事故报告书-三井住友海上火灾保险.DOC

三井住友海上火灾保险（中国）有限公司 Mitsui Sumitomo Insurance (China) Company, Limited 中国上海市浦东新区世纪大道100号 上海环球金融中心 34楼T70室 34-T70, Shanghai World Financial Center, 100 Century Avenue, Pudong New Area, Shanghai 保险公司签收致：三井住友海上火灾保险（中国）有限公司 保险公司签收 To: Mitsui Sumitomo Insurance (China) Company, Limited 雇主责任保险索赔函 兼 事故报告书 EMPLOYERS LIABILITY CLAIM AND ACCIDENT REPORT POLICY NUMBER 保单号码： INSURANCE CLASS 保险险种： EMPLOYERS LIABILITY 雇主责任险 INSURED 被保险人名称： CLAIM AMT 索赔金额： PRESENT ADDRESS 地址： WHICH OCCURRED AT 事故发生日期： _______(Y) ____(M)____ (D) 年 月 日 (TIME) : LOCATION OF THE LOSS 事故地点： SUMMARY OF THE LOSS 事故概要： [ ] SEE ATTACHED REPORT [ ] 附事故損失报告参照 CAUSED BY 损失原因： THERE IS NO OTHER INSURANCE APPLICABLE TO THIS LOSS EXCEPT AS STATED HEREUNDER 请说明其他对本事件有效之保险 INSURANCE COMPANY 保险公司名称 POLICY PERIOD 保险期间 COVERAGE OR BOND FORM 保险险种 AMOUNT OF INSURANCE 投保金额 PLEASE COMPLETE THIS FORM IN DETAIL AS MUCH AS POSSIBLE, OTHERWISE THE CLAIM WILL BE PREJUDICED. IT IS UNDERSTOOD AND AGREED THAT THE FURNISHING OF THIS FORM TO THE INSURED OR ITS PREPARATION BY ANY REPRESENTATIVE OF THE COMPANY OR THE ACCEPTANCE OR RETENTION OF THE PROOF THEREAFTER BY THE COMPANY SHALL NOT CONSTITUTE A WAIVER OF ANY OF THE CONDITIONS OF THE POLICY. 请务必完整填写此表格，以保障您的索赔权利。 兹声明：本公司向被保险人或其代表提供此事故报告书及其日后接受或保留其他之有关证明，均不构成公司对保险单上所载之任何条款 予以放弃。 I/WE HEREBY DECLARE INFORMATION GIVEN ABOVE IS MADE TRUE AND CORRECT AND TO THE BEST OF MY/OUR KNOWLEDGE. 我/我们郑重声明：本表格所反映的信息是尽我/我们所知及所信，本表格的资料全属正确无误。 I/WE HEREBY UNDERTAKE TO PROVIDE ANY DOCUMENTS OR ASSISTANCE TO THE INSURER FOR RECOVERY AGAISNT ANY OTHER THIRD LIABLE PARTY ACCORDING TO THE POLICY. 我/我们承诺根据保险合同规定，协助保险公司向任何有责任的第三方进行追偿。 AFTER I/WE’VE RECEIVED THE FINAL AND TOTAL CLAIM AMOUNT, WE WILL NOT CLAIM AGAINST YOUR COMPANY ANY MORE WITH REGARD TO THIS ACCIDENT. 我/我们收到上述最终及全部赔款后，就此事故不再向贵司提出任何索赔。 I/WE PROMISE THAT CONCERING THE LOSS/DAMAGE OF THIS INSURANCE CLAIM APPLICATION, HAVE NEVER RECEIVED ANY COMPENSATION FROM ANY THIRD PARTY. IF THERE IS ANY DISCREPANCY,