责任险索赔申请表（3页）.pdf
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mportant: The insured is requested to state as fully and accurately as possible
the information asked for hereunder and toreturn this form immediately to the
company via email to: 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： ） 。 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 :______________________________________________
Policy No.:_________________________ ________
公司名称 保险单号码
Business or Occupation:________________________________
Address: __________________________________
业务性质 地址
Contact Person: ______________ Tel. No.: _______________
Email: ____________________________________
联系人 电话 电邮地址
Are there any other insurance in force which would cover
this loss in whole or in part?
有无其他有效保险保障此次事故造成的全部或部分损失？
□ Yes(是) □ No(否) If answer is YES, state: 如选‘是’，请告知：
Name of Insurer:______________________________________
Policy Details:______________________________
投保公司名称 投保险种明细
THE ACCIDENT
事故详情
Date & Time: ________________________________________
Location: _________________________________
日期/时间 地点
Describe in detail how it occurred 陈述事故原因和经过
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