人身意外保險賠償申請表personalaccidentinsurance.pdfVIP

人身意外保險賠償申請表 PERSONAL ACCIDENT INSURANCE CLAIM FORM 根據保單條款，此賠償申請表應詳細填妥並簽署，及遞上各有關單據、病假紙及醫生介紹書，以免延緩 日期 索償進程。 Date: According to Policy Conditions, this form should be fully completed and signed, and the available medical bills, sick leave certificates and doctor’s referral letter be submitted, to avoid delay in claim process. 如投保人因傷不能書寫，投保人之家屬或負責人可代為填簽。 If the Insured is unable to write on account of disablement, this form should be filled up and signed by a close relative or other responsible person in charge of the Insured for the time being. 呈遞此賠償申請表，並不表示公司承擔賠償責任。 By furnishing this form the Company makes no admission of liability. 甲項 投保人資料 SECTION A INSURED’S INFORMATION 姓名 香港身份證／護照號碼 保單號碼 Name HKID Card/Passport No. Policy No. 出生日期 性別 職業 Date of Birth Sex Occupation 地址 Address 電郵地址 流動電話號碼 E-Mail Address Mobile Phone No. 傷者姓名(如非投保人) 與投保人關係 Name of Injured Person Relationship 職業 (if not the Insured) with the Insured Occupation 出生日期 聯絡電話 Date of Birth Tel No. 乙項 意外詳情 SECTION B PARTICULARS OF ACCIDENT 日期 時間 上午／下午 地點 Date Time a.m./p.m. Place 敘述意外發生之詳情 Describe exactly how the accident occurred 意外是否由工作引致