意外赔偿申请表ACCIDENTCLAIMFORM.PDFVIP

意 外 賠 償 申 請 表 ACCIDENT CLAI M FORM 保單持有人姓名 Name of Policyholder 受保人姓名 Name of Insured 保單編號 Policy No. 受保人身份證/ 護照號碼 I.D. / Passport of Insured 保險中介人資料 INSURANCE INTERMEDIARY INFORMATION 保險中介人姓名 Name of Insurance Intermediary 保險中介人代碼 Insurance Intermediary Code 聯絡電話 Contact No. 重要須知 IMPORTANT NOTE  ‐ 請以正楷填寫本申請表。任何資料如有更改，受保人/保單持有人/索償人必須在更改的位置簽署作實。Please complete this form in BLOCK LETTERS. All amendments should be endorsed by the Insured / Policyholder / Claimant in full signature. ‐ 本申請表中所用之「本公司」或「貴公司」之表述指中國人壽保險(海外)股份有限公司。The expressions the Company or our Company used in this form refers to China Life Insurance (Overseas) Company Limited. ‐ 本申請表第一部分必須由受保人/保單持有人/索償人填寫，並需於意外日期起二十天內連同有關之文件正本呈交本公司。Part I of this form must be completed by Insured/Policyholder/Claimant and returned to the Company within 20 days from date of accident together with all original documents. ‐ 如受保人為十八歲或以上，受保人必須親自填寫及簽署本申請表，如受保人為十八歲以下，本申請表應由受保人之家長或合法監護 人填寫及簽署。如受保人/保單持有人因傷殘不能書寫，其直系親屬可代為填寫本申請表及簽字，並提供醫生證明。If the insured is at or above age 18, the Insured must complete and sign this form by his or her good self. If the insured is under age 18, this form should be completed and signed by the insureds parent/ legal guardian. In the event that the Insured/ policyholder is physically incapacitated and prevented from signing, this form may be completed and signed by an immediate family member with relevant physicians statement provided. ‐ 若受保人/保單持有人/索償人以圖章蓋印簽署，必須由一位見證人予以見證。見證人之個人資料只會用於處理本索償申請及核實和確 認本申請表簽署人的身份之用。If the Insured/Policyholder/Claimant uses a signature stamp, it must be witnessed by a witness. The personal particulars of the witness will only be used for the purpose of processing this claim and verifying and confirming the identity of the signatory of this form. ‐ 受保人/保單持有人/ 索償人之簽署必須與本公司之紀錄相同。The signature