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CLAIMS HOTLINE è³ å„ Ÿéƒ¨ç†±ç·šï¼š+852 2867 8554 CLAIMS FAX è³ å„ Ÿéƒ¨å‚³çœŸï¼š+852 2530 0481 æ—…é�Šç¶œå�ˆä¿�éšœè¨ˆåŠƒç´¢å„ Ÿè¡¨æ ¼ TRAVELSURE PROTECTION PLAN CLAIM FORM 致： 昆士 蘭ä¿�險 （香港） 有é™�å…¬å�¸ 日期 To : QBE General Insurance (Hong Kong) Limited c/o AXA General Insurance Hong Kong Limited 21/F Manhattan Place 23 Wang Tai Road Kowloon Bay Kowloon Tel 2523 3061 Fax 2530 0481 è«‹å¡« å¦¥æ­¤ç´¢å„ Ÿè¡¨æ ¼ä¸Šä¹‹æ‰€æœ‰è³‡æ–™ã€‚ 倘若表格ä¸�敷應用，請å�¦åŠ ç´™å¼µå¡« 寫 。 Date : Please complete this claim form in full. If space provided for your answers is insufficient, please continue on a separate sheet. 此表格並ä¸�代表本公å�¸æœƒæ‰¿æ“” ä»» 何責任 。 The issue of this claim form is not an admission of liability on the part of the Company. ç´¢å„ Ÿç·¨è™Ÿ Claim number （供本公å�¸å¡« 寫 之用 For office use only） 甲項 ä¿�å–®æŒ�有人資料 SECTION A ä¿�å–®æŒ�有人姓 å�� POLICYHOLDER DETAILS ä¿�單編號 Name of Policyholder 通訊地å�€ Policy number Correspondence address 日間 è�¯çµ¡é›» 話 é›» 郵地å�€ Contact phone number (Day-time) ç´¢å„ Ÿäºº / å�—ä¿�人姓 å��（如 é�žä¿�å–®æŒ�有人） Email address Name of Claimant / Insured Person (if not the Policyholder) 通訊地å�€ Correspondence address 日間 è�¯çµ¡é›» 話 é›» 郵地å�€ Contact phone number (Day-time) Email address 乙項 一般事項 SECTION B 事發日期å�Šæ™‚ é–“ GENERAL INFORMATION （請於é�©ç•¶çš„ 地方加上 ✔ 號 Please ✔ as approprate） Date and time of incident or loss äº‹ç™¼åœ°é» ž Place of incident or loss ä»» ä½•äº‹ç™¼ç›®æ“ Šè€…çš„ 姓 å��和地å�€ Names and addresses of any witnesses to the incident or loss 閣下有å�¦å�‘ è­¦æ–¹æˆ–å…¶ä»–æ©Ÿæ§‹å ±å‘ Šå¤±äº‹æƒ…æ³�？ 有 å�¦ Have the police or other authorities been informed? 如 ç­” 「有ã€�，請æ��ä¾› (a) 報案警署或機構å��稱 name of the Police Station or authority (b) 報案日期å�Šæ™‚ é–“ date & time reported (c) 警方或該機構之檔 案編號 police or authority report number 注æ„�：請æ��供警方 / 航空公å�¸ / è©²æ©Ÿæ§‹ä¹‹æœ‰é—œå ±å‘ Šçš„ 正本。 Yes No If ” Yes”, please provide N. B. Please provide ORIGINAL written report from police, airline, or other authorities as relevant. 是 å�¦ 閣下æ��失之財物是å�¦å�Œæ™‚ å�—其他ä¿�險ä¿�障？ Is there any other insurance covering the loss/damage? 如 ç­” 「是ã€�，請æ��ä¾› (a) ä¿�險公å�¸å��稱 Yes No If ” Yes”, please provide name of the insurance company (b) 有關之ä¿�單號碼 relevant policy number (c) 投ä¿�金 é¡�（如 é�©ç”¨ï¼‰ amount insured (if applicable) (d) 會å�¦å�‘ 該公å�¸æ��å‡ºç´¢å„ Ÿï¼Ÿ 是 å�¦ Whether claim will be submitted to them? ç´¢å„ Ÿäºº / å�—ä¿�人以往有å�¦æ›¾è’™å�—類似性質的 æ��失？ Yes 有 No å�¦ Has the Claimant / Insured Person sustained other losses of similar nature? 如 ç­” 「有ã€�，請æ��供詳細資料 Yes No If ” Yes”, please provide details é �次 Page 1/4 HSI77-R12(YX) 1-4 10/12 E L 丙項 ç´¢å„ Ÿè³‡æ–™ SECTION C CLAIM INFORMATION （請於é�©ç•¶çš„ 地方加上 ✔ 號 Please ✔ as approprate） è«‹å¡« 寫 下列é�©ç•¶çš„ 部份並連å�Œç›¸é—œè­‰æ˜Žæ–‡ä»¶ä¸€ä½µé�žäº¤ã€‚ Please complete the appropriate section(s) below and submit to us all supporting documents. 