LIABILITYCLAIMFORM责任险索赔申请表.PDFVIP

安达保险有限公司 Chubb Insurance Company Limited 电话/O: (86 21) 2325 6688 上海市浦东新区 Unit 801 Century Metropolis 传真/F: (86 21) 5292 5880 世纪大道1229 号 No. 1229 Century Avenue 服务热线/Service Hotline: 400 889 2120 东方汇广场801 室 Pudong, Shanghai 邮编：200122 200122, P.R.C. LIABILITY CLAIM FORM 责任险索赔申请表 Important: The insured is requested to state as fully and accurately as possible the information asked for hereunder and to return this form immediately to the company via email to: chn.claims@ The acceptance of this form is not in itself an admission of liability on the part of the Company. 重要提示: 请索赔人尽可能全面而准确地填写此表格，并返还保险公司 （报案邮件地址：chn.claims@ ）。接受本申 请表并不表示本公司已承认赔偿责任。 THE INSURED Name :______________________________________________ Policy No.:_________________________ ________ 公司名称 保险单号码 被保险人 Business or Occupation:________________________________ Address: __________________________________ 业务性质 地址 Contact Person: ______________ Tel. No.: _______________ Email: ____________________________________ 联系人 电话 电邮地址 Are there any other insurance in force which would cover this loss in whole or in part? 有无其他有效保险保障此次事故造成的全部或部分损失？ □Yes(是) □No(否) If answer is YES, state: 如选‘是’，请告知： Name of Insurer:______________________________________ Policy Details:______________________________ 投保公司名称