PDF《TRAVEL INSURANCE》

ERV (China) Travel Service and Consulting Ltd.

Unit 1103A, Shun Tak Tower, No

1 Xiangheyuan Road,Dongcheng District, Beijing

100028 Tel:+86

10 8441

6500 Fax:+86

10 8451

1175 Email:[email protected] 欧乐旅行援助(北京)有限公司,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

电话: +86

10 8441 6500,传真: +86

10 8451

1175

邮箱: [email protected] TRAVEL INSURANCE CLAIMS FORM 旅游保险索赔单 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屡行理赔的根据.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. Claim under policy section(s) 申请事项 Insured'

s personal Information 被保险人个人信息 Company 公司名称 Position/title 职务 Name (characters and pinyin) 姓名 (汉字和拼音) Personal ID No. 身份证号码 Private address 家庭住址 Tel. office 单位电话 Postal code 邮编 E-mail address 邮箱 Tel. private 个人电话 Applicant'

s personal Information 申请人个人信息 Company 公司名称 Position/title 职务 Name (characters and pinyin) 姓名 (汉字和拼音) Personal ID No. 身份证号码 Relation to Insured 与被保险人的关系 Private address 家庭住址 Tel. office 单位电话 Postal code 邮编 E-mail address 邮箱 Tel. private 个人电话 Detail of Journey 旅行细节 Purpose of journey 旅行目的 Date of departure 出发日期 Date of return 回程日期 Tour operator/company (if any) 旅行组织者/公司(如有) Destination 目的地 What happened? 事故经过 When did the injury/illness occur? (date and time) 伤害/疾病的发生时间?(日期/时间) When was the injury/illness reported to the Ping An hotline? (date and time) 伤害/疾病何时通知的平安救援热线?(日期/时间) Where did the injury/illness occur? (place) 事故(伤/病)发生地点? Description of what happened C if relevant please use a separate piece of paper or sketch. 事故经过描述 C 如有相关需要您可使用另外的纸张 If the insured has passed away 如被保险人身故 Has the cause of death been determined? Yes ( please attach the death report) No 是否已检验死因?是(请附报告 否Details of treatment 治疗详情 Dates on which you consulted or were seen by a physician 看病日期 Period of hospitalisation From Until 住院时期 从至Diagnosis/Description of illness 诊断/病情描述 Have you previously been treated for the same illness? 是否接受过与此相同病情的治疗? In-patient 住院医疗 Policy No. 保单号 ERV China case No. 欧乐旅行援助案例号 Out-patient 门诊医疗 Dental treatment 牙科医疗 Repatriation of mortal remains or local funeral 遗体遣返回国或者就地安葬 Relative deal with funeral 亲属处理后事 Relative hospital visit 亲属慰问探访 Death 身故保险金 ERV (China) Travel Service and Consulting Ltd. Unit 1103A, Shun Tak Tower, No

1 Xiangheyuan Road,Dongcheng District, Beijing

100028 Tel:+86

10 8441

6500 Fax:+86

10 8451

1175 Email:[email protected] 欧乐旅行援助(北京)有限公司,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