中国人民保险 - 中国人民保险(香港)有限公司.DOC

香港干諾道中148號粵海投資大廈15字樓 15/F., Guangdong Investment Tower, 148 Connaught Rd. C., H. K. 電話(TEL): 2517 2332 傳真(FAX): (852)2540 6260 2540 6377 汽車保險索償書 MOTOR INSURANCE CLAIM FORM 保 戶 INSURED 姓名 Name 保單號碼 Policy No. 職業 Occupation 聯絡電話 Telephone 地址 Address 司 機 DRIVER 司機姓名 Name of Driver 與車主的關係 Relationship 職業 Occupation 司機年齢 Driver’s age 駕駛執照號碼 Driving Licence No. 聯絡電話 Telephone 駕駛年數 Driving Experience 執照首次發出日期 Date of first issue 地址 Address 投保車輛 INSURED VEHICLE 車牌號碼 Registration No. 汽車牌子、型號 Make Model 引擎號碼 Engine No. 車身號碼 Chassis No. 當失事時該車作何用途 State for what purpose the vehicle was used when the accident happened 出事詳情 DETAILS OF ACCIDENT 出事日期及時間 Date and time of accident 出事地點 Place of accident 出事時車速 Speed of insured vehicle at time of the accident 尊見以為失事過失屬何方 In your opinion who was at fault? 自己Self 對方 Opposite 雙方 Both parties 請 將 此 意 外 之 詳 細 情 形 填 寫 於 背 頁 並 加 以 說 明 Please give a full description on the back of this form, explaining how the accident happened. 證 人 WITNESSES 失事時本車內有幾人 How many persons are in the vehicle at the time of accident? 是否保戶/司機的僱員? 是/否 Are they your employee(s) yes/no 請填明當時確實在車內各人姓名及地址 State names and address of all persons actually in the vehicle at the time 請填述其他有關證人之姓名及地址 Sate name and address of all other witnesses 涉及意外的其他車輛編號及其司機姓名、地址 Please state the registration no. of other vehicle(s) involved in this accident, the name and address of the respective driver’s 警 方 POLICE 請填述向警署報案及報案編號 Please state to which police station did you or the driver reported the incident, and the reporting case no. 閣下或司機有否收到任何傳票或警方控告? 有 無 Have you or the driver received any summons fro prosecution, or any notice of other police action/enquiries /inquest? yes no 重要事項: 所有有關文件應於收到後立即呈交保險公司 Important: All related documents must be submitted to insurance company immediately upon receipt 汽車損毀 情況 OWN DAMA