1. 醫 療 å�Šç›¸é—œè²» 用 或 人身 æ„�外 Medical and Related Expenses 敘述å�—傷或疾病性質å�Šç¨‹åº¦ OR Personal Accident Describe the nature and extent of injuries or sickness 如 涉å�Šç–¾ç—…，閣下是å�¦å°±æœ‰é—œç–¾ç—…在旅é�Šå‰�接å�—é�Žå…¶ä»–醫 ç” Ÿçš„ æ²» 療 ？ 是 å�¦ If sickness is involved, did you receive treatment for this sickness from other doctor before this trip? 如 ç­” 「是ã€�，請æ��供醫 ç” Ÿçš„ 詳細資料 Yes No If ” Yes”, please provide details of the doctor involved 如 涉å�Šæ„�外，請敘述æ„�å¤–ç™¼ç” Ÿç¶“ é�Ž If accident is involved, please describe how the accident happened ç´¢å„ Ÿé‡‘ é¡� Amount claimed 注æ„�：請æ��供所有醫 療 è²» ç”¨æ”¶æ“ šçš„ 正本å�Šæ‰€æœ‰æœ‰é—œé†« 療 å ±å‘ Šçš„ 副本。 N. B. 2. Please provide all ORIGINAL medical receipts together with copy of all relevant medical reports. 或 è¡Œæ�Žå»¶èª¤ 或 個人錢財å�Šæ–‡ä»¶ è¡Œæ�Žå�Šå€‹äººè²¡ç‰© Baggage and Personal Effects 請敘述事發情æ³� OR Delayed Baggage OR Personal Money and Documents Describe how the incident or loss happened 該財物是å�¦é–£ä¸‹å…¨æ¬Šæ“�有？ 是 å�¦ Are you the sole owner of the property? 如 é�¸æ“‡ã€Œå�¦ã€�，請æ��供詳細資料 Yes No If ” No”, please provide details 閣下是å�¦èª�ç‚ ºå…¶ä»–人仕須就此事件或æ��失負責？ 是 å�¦ Can you identify any parties who may be responsible for the incident or loss? 如 é�¸æ“‡ã€Œæ˜¯ã€�，請註 明其姓 å��å�Šåœ°å�€ Yes No If ” Yes”, please provide his/her name and address 財物æ��失 / æ��壞或緊急物å“�購買詳情 Details of property lost or damaged or emergency purchased 物å“�之詳細資料（包括牌å­�å�Šç”¢å“�號碼） Full description of articles (including the brand name & model number) 購買日期 出售物å“�之商號å��稱å�Šåœ°å�€ 購買價錢 ç´¢å„ Ÿé‡‘ é¡� Date of purchase Name and address of the vendor Purchase price Amount claimed ç¸½ç´¢å„ Ÿé‡‘ é¡� Total Amount Claimed 注æ„�：請æ��供以上物å“�çš„ è³¼è²¨æ”¶æ“ šã€�ä¿�用證（如 é�©ç”¨ï¼‰ï¼Œæˆ–é‡�新購回物å“�æ”¶æ“ šä¹‹æ­£æœ¬ï¼Œå�Šç´¢å„ Ÿçš„ æ��壞物å“�相片之正本（如 é�©ç”¨ï¼‰ã€‚ N. B. 3. Please provide ORIGINAL purchase receipts, warranties (if applicable), or replacement receipts of the articles described above. Please also provide ORIGINAL photo(s) showing the extent of damage to the property claimed (if applicable). 個人責任 Personal Liability è«‹æ•˜è¿°äº‹ä»¶ç™¼ç” Ÿæƒ…æ³� Describe how the incident happened 閣下èª�ç‚ ºæ˜¯èª°å°Žè‡´äº‹ä»¶ç™¼ç” Ÿï¼Ÿ In your opinion, who cause this incident? ç¬¬ä¸‰è€…ç´¢å„ Ÿäººçš„ 姓 å��和地å�€ Name and address of third party claimant 請敘述å�—傷或物件æ��壞之性質å�Šç¨‹åº¦ Nature and extent of injuries or damages 注æ„�ï¼šæœ‰é—œç¬¬ä¸‰è€…ç´¢å„ Ÿæ–‡ä»¶ï¼Œè«‹ä¸�è¦�å›žè¦†ä¸¦å„˜æ—©å‘ ˆäº¤äºˆæœ¬å…¬å�¸ã€‚ N. B. 4. Please immediately forward to us all correspondence relating to the third party claim unanswered. 旅程延誤 / 更改行程 Travel Delay / Re-Routing äº‹ç™¼åŽŸå› Cause of the incident Please state the number of hours of delay 注æ„�：請æ��交é�‹è¼¸å…¬å�¸çš„ 書é�¢ç¢ºèª�書，列明延誤的 時 數和延誤的 原因。 