Study

Only available on StudyMode
  • Topic: Insurance, Actuarial science, Business insurance
  • Pages : 14 (2017 words )
  • Download(s) : 55
  • Published : January 6, 2013
Open Document
Text Preview
CLAIMS HOTLINE 賠償部熱線:+852 2867 8554 CLAIMS FAX 賠償部傳真:+852 2530 0481

旅遊綜合保障計劃索償表格 TRAVELSURE PROTECTION PLAN CLAIM FORM 致: 昆士蘭保險 (香港) 有限公司
日期

To : QBE General Insurance (Hong Kong) Limited c/o AXA General Insurance Hong Kong Limited 21/F Manhattan Place 23 Wang Tai Road Kowloon Bay Kowloon Tel 2523 3061 Fax 2530 0481 請填妥此索償表格上之所有資料。倘若表格不敷應用,請另加紙張填寫。

Date :

Please complete this claim form in full. If space provided for your answers is insufficient, please continue on a separate sheet. 此表格並不代表本公司會承擔任何責任。

The issue of this claim form is not an admission of liability on the part of the Company. 索償編號

Claim number
(供本公司填寫之用 For office use only)

甲項

保單持有人資料

SECTION A
保單持有人姓名

POLICYHOLDER DETAILS
保單編號

Name of Policyholder
通訊地址

Policy number

Correspondence address
日間聯絡電話 電郵地址

Contact phone number (Day-time)
索償人 / 受保人姓名(如非保單持有人)

Email address

Name of Claimant / Insured Person (if not the Policyholder)
通訊地址

Correspondence address
日間聯絡電話 電郵地址

Contact phone number (Day-time)

Email address

乙項

一般事項

SECTION B
事發日期及時間

GENERAL INFORMATION

(請於適當的地方加上 ✔ 號 Please ✔ as approprate)

Date and time of incident or loss
事發地點

Place of incident or loss
任何事發目擊者的姓名和地址

Names and addresses of any witnesses to the incident or loss 閣下有否向警方或其他機構報告失事情況? 有 否

Have the police or other authorities been informed?
如答「有」,請提供 (a) 報案警署或機構名稱 name of the Police Station or authority (b) 報案日期及時間 date & time reported (c) 警方或該機構之檔案編號 police or authority report number 注意:請提供警方 / 航空公司 / 該機構之有關報告的正本。

Yes

No

If "Yes", please provide

N.B.

Please provide ORIGINAL written report from police, airline, or other authorities as relevant. 是 否

閣下損失之財物是否同時受其他保險保障?

Is there any other insurance covering the loss/damage?
如答「是」,請提供 (a) 保險公司名稱

Yes

No

If "Yes", please provide

name of the insurance company
(b) 有關之保單號碼

relevant policy number
(c) 投保金額(如適用)

amount insured (if applicable)
(d) 會否向該公司提出索償? 是 否

Whether claim will be submitted to them?
索償人 / 受保人以往有否曾蒙受類似性質的損失?

Yes


No


Has the Claimant / Insured Person sustained other losses of similar nature? 如答「有」,請提供詳細資料

Yes

No

If "Yes", please provide details

頁次 Page 1/4

HSI77-R12(YX) 1-4 10/12 E L

丙項

索償資料

SECTION C

CLAIM INFORMATION

(請於適當的地方加上 ✔ 號 Please ✔ as approprate) 請填寫下列適當的部份並連同相關證明文件一併遞交。

Please complete the appropriate section(s) below and submit to us all supporting documents. 1. 醫療及相關費用 或 人身意外

Medical and Related Expenses
敘述受傷或疾病性質及程度

OR

Personal Accident

Describe the nature and extent of injuries or sickness
如涉及疾病,閣下是否就有關疾病在旅遊前接受過其他醫生的治療? 是 否

If sickness is involved, did you receive treatment for this sickness from other doctor before this trip? 如答「是」,請提供醫生的詳細資料

Yes

No

If "Yes", please provide details of the doctor involved
如涉及意外,請敘述意外發生經過

If accident is involved, please describe how the accident happened 索償金額

Amount claimed
注意:請提供所有醫療費用收據的正本及所有有關醫療報告的副本。

N.B.
2.

Please provide all ORIGINAL medical receipts together with copy of all relevant medical reports. 或 行李延誤 或 個人錢財及文件

行李及個人財物

Baggage and Personal Effects
請敘述事發情況

OR

Delayed Baggage

OR

Personal Money and Documents

Describe how the incident or loss happened
該財物是否閣下全權擁有? 是 否

Are you the sole owner of the property?
如選擇「否」,請提供詳細資料

Yes

No

If "No", please provide details
閣下是否認為其他人仕須就此事件或損失負責? 是 否

Can you identify any parties who may be responsible for the incident or loss? 如選擇「是」,請註明其姓名及地址

Yes

No

If "Yes", please provide his/her name and address
財物損失 / 損壞或緊急物品購買詳情

Details of property lost or damaged or emergency purchased
物品之詳細資料(包括牌子及產品號碼)

Full description of articles (including the brand name & model number)

購買日期

出售物品之商號名稱及地址

購買價錢

索償金額

Date of purchase

Name and address of the vendor

Purchase price

Amount claimed

總索償金額 Total Amount Claimed...
tracking img