车辆损毁索偿表只限挡风玻璃损毁-富卫香港.PDFVIP

MOTOR CLAIM FORM (WINDSCREEN DAMAGE ONLY) 車輛損毀索償申請表 (只限私家車汽車擋風玻璃損毀) It is important that a complete answer be given to every applicable question. If insufficient space is provided for your answers, please continue on a separate sheet. 請詳細填報表格上每一個適用的項目。如空位不足，請自備補充頁填寫。 POLICY NUMBER 保單號碼 NAME OF AGENT 保險代理人 INSURED’S INFORMATION 保户資料 Full Name 姓名 ____________________________________________________________ Policy No. 保單號碼 _____________________________ Correspondence Address# 通訊地址# _____________________________________