HSI77-R12(YX) 2-4 10/12 E L 請列明延誤的 時 數 N. B. Please submit us the carrier’s written confirmation as to the number of hours of delay and the reason of such delay. é �次 Page 2/4 5. æ��失訂 金 或å�–消旅程 或 æ��æ—©çµ�æ�Ÿæ—…程 Loss of Deposit or Cancellation äº‹ç™¼åŽŸå› OR Curtailment Cause of the incident 當閣下決定å�–消行程後，有å�¦å�³æ™‚ 通知航空公å�¸ / æ—…é�‹å…¬å�¸ / æ—…é�Šä»£ç�† / 酒店？（如 é�©ç”¨ï¼‰ 有 å�¦ Have you notified the airline(s) / transportation company(ies) / travel agent(s) / hotel(s) immediately once you found it necessary to cancel the trip? (If applicable) 如 é�¸æ“‡ã€Œå�¦ã€�ï¼Œè«‹åˆ—æ˜ŽåŽŸå› Yes No If ” No”, please provide reason(s) 航空公å�¸ / æ—…é�‹å…¬å�¸ / æ—…é�Šä»£ç�† / 酒店是å�¦å·²é€€å›žæœ‰é—œçš„ 訂 金 或部份待用的 金 é¡�？（如 é�©ç”¨ï¼‰ 是 å�¦ Did the airline(s) / transportation company(ies) / travel agent(s) / hotel(s) refund you any deposit / unused portion of expenses incurred by you? (If applicable) 如 é�¸æ“‡ã€Œæ˜¯ã€�，請列明已退回的 金 é¡� Yes No If ” Yes”, please state the amount refunded 注æ„�：請æ��交如 醫 療 å ±å‘ Šã€�æ­» 亡證ã€�團費 æ”¶æ“ šä¹‹æ­£æœ¬å�Šæ—…行社之證明書等，證明ä¸�能退還 之款項å�Šäº‹ä»¶ç™¼ç” Ÿä¹‹èµ·å› ã€‚ N. B. Please submit us the medical report, certificate of death, original receipts of travel tour, certificate of travel agent, etc. to certify non-refundable expenses and incident of claim. è�²æ˜Žå�ŠæŽˆæ¬Šæ›¸ 本人 / å�¾ç­‰è�²æ˜Žæœ¬äºº / å�¾ç­‰ç�²æœ‰é—œå�—ä¿�人授權代表他 / å¥¹å‘ ˆäº¤æ­¤ç´¢å„ Ÿè¡¨æ ¼ä¸¦ä½œå‡ºä»¥ä¸‹è�²æ˜Žã€‚ 本人 / å�¾ç­‰ï¼Œä¸¦ä»£è¡¨æœ‰é—œå�—ä¿�人，å�Œæ„�æ‰€æœ‰è³ å„ Ÿå°‡æ ¹æ“ šä¿�å–®æ¢�款被 付予有關å�—ä¿�人或其指定å�—益人（被 ä¿�險公å�¸æŽ¥ç´�）或撥作其é�ºç”¢ï¼ˆå¦‚ é�©ç”¨ï¼‰ã€‚ 本人 / å�¾ç­‰ï¼Œä¸¦ä»£è¡¨æœ‰é—œå�—ä¿�人è�²æ˜Žæ­¤è¡¨æ ¼å…§å¡« 報的 資料，就本人 / å�¾ç­‰å�Šæœ‰é—œå�—ä¿�人所知所言，全部正確無訛，並無任 何å�¯ä¿�留。 本人 / å�¾ç­‰ï¼Œä¸¦ä»£è¡¨æœ‰é—œå�—ä¿�人明白公å�¸å�¯ è¦�求 更多資料。 本人 / å�¾ç­‰ç¢ºèª�本人 / å�¾ç­‰å·²ç´°é–±æ˜†å£« 蘭ä¿�險（香港）有é™�å…¬å�¸å�Šå®‰ç››ä¿�險有é™�å…¬å�¸çš„ 收集個人資料è�²æ˜Žï¼ˆ 「通知ã€� ），並知悉å�Šå�Œæ„�有關於本人 / å�¾ç­‰æ–¼æ˜¯æ¬¡ç”³ 請由本人 / å�¾ç­‰æ‰€æ��供的 所有個人資料å�Šå…¶ä»–資料將å�¯èƒ½è¢« æŒ�有ã€�使用ã€�處ç�†æˆ–披 露予有關å�„ 方以用作「通知ã€�上所載的 用途 上。 本人 / å�¾ç­‰ï¼Œä¸¦ä»£è¡¨æœ‰é—œå�—ä¿�人授權æŒ�有本人 / å�¾ç­‰çš„ ä»» 何記錄 （包括任 何已å�–錄 之陳述） 或資料之人士 或團體 ，å�‘ 安盛ä¿�險有é™�å…¬å�¸æˆ–其代ç�†äººï¼Œæ��ä¾›èˆ‡æœ¬ç´¢å„ Ÿäº‹å®œæˆ–與ä¿�險公 å�¸çš„ è¿½å„ Ÿæ¬Šæœ‰é—œä¹‹è¨˜éŒ„ 或資料。 此授權書之影å�°æœ¬å°‡èˆ‡æ­£æœ¬å…·æœ‰å�Œç­‰æ•ˆåŠ›ã€‚ Declaration and Authorisation I/We hereby declare that I/We have been duly authorised by relevant Insured Person to submit this claim form and to make the following declarations. I/We, and on behalf of relevant Insured Person, agree that all indemnity will be paid to relevant Insured Person/ his or her designated beneficiary (as accepted by the Insurer)/ his or her estate (if applicable). I/We, and on behalf of relevant Insured Person, hereby declare that to the best of my and relevant