索赔申请书

索赔申请书 旅行意外伤害保险索赔申请书 Travel Accident Insurance Claim Form 所有问题均须由被保险人/索赔申请人完全回答 保单号码 All questions must be answered by Insured/ applicant Policy No.________________________________________ Hotline: 400 615 5156 Claims Department Zurich General Insurance Company (China) Limited, Room 606, 6th Floor, Office Building F, Phoenix Place, Tower 21, No.A5, Shuguangxili, Chaoyang District, 100028, Beijing 被保险人姓名英文/中文 年龄 Name of Insured in full (English/Chinese) Age________________ 保单持有人英文/中文 Name of Policy Holder in full (English/Chinese)_____________________________________________________________________ 被保险人地址 邮政编码 Address of Insured______________________________________________________________ Postal code_______________________ 联络电话(日间固定电话) 联络电话(手机) Tel. no. (Daytime) ____________________________________________Mobile____________________________________________ 职业(请详述) 身份证号码 Occupation (describe fully)_______________________________________Identity Card No.___________________________________ (若索赔申请人为被保险人本人，无需填写此栏 If the applicant is the insured, this part can be ignored ) 索赔申请人姓名英文/中文 年龄 Name of the applicant in full (English/Chinese)____________________________________________Age______________________ 索赔申请人地址 邮政编码 Add_________________________________________________________________________Postal code_________________________ 联络电话(日间固定电话) 联络电话(手机) Tel. no. (Daytime)_____________________________________________Mobile____________________________________________ 与被保险人关系 身份证号码 Relationship to the insured________________________________________Identity Card No.__________________________________ 保险期间由(The insurance period is from)____________________________________至(to)________________________________ 索赔类别 1. 医疗费用 2. 人身意外 3. 行李,随身财物 / 证件遗失 Claim Item Medical Expenses Personal Accident Loss of Personal Baggage and Travel Document 4. 旅程/行李延误 5. 个人责任 6. 行程取消 / 缩短 Travel and Baggage Delay Personal Liability Cancellation and Curtailment of Trip 7. 家居财物盗抢损失 8. 其它______________________________________________________ Loss of Home content due to Burglary Others 意外在何时何地发生When and where did the accident occur? (a) Date 日期_______________________________________(b) Time 时间_____________________________________________ (c) Place 地点________________________________________________________________________________________________ 1/3 请详述意外事故发生经过 How did the accident occur? (Please state fully)____________________________________________________________________ 索赔金额Claim amount :_________________________________________________________________________________________ 是否已向其它保险机构索赔, Have you submitted the claim to other insurer? 否 No 是 Yes 保单号码 Policy no. 保险公司名称 Name of insurance company ____________________ _______________________________________ ____________________ _______________________________________ 就诊医生 诊治日期 就诊原因 就诊医院 发票数量 发生金额 Name of Date Diagnosis Hospital Pieces of invoice Amount physician 如发生意外伤害，是否回国继续就诊?If the accident is happen, do you need to follow up treatment/consultation after coming back to China? 否 No 是 Yes 医院名称 Hospital name 主要治疗方式 Name of main treatment ____________________ _______________________________________ ____________________ _______________________________________ 损失,损毁之物件 原购买地点及购买日期 原购入价格 Loss or destruction of Original purchase location and Original purchase objects date price 如此栏不够填写，请另加纸张。If the paper is not enough, please add paper 2/3 开户名: 账号: Account name: Account number: 开户银行: 开户行地址: Bank of deposit: Bank address: 1.本人在此重申以上所述事实准确无误且本人对有关此项要求赔偿事件并未保留任何重要资料。 I hereby warrant that the above statements and facts are true, and that I have not withheld from the Company any material information connected with this claim. 2.本人/本公司在此声明及同意由苏黎世财产保险(中国)有限公司(以下简称苏黎世)所收集或持有的个人资料，包括附在此索赔申请 书后或以其它方式获取的资料，均可供苏黎世使用或向在中国境内或境外之任何人或机构披露作以下用途:(1)评估此项申请，(2)提 供保险及客户服务，(3)处理保险的索赔或有关之分析 。 I/We further hereby declare and agree that the personal information collected or held by Zurich Insurance Company (the “Zurich”), whether contained in this accident report form or otherwise obtained, may be used by Zurich or disclosed to any individual or organization within or outside China for the following purposes: (1) to assess and process this application, (2) to provide insurance and customers services, (3) to conduct insurance claims or analysis. ___________________________________ ________________________________________________ _________ Signature of Policy Holder 保单持有人签章 Signature of insured/applicant 被保险人/索赔申请人签字 Date 日期 3/3