意外健康险索赔申请表-2016-Lock.docx

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:申请或获赔金额Claimed/Settled amount银行帐户资料Bank Details赔款将通过银行转帐支付。所有索赔申请，均须填写此部分Settlement will be credited to your account by bank transfer, please provide the following details:转账授权 Fund Transfer Authorization （如适用where applicable）:本人 ，谨授权史带财产保险股份有限公司将以上保险事故的全部理赔款项划入本授权人指定的 （请填写收款人或收款单位的名字）的以下账户。收款人证件号（或组织机构代码）： 。I/We , hereby authorize Starr Property Casualty Insurance (China) Company Limited to release the indemnity of above incident to the below bank account of (please fill the name of payee) on behalf of me/us. Payee’s ID number （company code）: . 授权人签字Authorized Signature:收款账户所有人签字Payee Signature:户名Payee Name：开户银行(银行名/分行)Bank(Name/Branch)：账号Account Number：索赔项目 / 索赔资料 / 索赔金额Claim Item/Claim Materials/Claim Amount一般索赔资料(所