
<tr class="width-100" cellpadding="10">
|
|
1454
|
+
<td colspan="4" style="text-align:center;" class="text-lg font-bold">
|
|
1455
|
+
<h5>សំណួរបន្ថែម</h5>
|
|
1456
|
+
<h5>ADDITIONAL QUESTIONS</h5>
|
|
1457
|
+
</td>
|
|
1458
|
+
</tr>
|
|
1459
|
+
|
|
1460
|
+
<!-- Sub-header -->
|
|
1461
|
+
<tr>
|
|
1462
|
+
<td rowspan="2" class="align-top">
|
|
1463
|
+
<p>
|
|
1464
|
+
1.តើលោកអ្នកធ្លាប់បានទទួលការព្យាបាលជំងឺ ឬមានរោគសញ្ញាណមួយដូចខាងក្រោមដែរឬទេ?
|
|
1465
|
+
</p>
|
|
1466
|
+
<p>
|
|
1467
|
+
Have you ever had or treated for any of the following conditions or symptoms?
|
|
1468
|
+
</p>
|
|
1469
|
+
</td>
|
|
1470
|
+
<td colspan="2" class="text-center align-top">
|
|
1471
|
+
<span>សូមគូស / Please Tick</span>
|
|
1472
|
+
</td>
|
|
1473
|
+
<td rowspan="2" class="align-top">
|
|
1474
|
+
<p>
|
|
1475
|
+
ប្រសិនបើមាន សូមផ្តល់ព័ត៌មានលម្អិតខាងក្រោម
|
|
1476
|
+
</p>
|
|
1477
|
+
<p>
|
|
1478
|
+
If yes, please provide more details:
|
|
1479
|
+
</p>
|
|
1480
|
+
</td>
|
|
1481
|
+
</tr>
|
|
1482
|
+
|
|
1483
|
+
<!-- Question 1 -->
|
|
1484
|
+
<tr>
|
|
1485
|
+
<td style="width:10%; text-align: center; vertical-align: middle;">
|
|
1486
|
+
<p>មាន / Yes</p>
|
|
1487
|
+
</td>
|
|
1488
|
+
<td style="width:10%; text-align: center; vertical-align: middle;">
|
|
1489
|
+
<p>មិនមាន / No</p>
|
|
1490
|
+
</td>
|
|
1491
|
+
</tr>
|
|
1492
|
+
|
|
1493
|
+
<% const additionalQuestions=health_info.additional_question_info; const questionNumbers=Array.from({ length: 17 },
|
|
1494
|
+
(_, i)=> i + 2); // q2 - q18
|
|
1495
|
+
%>
|
|
1496
|
+
|
|
1497
|
+
<% questionNumbers.forEach(num=> { %>
|
|
1498
|
+
<tr class="question-row">
|
|
1499
|
+
<td class="align-top space-y-2 text-justify">
|
|
1500
|
+
<p>
|
|
1501
|
+
<%= num %>.
|
|
1502
|
+
<%= additionalQuestions['q' + num + '_question_kh'] %>
|
|
1503
|
+
</p>
|
|
1504
|
+
<p class="text-justify">
|
|
1505
|
+
<%= additionalQuestions['q' + num + '_question_en'] %>
|
|
1506
|
+
</p>
|
|
1507
|
+
</td>
|
|
1508
|
+
|
|
1509
|
+
<td style="text-align:center; vertical-align:middle;">
|
|
1510
|
+
<%- renderCheck(additionalQuestions['q' + num], true) %>
|
|
1511
|
+
</td>
|
|
1512
|
+
|
|
1513
|
+
<td style="text-align:center; vertical-align:middle;">
|
|
1514
|
+
<%- renderCheck(additionalQuestions['q' + num], false) %>
|
|
1515
|
+
</td>
|
|
1516
|
+
<td class="text-justify align-top">
|
|
1517
|
+
<div>
|
|
1518
|
+
<p>
|
|
1519
|
+
<%= additionalQuestions['q' + num + '_detail'] || '' %>
|
|
1520
|
+
</p>
|
|
1521
|
+
</div>
|
|
1522
|
+
</td>
|
|
