PDF《旅游保险索偿表》

第1页旅游保险索偿表TRAVEL INSURANCE CLAIM FORM Name of Insured 保户名称: Policy / Certificate No.

保单编号: Name of Claimant 索偿人姓名: Mailing Address 通讯地址: Telephone No. 联络

电话: Period of Journey 旅游日期: From 由to 至 Type of Claims: 1. Personal Accident 2. Medical Expenses 3. Baggage Delay 索偿类别 人身意外 医疗费用 行李延误 4. Loss of Money 5. Travel Delay 6. Personal Liability 金钱遗失 行程延误 个人责任 7. Baggage & Personal Effects 8. Cancellation / Curtailment of Trip 行李 / 随身财物 取消 / 缩短行程 Date & Time of Loss / Accident: 损失 / 意外日期及时间: Place of Loss / Accident: 损失 / 意外地点: Details of occurrence: 事件发生详情: Total Claimed Amount 索偿总额: TO BE COMPLETED FOR CLAIM UNDER C MEDICAL EXPENSES 如索偿类别为 C 医疗费用,必须填写此部份. A) For Accident Claim C Nature of Injury: 1) 意外 C 受伤性质: B) For Sickness Claims C Describe the diagnosis of sickness & treatment received: 2) 疾病 C 所患疾病的名称及所接受的治疗: ?? Please attached all original medical receipts and medical reports 请提供所有医疗费用收鸵搅票ǜ嬲 For Office Use Only Claim No. 第2页TO BE COMPLETED FOR CLAIM UNDER C BAGGAGE & PERSONAL EFFECTS 如索偿类别为 C 行李及随身财物,必须填写此部份. Items Loss / Damage Date & Place of Purchase Purchase Value 损失 / 损毁之物件 购买地方及日期 购入价值 * Please attached all original purchase receipts / invoices for baggage and personal effects 请提供所有行李延误或遗失 / 损毁物件之购买收 / 发票正本 * Relevant Loss Report from Hotel Management, Airline Company or Police, etc 有关酒店、航空公司或警方等之纪录报告 Additional documents relevant to the claim may be required and to be forwarded upon request of China Pacific Insurance Co. (HK) Ltd. (The Company). 如有需要,中国太平洋保险(香港)有限公司z本公司{将要求索偿人提供额外之有关文件以供处理索偿事宜用 途. DECLARATION AND AUTHORIZATION 声明及授权书 I declare that to the best of my knowledge and belief the above statement and particulars contained are in all respects true and completed and are made without reservation of any kind. I hereby authorized my physician, medical practitioner, hospital or clinic by whom or where I have been observed or treated to give full particulars about my health including my whole medical history to China Pacific Insurance Co. (HK) Ltd. A photocopy of this authorization shall have the full effect of the original authorization. 本人谨此声明本人确认以上所填报之资料及所列各项之事件乃属完全真确并无对保险公司作任何资料之保留 . 本人兹授权於 任何曾替本人作诊疗之医生、医务人员、医院或诊所提供有关本人病历之资料予中国太平洋保险(香港)有限公司,此授权之 影印本亦属有效. PERSONAL DATA COLLECTION STATEMENT 收集个人资料声明 The information you provide to us is collected to enable us to carry on insurance business and may be used for the purpose of ? Any insurance or financial related product or service or any alternations, variations, cancellation or renewal of them. ? Any claim or analysis of it And may be transferred to any related business partners, companies carrying on insurance or reinsurance related business or an intermediary or a claims or investigation or other service provider providing services relevant to insurance business or any association or federation of insurance companies that exists or is formed from time to time. You have the right to obtain access to and to request correction of any personal information concerning yourself held by CPIC. Requests for such access can be made to our Personal Data (Privacy) Ordinance Compliance Officer. Telephone No. (852)