火险家居保险赔偿申请表

/Fire/HomeCareInsuranceClaimForm:()To:HangSengGeneralInsurance(HongKong)CompanyLimitedDate:L32Tower2EnterpriseSquareV38WangChiuRoadKowloonBayHongKongTel:(852)21987800Fax:[phone]AccordingtoPolicyConditions,thisformshouldbefullycompletedandsigned,andtherelevantclaimdocumentslistedonnextpagebefurnished,toavoiddelayinclaimprocess.TheCompanymayrequestotherspecificclaimformbecompleted.ByfurnishingthisformtheCompanymakesnoadmissionofliability.SECTIONAINSURED’SINFORMATIONNamePolicyNo.OccupationMobilephoneNo.Address(SMS)?DoyouagreetoreceiveSMSclaimnotificationviayourmobilephone?YesNoSECTIONBCLAIMINFORMATIONDateofIncidentTimePlaceDetailedCircumstancesofIncidentItem(s)ClaimedTotalAmountClaimedHK$(Forclaimoflostproperties,pleasecompletetheScheduleofLossasprintedonnextpage)ForPropertyLoss/Damage:1.HasPolice/FireServicesbeenreported?YesNoIfyes,whichPolice/FireStation?DateReportedCaseNo.2.IsInsuredthesoleowneroflost/damagedproperty?YesNo3.Arethereanyotherinsurancesuponthesameproperty?YesNoIfyes,pleasestatenameofinsurancecompany4.HasInsuredsustainedlossesofthesamenaturebefore?YesNoIfyes,pleasegivefullparticulars5.HasInsuredeverclaimedonanyinsurancecompanyforlossofsamenature?YesNoIfyes,pleasestatenameofinsurancecompany6.HasInsuredalreadyreplacedthelost/damagedproperty?YesNoDECLARATIONANDAUTHORISATIONI/Wedeclarethattheaboveinformationistrueandcompletetothebestofmy/ourknowledgeandbeliefandI/wehavenotwithheldanymaterialinformationconnectedwiththisclaim.I/WeunderstandthattheCompanycanrequestformoreinformationorspecificclaimformbecompleted.I/WealsohavereadandunderstandthePersonalInformationCollectionStatementasprintedonnextpage.()I/Weherebyauthorizeanyauthoritiesororganizationthathasanyrecordsorknowledgeofme/usormy/ourpropertyloss,tofurnishtoHangSengGeneralInsurance(HongKong)CompanyLimitedoritsauthorizedrepresentative,anyandallinformationwithrespecttomy/ourclaimorreportofpropertylossforthepurposeofassessmentofmy/ourpresentclaim.Aphotostatcopyofthisauthorizationshallbeconsideredaseffectiveandvalidastheoriginal.SignatureofInsured(withcompanychopifappropriate)HSI212-R5(YX)1-207/08ESCHEDULEOFLOSSDescriptionofLostArticles(includingcash)FromWhomAcquiredDateAcquiredOriginalCostReplacementCostAmountClaimed(HK$)()(Pleaseuseaseparatesheetifthespaceprovidedisinsufficient)TOTALAMOUNTCLAIMED---(内)-;--()-/3832(2198780026295163)#PersonalInformationCollectionStatementTheinformationyouprovidetousiscollectedtoenableusandanyofouraffiliatedcompaniestocarryonbusinessandmaybeusedforthepurposeof:-anyinsurance,banking,providentfundschemeorfinancialrelatedproductsorservicesoranysaleormarketing,oranyalterations,variations,cancellationorrenewalofsuchproductsorservices;-anyclaimsorinvestigationoranalysisofsuchclaims;-exercisinganyrightofsubrogation,ifapplicable;Furthertheinformationyouprovidetousmaybetransferred(inandoutsidetheHongKongSpecialAdministrativeRegion)to:-anyofthecompanyorcompanieswithintheHangSengGroupforthepurposeofinsurance,bankingorotherbusinessoftheaffiliatedcompanyconcerned;-anyrelatedcompany,oranyothercompanycarryingoninsuranceorreinsurancerelatedbusiness,oranintermediary,oraclaimorinvestigationorotherserviceproviderprovidingservicesrelevanttoinsurancebusiness,foranyoftheaboveorrelatedpurposes;-anyassociation,federationorsimilarorganisationofinsurancecompanies(“Federation”)thatexistsorisformedfromtimetotimeforanyoftheaboveorrelatedpurposesortoenabletheFederationtocarryoutitsregulatoryfunctionsorsuchotherfunctionsthatmaybeassignedtotheFederationfromtimetotimeandarereasonablyrequiredintheinterestoftheinsuranceindustryoranymember(s)oftheFederation;-anymembersoftheFederationbytheFederationforanyoftheaboveorrelatedpurposes.Moreover,weareherebyauthorisedtoobtainaccesstoand/ortoverifyanyofyourdatawiththeinformationcollectedbytheFederationfromtheinsuranceindustry.Youhavetherighttoobtainaccesstoandtorequestcorrectionofanypersonalinformationconcerningyourselfheldbyus.RequestsforsuchaccesscanbemadeinwritingtotheDataProtectionOfficer,L32Tower2EnterpriseSquareV38WangChiuRoadKowloonBayHongKong.(Telephone:[phone],Fax:[phone]).ClaimDocuments1.Previousdecoration/purchaseinvoice/receiptofthelost/damagedhouseholdcontents.2.Incidentreportfromthebuildingmanagementtoshowthedateofincidentandcauseofdamagetohouseholdcontents.3.Photosshowingtheextentofdamagetohouseholdcontents.4.Originalrepairquotation.5.OriginalPoliceMemo/copyofPoliceStatement.6.Anythirdpartycorrespondence,summonsorwritsshouldbeforwardedtousimmediatelyunanswered.7.Otherrelevantclaimdocuments.ThisClaimFormmustbesubmittedimmediately,evenifanyoftheclaimdocumentsisnotreadilyavailable.()HSI212-R5(YX)2-207/08E