1523
|
+
</tr>
|
|
1524
|
+
<% }) %>
|
|
1525
|
+
</table>
|
|
1526
|
+
|
|
1527
|
+
<div class="question-row declaration-header">
|
|
1528
|
+
<table class="table w-full table-fixed border-collapse form-table" cellpadding="20">
|
|
1529
|
+
<tr>
|
|
1530
|
+
<td colspan="4" style="text-align:center;" class="text-lg font-bold">
|
|
1531
|
+
<h5>សេចក្តីប្រកាសរបស់អ្នកស្នើសុំ</h5>
|
|
1532
|
+
<h5>DECLARATION BY THE APPLICANT</h5>
|
|
1533
|
+
</td>
|
|
1534
|
+
</tr>
|
|
1535
|
+
</table>
|
|
1536
|
+
|
|
1537
|
+
<!-- Declaration by the application-->
|
|
1538
|
+
<div class="mt-5 space-y-3 text-justify">
|
|
1539
|
+
<p>ខ្លឹមសារនៃពាក្យស្នើសុំនេះត្រូវបានពន្យល់យ៉ាងច្បាស់ហើយខ្ញុំបានយល់ទាំងស្រុង។</p>
|
|
1540
|
+
<p>The contents of this application have been explained to me, and I have fully understood them. </p>
|
|
1541
|
+
<p>
|
|
1542
|
+
ខ្ញុំសូមបញ្ជាក់ថា
|
|
1543
|
+
ចម្លើយដែលផ្តល់ជូននៅក្នុងឯកសារនេះពិតជាត្រឹមត្រូវទោះបីជាត្រូវបានបំពេញដោយខ្ញុំឬដោយអ្នកផ្សេងទៀតក្នុងនាម
|
|
1544
|
+
របស់ខ្ញុំក៏ដោយខ្ញុំទទួលខុសត្រូវទាំងស្រុងចំពោះព័ត៌មានទាំងនោះហើយខ្ញុំមិនបានលាក់បាំងព័ត៌មានអ្វីទាំងអស់។
|
|
1545
|
+
</p>
|
|
1546
|
+
<p>
|
|
1547
|
+
I confirm that the answers provided in this
|
|
1548
|
+
document are true, and whether written by me or anyone else on my behalf I
|
|
1549
|
+
accept full responsibility for them, and that I have not withheld any material
|
|
1550
|
+
information.
|
|
1551
|
+
</p>
|
|
1552
|
+
<p>
|
|
1553
|
+
ខ្ញុំយល់ស្របថានឹងមិនមានការទទួលខុសត្រូវណាមួយពីក្រុមហ៊ុន
|
|
1554
|
+
<span class="font-bold text-lg">ហ្វីលីព ឡាយហ្វ៍ អាសួរេន (ខេមបូឌា) ម.ក </span>
|
|
1555
|
+
រហូតទាល់តែបណ្ណសន្យា
|
|
1556
|
+
រ៉ាប់រងនេះត្រូវបានចេញនិងប្រគល់ជូនខ្ញុំហើយបុព្វលាភធានារ៉ាប់រងដំបូងបានបង់។រាល់ការទូទាត់បុព្វលាភធានារ៉ាប់រងទៅឲ្យម្ចាស់បណ្ណសន្យារ៉ាប់រង
|
|
1557
|
+
ឬអ្នកស្នើសុំធានារ៉ាប់រងនឹងត្រូវធ្វើឡើងតាមរយៈឯកសារព័ត៌មានធនាគារដែលបានភ្ជាប់ក្នុងអំឡុងពេល
|
|
1558
|
+
ដាក់ពាក្យស្នើសុំធានារ៉ាប់រងនេះប្រសិនបើគ្មានការផ្ដល់ព័ត៌មានធនាគារថ្មីណាមួយមកកាន់ក្រុមហ៊ុន។
|
|
1559
|
+
</p>
|
|
1560
|
+
</p>
|
|
1561
|
+
<p>I agree that there shall be no liability upon
|
|
1562
|
+
<span class="font-bold text-lg">Phillip Life Assurance (Cambodia) Plc</span>. until a policy has
|
|
1563
|
+
been issued and
|
|
1564
|
+
delivered to me and the first premium is paid in full. All premium to be refunded to Policyholders
|
|
1565
|
+
or Applicants will
|
|
1566
|
+
be made through the bank information given
|
|
1567
|
+
during an application process, if no latest bank information has been provided and received by the
|
|
1568
|
+
company.
