创兴雇员赔偿保险意外伤亡报告表（6页）.pdf
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保单号码 Policy No. :
到期日Expiry Date :
被保之僱主
The Insured
Employer
1. 僱主名称 Name of Employer
2. 行业 Nature of Business
3. 地址 Address
4. 电话 Tel. No.
5. 姓名 Name
6. 电话 Tel. No. 年龄Age 性别 Sex
7. 住址 Address
受伤或死亡之僱员
The Injured /DeceasedEmployee
8.已婚或未婚
Whether married or single
9.僱用时订明何种工作
State occupation in which the injured person is employed
10.受伤时担任何种工作
On what work was the injured person engaged at the time of the
accident ？
11.伤者是否直接僱用,否则请列明其判头姓名地址
Is the injured person in your direct employ？ If not, please give Name
and Address of Contractor
12.伤者何时始被僱用
When did the injured person enter your service？
到期日Expiry Date :
被保之僱主
The Insured
Employer
1. 僱主名称 Name of Employer
2. 行业 Nature of Business
3. 地址 Address
4. 电话 Tel. No.
5. 姓名 Name
6. 电话 Tel. No. 年龄Age 性别 Sex
7. 住址 Address
受伤或死亡之僱员
The Injured /DeceasedEmployee
8.已婚或未婚
Whether married or single
9.僱用时订明何种工作
State occupation in which the injured person is employed
10.受伤时担任何种工作
On what work was the injured person engaged at the time of the
accident ？
11.伤者是否直接僱用,否则请列明其判头姓名地址
Is the injured person in your direct employ？ If not, please give Name
and Address of Contractor
12.伤者何时始被僱用
When did the injured person enter your service？
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