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Important: The insured is requested to 

state as fully and accurately as possible 

the information asked for hereunder and to return this

form immediately to the company via email, 

address: chn.claims@chubb.com. The acceptance 

of this form is not in itself an

admission of liability on the part of the Company.

重要提示: 请索赔人尽可能全面而准确地填写此表格，并返还保险公司（报案邮件地址：chn.claims@chubb.com）。接受本申请表并不表示本公司已承认赔偿责任。

接受本申请表并不表

示本公司已承认赔偿责任。

The Insured 被保险人

Name:

公司名称

Policy No:

保险单号码

Business or Occupation:

业务性质

Address:

地址

Contact Person:

联系人

Tele No.:

电话

Fax No.:

传真

Email:

电邮地址

The Claims Details 索赔详情 ---3 rd Party Liability 第三方责任