|
|
1569
|
+
</p>
|
|
1570
|
+
<p>
|
|
1571
|
+
ខ្ញុំយល់ព្រម និងផ្តល់សិទ្ធិឲ្យស្ថាប័នវេជ្ជសាស្ត្រ
|
|
1572
|
+
ការិយាល័យរបស់ក្រុមហ៊ុនធានារ៉ាប់រង
|
|
1573
|
+
ឬក្រុមហ៊ុនធានារ៉ាប់រងអាយុជីវិតដទៃទៀត ដើម្បីប្រគល់ទៅឲ្យក្រុមហ៊ុនធានារ៉ាប់រង
|
|
1574
|
+
<span class="font-bold text-lg">ហ្វីលីព ឡាយហ្វ៍ អាសួរេន (ខេមបូឌា) ម.ក</span>
|
|
1575
|
+
នូវព័ត៌មានទាក់ទងនឹងខ្ញុំ
|
|
1576
|
+
គ្រប់ពេលដោយមិនគិតពីលទ្ធផលនៃពាក្យស្នើសុំរបស់ខ្ញុំឡើយ។
|
|
1577
|
+
</p>
|
|
1578
|
+
<p>And I also agree and authorise (a) any
|
|
1579
|
+
medical source, insurance office, or other Life Insurance company to release to
|
|
1580
|
+
<span class="font-bold text-lg">Phillip Life Assurance (Cambodia) Plc.</span> any relevant
|
|
1581
|
+
information concerning me
|
|
1582
|
+
at
|
|
1583
|
+
any time, regardless of the outcome of my application.
|
|
1584
|
+
</p>
|
|
1585
|
+
<p>
|
|
1586
|
+
ខ្ញុំអនុញ្ញាត និងយល់ព្រមឲ្យក្រុមហ៊ុនប្រើប្រាស់ព័ត៌មាន
|
|
1587
|
+
និងទិន្នន័យទាំងស្រុងដែលខ្ញុំបានផ្ដល់នៅក្នុងពាក្យស្នើសុំរបស់ខ្ញុំ
|
|
1588
|
+
ក្នុងគោលបំណងស្របតាមច្បាប់ដូចជាការផ្សព្វផ្សាយទីផ្សារ ការសិក្សាទីផ្សារ និងការបម្រើអតិថិជនដោយក្រុមហ៊ុន
|
|
1589
|
+
សម្ព័ន្ធក្រុមហ៊ុន ឬជាដៃគូពាណិជ្ជកម្មរបស់ក្រុមហ៊ុនដោយមិនចាំបាច់មានការយល់ព្រម
|
|
1590
|
+
និងជូនដំណឹងបន្ថែមពីខ្ញុំឡើយ។
|
|
1591
|
+
ក្រុមហ៊ុនមិនត្រូវបានអនុញ្ញាតឲ្យបញ្ចេញព័ត៌មានណាមួយទៅភាគីទីបីណាមួយឬប្រើប្រាស់ព័ត៌មាននោះសម្រាប់គោលបំណងផ្សេងទៀតដែលមិនទាក់ទងនឹងគោលបំណងទាំងឡាយខាងលើឡើយ
|
|
1592
|
+
ប្រសិនបើគ្មានការយល់ព្រមព្រៀងជាលាយលក្ខណ៍អក្សរនោះ។
|
|
1593
|
+
</p>
|
|
1594
|
+
<p style="margin-bottom:5px">
|
|
1595
|
+
I authorize and consent the Company to use all of my information provided in my application form
|
|
1596
|
+
in legal purpose such as marketing, market survey and customer service by company, affiliate,
|
|
1597
|
+
or business partner without my prior consent or notification. The Company shall not allow to
|
|
1598
|
+
disclose any information of any other purpose not related to above mentioned purpose without prior
|
|
1599
|
+
consent in written.
