CHUBB GROUP OF INSURANCE COMPANIES FEDERAL INSURANCE COMPANYIncorporated under the laws of Indiana, U.S.A., licensed to do business in the Hong Kong Special Administrative RegionPlease complete and return the Claim Form together with the supporting documents to Ms Ice Ip of Aon Hong Kong Ltd., 21/F Aon China Building, 29 Queens Road Central, Hong Kong. Telephone No: (852) 2861 6587, Fax No: (852) 2243 8514Page 1 of 2GROUP PERSONAL INSURANCE CLAIM FORM 人身意外保險索償申請表人身意外保險索償申請表This form is issued without admission of liability on the part of Federal Insurance Company and must be completed as truthfully and accurately by the Policyholder and/or Insured Person/Claimant and returned to Aon (address as above) together with the supporting documents within 30 days after the occurrence of the claimed condition. Further information/documents may be requested depending on the nature and extent of the claim. Separate forms must be used for different claimants. 茲此聲明,填寫本申請表不代表聯邦保險公司巳承諾了保險責任。投保人/被保險人或索償人應正確詳細填寫此申請表，並將後頁所列索償所需的資料于索償事 由發生 天內交回 Aon (地址如上)。視案件性質，本公司有權要求進一步資料。 每份申請表僅限一位申請索償人填寫。THE POLICYHOLDER 投保人資料投保人資料 Name 名稱 City University of Hong Kong (Non-Local Students)Policy No. 保險單號碼 93088143-GPA Correspondence Address 通訊位址E-mail 電郵地址Contact Person 聯繫人Contact Tel. No. 聯繫電話Facsimile No.傳真號碼THE INSURED PERSON/CLAIMANT 受保人受保人/ /索償人資料索償人資料 Name 姓名 Relationship to Policyholder與投保人關係Student/Coach No.學生/教練編號Occupation 職業H.K. I.D. Card No.身分證號碼Residential Address 現住地址Contact Tel. No. 聯繫電話E-mail 電郵 地址If Insured Person/Claimant is aged under 18, please specify 受保人/索償人如為十八歲以下，請注明： Name of Payee 收款人姓名:Relation to Insured Person 與被保險人關係：CLAIM DETAILS 索償事由索償事由 Date of Incident 事件發生之日期Time a.m./p.m. 時間 上午/下午Place of Incident 事件發生之確切地點Describe in detail how the incident happened 請詳述事件發生的原因和經過Result of Incident 事件導致的結果： Injury 受傷 Sickness 疾病Permanent Disability 永久傷殘Death 死亡 Part(s) of body affected 受影響的身體部位Nature of Injury 受傷性質Name of Witness 證人姓名Address 地址Contact Tel. No. 聯繫電話HOSPITALIZATION / SURGERY EXPENSES CLAIM 住院住院 / 手術費用索償手術費用索償 （Please fill in this part for hospitalization / surgery claim. 因意外或疾病而入住醫院，須填寫此部分） Symptoms and Diagnosis 傷病的名稱及症狀：Date of the symptom first appeared 首次就診前該症 狀已存在多久？Date of first consultation for this condition or related illness 首次接受治療日期：Attending Physician 主診醫生：Name of Clinic/Hospital first attended 首次接受治療診所/醫院：Name of In-patient Hospital 住院醫院名稱：Date of Admission 入院日期：Date of Discharge 出院日期：Page 2 of 2OTHER APPLICABLE INSURANCE 其他有關的生效保險其他有關的生效保險Do you have any other insurance policies covering the loss or expenses incurred (e.g. Travel Insurance, Household Insurance)? If so, please state: 是項索償是否受保於其他保險合約(例如旅遊保險, 家居保險等) ？ 如有， 請說明：Name of Insurer 保險公司:Policy Number 保險單號碼:Claimed Item 索賠項目: Claimed / Settled Amount 索償/已賠付金額HK$CLAIMED ITEM, AMOUNT 完整的門、急診病歷或出院總結正本 Original Medical Examination Report; 醫院出具的所有檢查報告正本 In-hospital Services 住院費補償Surgical Fees 手術費補償Original Medical Record from in-patient/out-patient/emergency units with attending doctors diagnosis 完整的門、急診病歷正本，或主診醫生的診斷證明正本 Original Hospital Record / Discharge Summary 出院總結及住院清單正本Original In-hospital Services Bills 住院醫療正式收據正本Medical Examination Reports issued by the Hospital 醫院出具的所有檢查報告Sickness Certificate 病假證明Letter from employer stating that the insured person is under employment during the sick leave period as a result of the injury and amount of the salary earned, if claiming loss of income 如索償入息補償，請提供由僱主發出之信件，證明受保人在受傷休假期間仍然受僱 及薪酬金額 Accidental Disablement 意外殘疾給付 Documentary proof certifying the claimant is suffering from permanent disability 證明索 償人永久傷殘的有關文件Accidental Death 意外身故保險金索償Death Certificate 死亡證明正本 Grant of Probate / Letters of Administration 授予遺囑認證書 / 遺產管理書Identity documents of the beneficiary and relationship proof 身故保險金受益人的身份證件 或其他相關類似證明，以及受益人關係證明All Claims 所有索償Police Report, if applicable 警方報告, 如適用Other documents in relation to this claim 其他與索償相關的證明和資料DECLARATION & AUTHORISATION 聲明及授權聲明及授權The undersigned hereby declare that to the best of my/our knowledge and belief, the above statements and particulars are fully and truly made. I/We agree that any of my/our personal information collected or held by Federal Insurance Company (“Company”) or its authorized representatives is provided and be held, used and disclosed by the Company to individuals/organizations associated with the Company or any selected third party for the purpose of processing the claims herein, providing data matching, and to communicate with me/us for such purposes. The undersigned understand that the Company may be unable to process the claims herein if I/we fail to provide any information requested in this Claim Form. The undersigned further understand that I/We have the right to obtain access to and to request correction of any personal information held by the Company concerning me/us. Such request can be made to the Companys Operations Servic