Insured Person knowledge and belief the above statement and particulars contained herein are in all respects true and complete and are made without reservation of any kind. I/We, and on behalf of relevant Insured Person, understand that the Company can request for more information. I/We confirm that I/We have read the Personal Information Collection Statement of QBE General Insurance (Hong Kong) Limited and AXA General Insurance Hong Kong Limited (” Notice”) and acknowledge and agree that all personal data and information with respect to me/us which are provided by me/us in relation to this application may be held, used, processed or disclosed to such parties for such purposes as set out in the Notice. I/We, and on behalf of relevant Insured Person further authorise individual or entity holding any records (including any statements taken) or knowledge of me/us which is/ are relevant to the settling of this claim and/or the Insurer’s rights of recovery thereunder to furnish such records or knowledge to AXA General Insurance Hong Kong Limited or its authorised representatives. A photostat of this authorisation shall be considered as effective and valid as the original. ä¿�å–®æŒ�有人簽署 Signature of Policyholder 日期 ç´¢å„ Ÿäºº / å�—ä¿�人簽署 Date Signature of Claimant / Insured Person é �次 Page 3/4 HSI77-R12(YX) 3-4 10/12 E L Personal Information Collection Statement The information you provide to QBE General Insurance (Hong Kong) Limited and AXA General Insurance Hong Kong Limited (together, the “ Companies” or “ we”) is collected to enable the Companies (whether jointly or severally) and / or any other member of their respective groups (i. e. QBE Group and AXA Group) to carry on business and may be used, stored, processed, transferred or disclosed to and/or shared with individuals, entities and/or organizations for the purposes of: 1. processing and evaluating applications for any insurance products and daily operation of the related services; 2. providing subsequent services to you, including but not limited to administering the policies issued; 3. sales or marketing or any alterations, variations, cancellation or renewal of any insurance and related services; 4. sales or marketing of banking, financial services, provident schemes products or related services of the business partners of the Companies; 5. data matching; 6. any claims or investigation or analysis of such claims; 7. exercising any right under the insurance policy including right of subrogation, if applicable; 8. meeting the requirements under any law and regulation, requests from regulators, industry bodies, government agencies and court order; 9. to conduct research, insurance survey and analysis for the purpose of product design and development; and 