|
|
1600
|
+
</p>
|
|
1601
|
+
</div>
|
|
1602
|
+
</div>
|
|
1603
|
+
|
|
1604
|
+
<div class="question-row declaration-header">
|
|
1605
|
+
<table class="width-100 form-table" style="margin-top: 10px;" cellpadding="15">
|
|
1606
|
+
<tbody>
|
|
1607
|
+
<tr class="text-start-top">
|
|
1608
|
+
<!-- Policyholder -->
|
|
1609
|
+
<td width="50%">
|
|
1610
|
+
<div style="
|
|
1611
|
+
display: flex;
|
|
1612
|
+
flex-direction: column;
|
|
1613
|
+
justify-content: space-between;
|
|
1614
|
+
min-height: 250px;
|
|
1615
|
+
text-align: left; /* change to left */
|
|
1616
|
+
">
|
|
1617
|
+
<div>
|
|
1618
|
+
<p style="margin:0;">
|
|
1619
|
+
ហត្ថលេខា ឬស្នាមមេដៃរបស់ម្ចាស់បណ្ណសន្យារ៉ាប់រង
|
|
1620
|
+
</p>
|
|
1621
|
+
<p style="margin:0;">
|
|
1622
|
+
Signature or thumb print of Policyholder
|
|
1623
|
+
</p>
|
|
1624
|
+
</div>
|
|
1625
|
+
<div class="flex items-center gap-2 w-full">
|
|
1626
|
+
<span>ហត្ថលេខា ឬស្នាមមេដៃ / Signature or thumb print</span>
|
|
1627
|
+
|
|
1628
|
+
<div class="flex-1 border-b border-black min-h-[18px] mt-1"></div>
|
|
1629
|
+
</div>
|
|
1630
|
+
</div>
|
|
1631
|
+
</td>
|
|
1632
|
+
|
|
1633
|
+
<!-- Life assured -->
|
|
1634
|
+
<td width="50%">
|
|
1635
|
+
<div class="flex flex-col justify-between min-h-[250px] text-left">
|
|
1636
|
+
<div>
|
|
1637
|
+
<p style="margin:0;">
|
|
1638
|
+
ហត្ថលេខា ឬស្នាមមេដៃរបស់អ្នកត្រូវបានធានារ៉ាប់រង
|
|
1639
|
+
(ហត្ថលេខារបស់ឪពុកម្តាយ ឬអាណាព្យាបាលស្របច្បាប់ ប្រសិនបើអ្នក
|
|
1640
|
+
ត្រូវបានធានារ៉ាប់រងមានអាយុក្រោម ១៨ ឆ្នាំ)
|
|
1641
|
+
</p>
|
|
1642
|
+
<p style="margin:0;">
|
|
1643
|
+
Signature or thumb print of Life assured (Parent or the legal guardian's signature if the
|
|
1644
|
+
Life assured is less than 18
|
|
1645
|
+
years old)
|
|
1646
|
+
</p>
|
|
1647
|
+
</div>
|
|
1648
|
+
<div class="flex items-center gap-2 w-full">
|
|
1649
|
+
<span>ហត្ថលេខា ឬស្នាមមេដៃ / Signature or thumb print</span>
|
|
1650
|
+
|
|
1651
|
+
<div class="flex-1 border-b border-black min-h-[18px] mt-1"></div>
|
|
1652
|
+
</div>
|
|
1653
|
+
</div>
|
|
1654
|
+
</td>
|
|
1655
|
+
</tr>
|
|
1656
|
+
<!-- Names -->
|
|
1657
|
+
<tr>
|
|
1658
|
+
<td style="text-align: start; padding-top: 10px;">
|
|
1659
|
+
<span>ឈ្មោះ</span>
|
|
1660
|
+
<span>/ Name:</span>
|
|
1661
|
+
<span style="font-weight: bold;">
|
|
1662
|
+
<%= signature_info.ph_full_name %>
|
|
1663
|
+
</span>
|
|
1664
|
+
<!-- <span style="text-transform: uppercase; font-weight: bold;">SOK CHANTHA</span> -->
|
|
1665
|
+
</td>
|
|
1666
|
+
<td style="text-align: start; padding-top: 10px;">
|
|
1667
|
+
<span>ឈ្មោះ</span>
|
|
1668
|
+
<span>/ Name:</span>
|
|
1669
|
+
<span style="font-weight: bold;">
|
|
1670
|
+
<%= signature_info.la_full_name %>
