最新全新-Royal & Sun Alliance Insurance plc.doc

文档介绍：太阳联合保险(中国)有限公司
英国RSA集团成员
上海市浦东新区芳甸路1155号32楼, 201204
电话:[phone]
传真:[phone]




PERSONAL ACCIDENT INSURANCE CLAIM FORM

人身意外伤害险索赔申请表


Policy No. 保单号码:_________________________ Expiry Date 保单有效期至:YYYYYYYYYYYY/// MMMMMM /// DDDDDD

Insurance plan 保险计划: □ Guard Plan 守护神计划
□ Protect Superior Plan 卫士A计划
□ Protect Standard Plan 卫士B计划

Particulars of the Insured and the Claimant 被保险人和索赔人资料

Name of Insured 被保险人姓名:_______________________

ID No. or Passport No 身份证或护照号码:__________________________

Corresponding Address 通讯地址:________________________________________________________

Daytime Tel 日间联络电话:___________________________ Fax 传真:_____________________

Name of Claimant 索赔人姓名:________________________

ID No. or Passport No身份证号码:__________________________

Corresponding Address 通讯地址:________________________________________________________

Daytime Tel 日间联络电话:___________________________ Fax 传真:_____________________

Relationship to Insured Person索赔人与被保险人关系:_________________________________

Date of Accident 出险日期:YYYYYYYYYYYY/// MMMMMM /// DDDDDD
Have you applied for claims in another pany for this event/accident? If “Yes”, please specify. 就此事件/意外,你有否向其他保险公司索赔?如“有”者,请列明有关详情。

Please indicate your current status
请指出你现在的情况
Fully recovered from this injury 完全康复/ Still under treatment 治