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1、三井住友海上火灾保险（中国）有限公司 Mitsui Sumitomo Insurance (China) Company, Limited 中国上海市浦东新区世纪大道 100 号 上海环球金融中心 34 楼 34F, Shanghai World Financial Center, 100 Century Avenue, Pudong New Area, Shanghai, China 致： 三井住友海上火灾保险（中国）有限公司 To: Mitsui Sumitomo Insurance (China) Company, Limited 境外旅行综合保险索赔函 事故报告书 OVERSEAS T
2、RAVEL COMPREHENSIVE INSURANCE CLAIM AND ACCIDENT REPORT POLICY NUMBER 保险单号码： INSURANCE CLASS 保险险种： INSURED NAME CLAIM AMT 被保险人姓名： 索赔金额： IDENTIFICATION TYPE IDENTIFICATION No. 证件类型： 证件号码： WHICH OCCURRED ON (Y) /(M) /(D) / / 年 月 日 LOCATION OF THE LOSS 事故发生日期： 事故地点： SUMMARY OF THE LOSS SEE ATTACHED REP
3、ORT 附事故损失报告参照 CAUSED BY 事故概要： 损失原因： THERE IS NO OTHER INSURANCE APPLICABLE TO THIS LOSS EXCEPT AS STATED HEREUNDER 请说明其他对本事件有效之保险 INSURANCE COMPANY 保险公司名称 POLICY PERIOD 保险期间 COVERAGE OR BOND FORM 保险险种 AMOUNT OF INSURANCE 保险金额 PLEASE COMPLETE THIS FORM IN DETAIL AS MUCH AS POSSIBLE, OTHERWISE THE CLA
4、IM WILL BE PREJUDICED. IT IS UNDERSTOOD AND AGREED THAT THE FURNISHING OF THIS FORM TO THE INSURED OR ITS PREPARATION BY ANY REPRESENTATIVE OF THE COMPANY OR THE ACCEPTANCE OR RETENTION OF THE PROOF THEREAFTER BY THE COMPANY SHALL NOT CONSTITUTE A WAIVER OF ANY OF THE CONDITIONS OF THE POLICY. 请务必完整
5、填写此表格，以保障您的索赔权利。 兹声明：本公司向被保险人或其代表提供此事故报告书及其日后接受或保留其他之有关证明，均不构成公司对保险单上所载之任何条款 予以放弃。 I/WE HEREBY DECLARE INFORMATION GIVEN ABOVE IS MADE TRUE AND CORRECT AND TO THE BEST OF MY/OUR KNOWLEDGE. 我 /我们郑重声明：本表格所反映的信息是尽我 /我们所知及所信，本表格的资料全属正确无误。 ON THE DATE OF 日期： (Y:年 ) (M:月 ) (D:日 ) AT THE LOCTION OF SIGNATU
6、RE OF THE INSURED 地址： 被保险人署名 PLEASE PAY BY CHECK 请用支票支付 PLEASE PAY BY WIRE-TRANSFER 请通过银行转帐 NAME OF BANK 银行名 NAME OF BRANCH 分支行名 ACCOUNT NUMBER 帐号 ACCOUNT NAME 帐号名称 FOR BODY INJURY LOSSES 如系境外人身伤害事故，请填写以下内容 THE ITEMS FOR CLAIMS 索赔项目： 境外意外伤害 Overseas Accidental Death & Dismemberment 境外意外烧烫伤 Overseas
7、Accidental Burns& Scalding 境外医疗费用 Overseas Medical Reimbursement 境外住院津贴 Overseas Daily Hospital Allowance 境外紧急救援 Overseas Emergency Rescue Services 其他 Others FOR OTHERS 如系其他事故，请填写以下内容 THE TYPE FOR BODY INJURY 伤害类型： THE ITEMS FOR CLAIMS 索赔项目： RELATIVE DOCUMENTS 相关证明资料 FOR THEFT OR ROBBERY 如系盗窃或抢劫，请填写
8、以下内容 POLICE REPORT 警署的有关记录 WHERE MADE 所属之地区 DATE FILED 报案日期 POLICE CASE REFERENCE NUMBER 警署之挡案编号 STATEMENT OF CLAIM FOR OVERSEA PROPERTY LOSS/DAMAGE 境外财产损失索赔 申 请 明 细书 DESCRIPTION OF NAME AND ACQUIRED FROM DATE ACQUIRED ORIGINAL COST AMOUNT LOST/DAMAGED ADDRESS OF (NAME AND 购买 日期 OR PRICE CLAIMED PROPERTIES OWNER ADDRESS) 原价 索赔金额 受损物件 之 详细说 姓名及地址 购买店名称和地址 明