|
|
1671
|
+
</span>
|
|
1672
|
+
<!-- <span style="font-weight: bold;">PHAN DARA</span> -->
|
|
1673
|
+
</td>
|
|
1674
|
+
</tr>
|
|
1675
|
+
<!-- Dates -->
|
|
1676
|
+
<tr>
|
|
1677
|
+
<td style="text-align: start; padding-top: 10px;">
|
|
1678
|
+
<span>កាលបរិច្ឆេទ</span>
|
|
1679
|
+
<span>
|
|
1680
|
+
Date:
|
|
1681
|
+
<%- signature_info.ph_signature_date ? '<u><b>' + signature_info.ph_signature_date + '</b></u>'
|
|
1682
|
+
: '<span style="display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;"></span>'
|
|
1683
|
+
%>
|
|
1684
|
+
</span>
|
|
1685
|
+
</td>
|
|
1686
|
+
<td style="text-align: start; padding-top: 10px;">
|
|
1687
|
+
<span>កាលបរិច្ឆេទ</span>
|
|
1688
|
+
<span>
|
|
1689
|
+
Date:
|
|
1690
|
+
<%- signature_info.la_signature_date ? '<u><b>' + signature_info.la_signature_date + '</b></u>'
|
|
1691
|
+
: '<span style="display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;"></span>'
|
|
1692
|
+
%>
|
|
1693
|
+
</span>
|
|
1694
|
+
</td>
|
|
1695
|
+
</tr>
|
|
1696
|
+
</tbody>
|
|
1697
|
+
</table>
|
|
1698
|
+
</div>
|
|
1699
|
+
|
|
1700
|
+
<div class="question-row declaration-header">
|
|
1701
|
+
<table class="form-table w-full table-fixed mt-2" cellpadding="15">
|
|
1702
|
+
<!-- Signature line -->
|
|
1703
|
+
<tr>
|
|
1704
|
+
<td style="height: 50px; vertical-align: center; text-align: start;">
|
|
1705
|
+
<p>
|
|
1706
|
+
<span>
|
|
1707
|
+
ហត្ថលេខា ឬស្នាមមេដៃរបស់ទីប្រឹក្សាធានារ៉ាប់រង ឬសាក្សី
|
|
1708
|
+
</span>
|
|
1709
|
+
<span>
|
|
1710
|
+
(Signature or thumb print of Advisor/witness)
|
|
1711
|
+
</span>
|
|
1712
|
+
<br>
|
|
1713
|
+
<div class="flex-1 border-b border-black min-h-[50px] mt-1"></div>
|
|
1714
|
+
</p>
|
|
1715
|
+
</td>
|
|
1716
|
+
</tr>
|
|
1717
|
+
<!-- Name -->
|
|
1718
|
+
<tr>
|
|
1719
|
+
<td style="text-align: start; vertical-align: center; padding-top: 5px;">
|
|
1720
|
+
<span>ឈ្មោះ</span>
|
|
1721
|
+
<span>
|
|
1722
|
+
Name:
|
|
1723
|
+
<%- signature_info.agent_full_name ? '<u><b>' + signature_info.agent_full_name+ '</b></u>'
|
|
1724
|
+
: '<span style="display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;"></span>'
|
|
1725
|
+
%>
|
|
1726
|
+
</span>
|
|
1727
|
+
</td>
|
|
1728
|
+
</tr>
|
|
1729
|
+
<!-- Date -->
|
|
1730
|
+
<tr>
|
|
1731
|
+
<td style="text-align: start; vertical-align: center; padding-top: 5px;">
|
|
1732
|
+
<span>កាលបរិច្ឆេទ</span>
|
|
1733
|
+
<span>
|
|
1734
|
+
Date:
|
|
1735
|
+
<%- signature_info.agent_signature_date ? '<u><b>' + signature_info.agent_signature_date+ '</b></u>'
|
|
1736
|
+
: '<span style="display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;"></span>'
|
|
1737
|
+
%>
|
|
1738
|
+
</span>
|
|
1739
|
+
</td>
|
|
