意外健康险索赔申请表AccidentalandHealthClaimForm.pdfVIP

意外健 康 险 索赔 申 请表 Accidental and Health Claim Form 索赔申请人应正确详细填写此申请表，并将附件所列索赔所需的文件于索偿事由发生３０天内交回保单签发机构 Please complete this form accurately and return with the supporting documents within 30 days after the occurrence of the claimed condition to the insurance company. 视索赔性质及金额，保险公司有权要求进一步资料。每份申请表仅限一位索赔申请人填写。 Further documents may be requested depending on the nature and extent of the claim. Separate forms must be used for different claimants. 被保险人/索赔申请人资料Insured / claimant 保险单号码Policy Number (旅行险类Travel Insurance only)行程日期Trip period ： 由From 至To 目的地/Destination ： 姓名Name （被保险人Insured/索赔人Claimant ） 性别Sex 年龄Age 职业Occupation 身份证/护照号码ID/Passport Number 通讯地址Address 邮政编码Postal Code 联系电话Phone 电邮地址Email 理赔授权Claim Authorization （如适用where applicable ） 本人 ，谨授权 （被授权人证件号/组织机构代码证号 ）向史带财产保险股份 有限公司全权办理相关理赔手续。 I/We , hereby authorize (Delegated person‘s ID number /Company code ) to deal the claim procedure with Starr Property Casualty Insurance (China) Company Limited on behalf of me/us. 授权人签字Authorized Signature: 被授权人Delegated Signature: 保险事故Incident Details 事故地点Loss Location 事发日期Loss Date 时间Time 事故描述Loss Description 证人姓名Witness 地址Address 联系电话Phone / 电邮Email 如果此次损失可向其他保险公司索赔，请说明If this incident can be claimed through other insurance company, please state 保险公司Insurance company: 保险单号码Policy number: 索赔项目Claim item