10. any purposes relating to the above purposes. The information you provide to the Companies may be provided to the following parties for the purposes set out in the above paragraph: a. entities or organizations associated with the Companies; b. any agent, contractor or third party service provider who provides administrative, telecommunications, computer, payment, debt collection, data processing or storage or related services or any other company carrying on insurance or reinsurance related business, or an intermediary, or a claim or investigation or other service provider providing services relevant to insurance business, for any of the above or related purposes; c. any association, federation or similar organisation of insurance companies (” Federation”) that exists or is formed from time to time for any of the above or related purposes or to enable the Federation to carry out its regulatory functions or such other functions that may be assigned to the Federation from time to time and are reasonably required in the interest of the insurance industry or any member(s) of the Federation; and d. any members of the Federation by the Federation for any of the above or related purposes. e. Fund management companies f. Financial institutions g. Government authorities or regulators; h. lawyers; i. auditors; and j. any party under a duty of confidentiality to the Companies including a group company of the Companies which has undertaken to keep such information confidential Such information may be transferred to a place outside the Hong Kong Special Administrative Region. It is voluntary for you to provide your personal data. However, your personal data is necessary for us to process your application. Moreover, we are hereby authorised to obtain access to and/or to verify any of your data with the information collected by the Federation from the insurance industry. You have the right to ascertain the Companies policies and practices in relation to personal data, obtain access to and to request correction of any personal information concerning yourself held by the Companies subject to payment of an administrative fee. Requests for such access or correction can be made in writing to the Data Protection Officer: QBE General Insurance (Hong Kong) Limited: Suite 1608, 16/F, Devon House, Taikoo Place, 979 King’s Road, Quarry Bay, Hong Kong. Fax: (852) 3607 0391. AXA General Insurance Hong Kong Limited: 21/F, Manhattan Place, 23 Wang Tai Road, Kowloon Bay, Kowloon, Hong Kong. Fax: (852) 2810 0706 If you do not want to receive any sale or marketing of any of the products or services from the Companies, you may also contact our Data Protection Officer . 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