1740
|
+
</tr>
|
|
1741
|
+
</table>
|
|
1742
|
+
</div>
|
|
1743
|
+
|
|
1744
|
+
<div class="question-row declaration-header">
|
|
1745
|
+
<table style="margin-top: 10px;" class="width-100 form-table" cellpadding="15">
|
|
1746
|
+
<tbody class="width-100">
|
|
1747
|
+
<!-- Title -->
|
|
1748
|
+
<tr class="width-100" cellpadding="10">
|
|
1749
|
+
<td colspan="3" style="text-align:center;" class="text-lg font-bold">
|
|
1750
|
+
<h5>ការបញ្ជាក់ដោយអ្នកតំណាង ហ្វីលីព ឡាយហ្វ៍ អាសួរេន (ខេមបូឌា) ម.ក</h5>
|
|
1751
|
+
<h5>Phillip Life Assurance (Cambodia) Plc Representative Certification</h5>
|
|
1752
|
+
</td>
|
|
1753
|
+
</tr>
|
|
1754
|
+
<!-- Content -->
|
|
1755
|
+
<tr>
|
|
1756
|
+
<td style="text-align: start;">
|
|
1757
|
+
<p>
|
|
1758
|
+
ខ្ញុំបានជួបអ្នកដាក់ពាក្យស្នើសុំ និងអ្នកដែលនឹងត្រូវបានធានារ៉ាប់រងដោយផ្ទាល់
|
|
1759
|
+
និងបានពន្យល់អំពី ខ និងលក្ខខណ្ឌនៃបណ្ណសន្យារ៉ាប់រងដល់អ្នកដាក់ពាក្យស្នើសុំ។
|
|
1760
|
+
</p>
|
|
1761
|
+
|
|
1762
|
+
<p>
|
|
1763
|
+
ខ្ញុំបានឃើញអត្តសញ្ញាណប័ណ្ណរបស់អ្នកដាក់ពាក្យស្នើសុំ និងបានថតចំលងត្រឹមត្រូវតាមច្បាប់ដើម។
|
|
1764
|
+
ខ្ញុំសូមបញ្ជាក់ថាលេខអត្តសញ្ញាណប័ណ្ណរបស់អ្នកដាក់ពាក្យស្នើសុំគឺ
|
|
1765
|
+
<u><b>
|
|
1766
|
+
<%= rep_certification_info.identifier_no %>
|
|
1767
|
+
</b></u>
|
|
1768
|
+
និងមានថ្ងៃខែឆ្នាំកំណើត
|
|
1769
|
+
<u><b>
|
|
1770
|
+
<%= rep_certification_info.date_of_birth %>
|
|
1771
|
+
</b></u>
|
|
1772
|
+
ពិតជារបស់អ្នកដាក់ពាក្យស្នើសុំពិតប្រាកដមែន។
|
|
1773
|
+
</p>
|
|
1774
|
+
<br>
|
|
1775
|
+
<p class="text-justify">
|
|
1776
|
+
I have personally seen the Applicant and the Life Assured and have explained the terms and
|
|
1777
|
+
conditions of the policy to
|
|
1778
|
+
the Applicant.
|
|
1779
|
+
I have seen the ID of the Applicant and original copy. I certify that the date of birth and ID
|
|
1780
|
+
number truly belong to
|
|
1781
|
+
the Applicant.
|
|
1782
|
+
</p>
|
|
1783
|
+
<br><br><br><br>
|
|
1784
|
+
|
|
1785
|
+
<!-- Signature -->
|
|
1786
|
+
<p>
|
|
1787
|
+
<span>ហត្ថលេខា និងឈ្មោះ</span>
|
|
1788
|
+
<span> / Signature and name: </span>
|
|
1789
|
+
<u>
|
|
1790
|
+
<span style="text-transform: uppercase; font-weight: bold">
|
|
1791
|
+
<%= rep_certification_info.rep_full_name %>
|
|
1792
|
+
</span>
|
|
1793
|
+
</u>
|
|
1794
|
+
</p>
|
|
1795
|
+
</td>
|
|
1796
|
+
</tr>
|
|
1797
|
+
</tbody>
|
|
1798
|
+
</table>
|
|
1799
|
+
</div>
|
|
1800
|
+
|
|
1801
|
+
<div class="question-row declaration-header">
|
|
1802
|
+
<table style="margin-top: 10px; width: 100%; table-layout: fixed;" class="form-table" cellpadding="15">
|
|
1803
|
+
<tbody>
|
|
1804
|
+
<!-- Header -->
|
|
1805
|
+
<tr>
|
|
1806
|
+
<td colspan="3" style="text-align: center;" class="text-lg font-bold">
|
|
1807
|
+
