Important
The ownership of Cigna Worldwide Life Insurance Company Limited (“Cigna Life”) was transferred to the Chubb group in July 2022 and Cigna Life had been renamed to “Chubb Life Insurance Hong Kong Limited”. The policies originally under Cigna Life have already been transferred to one of the following companies: (1) Chubb Life Insurance Hong Kong Limited or (2) Cigna Worldwide General Insurance Company Limited. Meanwhile, please note that Chubb Life Insurance Hong Kong Limited and Chubb Life Insurance Company Limited are two different entities currently. To avoid using incorrect provider’s form and information, it is suggested you send Service Log to check the latest policy information. (Updated: 12 Apr 2024)
SAMPLE FOR REFERENCE ONLY!
New Business Forms
Form [A1] Appointment Request Form for Counter Service Payment (Union Pay Card) (Updated: 12 Dec 2017)
Form [A3] Additional Declaration (Updated: 22 Jan 2024)
Form [C1] Customer Protection Declaration Form (Sample) (Updated: 12 May 2016)
Form [C15] Cigna HealthSecure Critical Illness Series Application Form (For single and family) (Updated: 07 Dec 2021)
Form [E1] Exceptional Payment Declaration Form (Updated: 05 Oct 2021)
Form [I1] Important Facts Statement for Mainland Policyowner “IFS-MP” (Updated: 30 Jul 2019)
Form [I2] Important Facts Statement – Policy Replacement (Updated: 02 Nov 2020)
Form [L1] Large Amount Questionnaire (Total sum insured is US1M or over)
Form [L2] Large Amount Questionnaire (Total sum insured is less than or equal to US$999,999)
Form [S1] Self-Certification Form – Individual (Updated: 2 Jan 2019)
Form [S3] Self-Certification Form – Entity (Updated: 2 Jan 2019)
Form [S4] Self-Certification Form – Controlling Person (Updated: 2 Jan 2019)
Questionnaires：
[Hepatitis Carrier Questionnaire]
[Special Health Questionnaire]
[Stomach Disorder Questionnaire]
(Updated: 30 Jul 2019)
POS Forms
Form [A2] Assignment/Release of Assignment of Policy as Collateral Security (Updated: 30 Jul 2019)
Form [C3] Cancellation Form (For GI Any other written request will not be accepted after 30 Sep 2020 ) (Updated: 22 Jan 2024)
Form [C7] Change Of Personal Particulars And Beneficiary Designation Form (Updated: 22 Jan 2024)
Form [C8] Change Of Ownership Form (Updated: 22 Jan 2024)
Form [C9] Change of Benefit Form (Updated: 22 Jan 2024) (Sample) (Updated: 12 May 2016)
Form [C16] Cigna Guarantee of Payment Application Form (Updated: 25 Sep 2020)
Form [D1] Direct Debit Authorisation Form (for Cigna Worldwide Life Insurance Health Products) (Updated: 08 Jul 2022) - (Sample) (Updated: 14 November 2017)
Form [D2] Direct Debit Authorization Form (for Cigna Worldwide General Insurance Company Limited) (Updated: 22 Jan 2024)
Form [D3] Direct Debit Authorization Form (for Cigna Worldwide Life Insurance Company Limited) (Updated: 09 Feb 2023)
Form [F1] Fund Withdrawal/Automatic Premium Payment Application Form (Updated: 20 June 2017)
Form [H1] HealthFirst Series Hospitalization/Medical Expense Claim Form (For Claims) (Updated: 06 Jan 2023)
Form [H2] HealthFirst Series Hospital Pre-Admission Form - (Sample) (For Claims)
Form [P1] Policy Conversion - Continuing Personal Medical Exclusion Application Form (Individual / Family)（Life） (Updated: 07 Dec 2021)
Form [P2] Policy Conversion - Continuing Personal Medical Exclusion Application Form (Individual / Family) (GI) (Updated: 07 Dec 2021)
Form [R1] Request for Physical Policy Document / Medical Document Copy (Updated: 22 Jan 2024)
Form [S2] Statement of Insurability (For reinstatement/additional coverage/optional insurance benefits) (Updated: 22 Jan 2024)
Form [S6] Surrender Form (For Life) (Updated: 25 Sep 2023)
Cigna Customer Hotline：25601990 >1>3