UM-SJTU Joint Institute Medical Insurance Application 2021-2022

Standard Practice Guide 12-Medical Insurance 2021-2022
Medical Insurance Plan 2021-2022

Insured Info

Same as last year's, including the family's health plans. （I acknowledge that premium copayment may occur.）

Your own Insurance Plan *

Plan 1- Mainland China (80% reimbursement of High Cost Provider); No extra money

Plan 2- Mainland China (100% reimbursement of High Cost Provider); Extra money CNY1,275/person

Plan 1- Worldwide excl. US,Canada (80% reimbursement of High Cost Provider); Extra money CNY2,488/person

Plan 2- Worldwide excl. US,Canada (100% reimbursement High Cost Provider); Extra money CNY3,763/person

Plan 1- Worldwide (80% reimbursement of High Cost Provider); Extra money CNY3,426/person

Plan 2- Worldwide (100% reimbursement High Cost Provider); Extra money CNY4,701/person

Full Name (on the Identity document) *

Gender *

Male

Female

Date of Birth *

Personal Identity Type *

Passport

China ID Card

OthersOthers

Personal Identity Number *

Phone Number

Email *

Additional insured（Multiple choice）
Dependents: the spouses of Primary Insureds aged below 65 (inclusive) who can work and live normally may be enrolled as Dependents. A Primary Insured and his/her spouse may renew the policy till they are 70 years old; a Primary Insured's child aged below 19 (inclusive) (the age limit can be extended to 23 if the child is a full-time and unmarried student) may be enrolled as a Dependent.

Spouse

Children

Insurance Plan for Spouse

Plan for spouse and children should be no higher than the plan for the primary insured person.

Plan 1- Mainland China (80% reimbursement of High Cost Provider); Extra money CNY6,400/person

Plan 2- Mainland China (100% reimbursement of High Cost Provider); Extra money CNY7,675/person

Plan 1- Worldwide excl. US,Canada (80% reimbursement of High Cost Provider); Extra money CNY8,888/person

Plan 2- Worldwide excl. US,Canada (100% reimbursement of High Cost Provider); Extra money CNY10,163/person

Plan 1- Worldwide (80% reimbursement of High Cost Provider); Extra money CNY9,826/person

Plan 2- Worldwide (100% reimbursement of High Cost Provider); Extra money CNY11,101/person

Group Accident Insurance + Short-term Life Insurance (Death from Illness)

Yes, CNY 120/person

No

Spouse Info

Spouse Full Name (on the Identity document)

Date of Birth

Personal Identity Type of Spouse

Passport

China ID Card

OthersOthers

Personal Identity Number of Spouse

Insurance Plan for Children