<h5>ហ្វីលីព ឡាយហ្វ៍ អាសួរេន (ខេមបូឌា) ម.ក</h5>
|
|
1808
|
+
<h5>Phillip Life Assurance (Cambodia) Plc</h5>
|
|
1809
|
+
</td>
|
|
1810
|
+
</tr>
|
|
1811
|
+
<!-- Content -->
|
|
1812
|
+
<tr>
|
|
1813
|
+
<td style="text-align: left;" colspan="3">
|
|
1814
|
+
<div>
|
|
1815
|
+
<span>សម្រាប់ប្រើក្នុងក្រុមហ៊ុនតែប៉ុណ្ណោះ</span>
|
|
1816
|
+
<span>/ For office Use Only:</span>
|
|
1817
|
+
|
|
1818
|
+
<p style="text-align: left;">
|
|
1819
|
+
<span>លេខពាក្យស្នើសុំធានារ៉ាប់រង</span>
|
|
1820
|
+
<span>/ Application Number:</span>
|
|
1821
|
+
<span style="font-weight: bold">
|
|
1822
|
+
<%= agent_source_info.application_no %>
|
|
1823
|
+
</span>
|
|
1824
|
+
</p>
|
|
1825
|
+
<p style="text-align: left;">
|
|
1826
|
+
<span>លេខសម្គាល់អតិថិជន</span>
|
|
1827
|
+
<span>/ Client Number:</span>
|
|
1828
|
+
<span style="font-weight: bold">
|
|
1829
|
+
<%= agent_source_info.client_no %>
|
|
1830
|
+
</span>
|
|
1831
|
+
</p>
|
|
1832
|
+
<p style="text-align: left;">
|
|
1833
|
+
<span>លេខបណ្ណសន្យារ៉ាប់រង</span>
|
|
1834
|
+
<span>/ Policy Number:</span>
|
|
1835
|
+
<span style="font-weight: bold">
|
|
1836
|
+
<%= agent_source_info.policy_no %>
|
|
1837
|
+
</span>
|
|
1838
|
+
</p>
|
|
1839
|
+
<p style="text-align: left;">
|
|
1840
|
+
<span>លេខសម្គាល់ប្រភព</span>
|
|
1841
|
+
<span>/ Source Code:</span>
|
|
1842
|
+
<span style="font-weight: bold">
|
|
1843
|
+
<%= agent_source_info.source_code %>
|
|
1844
|
+
</span>
|
|
1845
|
+
</p>
|
|
1846
|
+
<p style="text-align: left;">
|
|
1847
|
+
<span>លេខសម្គាល់អ្នកប្រឹក្សាធានារ៉ាប់រង</span>
|
|
1848
|
+
<span>/ Insurance Advisor Code:</span>
|
|
1849
|
+
<span style="font-weight: bold">
|
|
1850
|
+
<%= agent_source_info.advisor_code %>
|
|
1851
|
+
</span>
|
|
1852
|
+
</p>
|
|
1853
|
+
<p style="text-align: left;">
|
|
1854
|
+
<span>លេខទូរស័ព្ទអ្នកប្រឹក្សាធានារ៉ាប់រង</span>
|
|
1855
|
+
<span>/ Insurance Advisor Contact Number:</span>
|
|
1856
|
+
<span style="font-weight: bold">
|
|
1857
|
+
<%= agent_source_info.advisor_contact %>
|
|
1858
|
+
</span>
|
|
1859
|
+
</p>
|
|
1860
|
+
</div>
|
|
1861
|
+
</td>
|
|
1862
|
+
</tr>
|
|
1863
|
+
|
|
1864
|
+
</tbody>
|
|
1865
|
+
</table>
|
|
1866
|
+
<div class="mt-5 space-y-2">
|
|
1867
|
+
<p>ព័ត៌មានលម្អិតបន្ថែម:
|
|
1868
|
+
សូមប្រើប្រាស់កន្លែងខាងក្រោមដើម្បីឆ្លើយនឹងសំណួរប្រសិនបើទំហំនៅក្នុងកម្រងសំណួរខាងលើមិនគ្រប់គ្រាន់។</p>
|
|
1869
|
+
<p>Additional Details: Please use the space bellow if there are insufficient space in the
|
|
1870
|
+
questionnaire to provide your answers.</p>
|
|
1871
|
+
</div>
|
|
1872
|
+
</div>
|
|
1873
|
+
|
|
1874
|
+
|
|
1875
|
+
</div>
|
|
1876
|
+
</div>
|
|
1877
|
+
</div>
|
|
1878
|
+
</body>
|
|
1879
|
+
|
|
1880
|
+
</html>
|
|
1881
|
+
`;
|