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MEDICAL BENEFITS OPTION FORM
                               ACADEMIC YEAR 2011/2012

Select the option by providing a tick accordingly.



□        Medical Insurance Policy
         General information on the policy coverage:
         l Annual Limit: RMB 5,000,000 per annum
         l Hospitalization : 100% reimbursement
         l Outpatient & Emergency (most hospitals/clinics in Shanghai): 80% (annual sub-limit : RMB 30,000)
            (co-payment scheme : 20%)
         l Emergency Assistance
         Teachers from Asian countries : Coverage will be within Asia
         Teachers from countries other than USA/Canada : Coverage will be worldwide excluding USA/Canada
         Teachers from USA/Canada : Coverage will be worldwide
            * The above coverage is subject to certain terms and conditions.

         You shall be responsible to compensate SSIS the annual Medical Insurance premium borne by SSIS should
         you leave SSIS before the end of the academic year. (Annual premium will be approx. RMB 10,000
         depending on the number of teachers who opt for this option)

□        Reimbursement of personal medical bills amounting to not more than RMB 5,000/- per school calendar
         year. 50% of all unused amounts shall be encashed at the end of the academic year on a yearly basis.
         Encashment benefit only applies to those who work till the end of the academic year.

Note :
The option selected will remain in effect for 12 months, commencing from 1st August 2011. Once the
selection has been made, no changes to the medical benefit option will be allowed for the Academic Year.




I have read and agreed on the details given above.

Signature of Applicant : __________________________________

Name of Applicant : _____________________________________

Campus : _____________                       Date : ______________________


Please make a copy of this form for your own files and submit the completed original to Human Resources
Department.

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QL-BGlZPPQY

  • 1. MEDICAL BENEFITS OPTION FORM ACADEMIC YEAR 2011/2012 Select the option by providing a tick accordingly. □ Medical Insurance Policy General information on the policy coverage: l Annual Limit: RMB 5,000,000 per annum l Hospitalization : 100% reimbursement l Outpatient & Emergency (most hospitals/clinics in Shanghai): 80% (annual sub-limit : RMB 30,000) (co-payment scheme : 20%) l Emergency Assistance Teachers from Asian countries : Coverage will be within Asia Teachers from countries other than USA/Canada : Coverage will be worldwide excluding USA/Canada Teachers from USA/Canada : Coverage will be worldwide * The above coverage is subject to certain terms and conditions. You shall be responsible to compensate SSIS the annual Medical Insurance premium borne by SSIS should you leave SSIS before the end of the academic year. (Annual premium will be approx. RMB 10,000 depending on the number of teachers who opt for this option) □ Reimbursement of personal medical bills amounting to not more than RMB 5,000/- per school calendar year. 50% of all unused amounts shall be encashed at the end of the academic year on a yearly basis. Encashment benefit only applies to those who work till the end of the academic year. Note : The option selected will remain in effect for 12 months, commencing from 1st August 2011. Once the selection has been made, no changes to the medical benefit option will be allowed for the Academic Year. I have read and agreed on the details given above. Signature of Applicant : __________________________________ Name of Applicant : _____________________________________ Campus : _____________ Date : ______________________ Please make a copy of this form for your own files and submit the completed original to Human Resources Department.