PDF《TRAVEL INSURANCE》

Sompo Japan Nipponkoa Insurance (China) Co.

, Ltd. 1-3 TRAVEL INSURANCE CLAIMS FORM 旅游保险索赔单 Policy No. 保单号 ERV China case No. 欧乐旅行援助案例号 Before filling in this form, please note that the information you provide will form the basis of our processing of your claim. If there are special circumstances that are not adequately covered by the various sections of this form, please let us have the details on a separate sheet of paper together with this form. 在填写此表前,请注意您提供的信息将构成我们履行理赔的根据.如果此表中所列各项未能涵盖一些特殊情况,请随此表附上单独写有详情的文件. ERV(China)Travel Service and Consulting Ltd. is authorized by Sompo Japan Insurance (china) Co., Ltd to handle claim issue under any Travel Policy. Please complete this form and mail to the following address within

30 days after the accident. ERV reserve the right to require further document and information. 日本财产保险(中国)有限公司委托欧乐旅行援助(北京)有限公司处理旅行险的索赔事宜,请详细填写此表并提供相关索赔资料于索赔事件发生

30 天内 寄送至以下地址.欧乐旅行援助有权要求进一步提供文件和资料. ERV (China) Travel Service and Consulting Ltd., 欧乐旅行援助(北京)有限公司 Unit 1103A, Shun Tak Tower, No

1 Xiangheyuan Road, Dongcheng District, Beijing

100028 P.R. China 中国北京市东城区香河园路

1 号院

11 号楼信德京汇中心 1103A 单元 邮编:

100028 Tel: +86

10 8441 6555,Fax : +86

10 8451

1175 E-mail : [email protected] Insured'

s personal Information 被保险人信息 Company 公司名称 Residential Address/Post Code 通讯地址/邮编 Name (characters and pinyin) 姓名 (汉字及拼音) Personal ID No./Passport No.身份证/护照号码 Gender/Age/Position 性别 / 年龄 / 职务 Contact number 联系电话 Mobile 手机 E-mail address 电邮地址 Applicant'

s personal Information 申请人个人信息 Company 公司名称 Residential Address/Post Code 通讯地址/邮编 Name (characters and pinyin) 姓名 (汉字及拼音) Personal ID No./Passport No.身份证/护照号码 Relation to Insured 与被保险人的关系 Contact number 联系电话 Mobile 手机 E-mail address 电邮地址 Account information 银行账户资料 The compensation will be credited to your account by bank transfer, Please provide the following details.赔款将通过银行转帐支付,请务必详细填写 Name of account holder 户名 Bank name and address 开户银行(请务必填写开户行所在的省和市) Bank account No.账号 Claim under policy section(s)申请事项 In-patient 住院医疗 Out-patient 门诊医疗 Dental treatment 牙科医疗 Relative hospital visit 亲属慰问探访 Relative deal with funeral 亲属前往处理后事 Repatriation of mortal remains or local funeral 遗体遣返回国或者就地安葬 Others 其他 请注明: Where did the accident occur(place)事故发生地点 When did the accident occur(date and time)事故发生日期 / 时间 Name of Witness 证人姓名 Address 地址 Contact Number 联系电话 Do you entitled to recover losses from any other insurance policy ?Please specify.此次损失是否可向其他保险公司索赔,请说明: Company 保险公司 Policy No.保险单号码 Claim under policy section(s)索赔项目 Compensation 索赔/已赔付金额 2-3 Claimed Item/Supporting Documents Required/Claimed Amount 索赔项目 / 索赔文件 / 索赔金额 All Claims 一般索赔文件 (所有索赔均须提供) 1. Copy of claimant'