SUN HUNG KAI PROPERTIES INSURANCE LTD
Rm2309-16 Sun Hung Kai Centre,
30 Harbour Road, Wanchai, Hong Kong.
Telephone : 2827 8111 Facsimile : 2827 0622
Web Site:http://www.shkpinsurance.com.hk
E-Mail: shkpi@shkp.com.hk
PERSONAL ACCIDENT CLAIM FORM
Claim No.
Policy No.
By furnishing this form the Company makes no admission of liability.
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The claimant must obtain, at his own expense, the following statement from the attending physician (overleaf).
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Itemised bill(s) and relevant report(s) (e.g. accident investigation report, medical report, etc.) must be submitted together with this form in order to avoid delay.
PARTICULARS OF CLAIMANT
Name of claimant
Sex
Home address
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Tel
Present Occupation
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Name and address of Employer
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If the claimant is not the insured, please state the relationship with insured
Age
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PARTICULARS OF ACCIDENT
1.
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Please state date, time and place of accident
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Date
Time
Place
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If the accident happened outside Hong Kong Special Administrative Region, please state purpose of jounrey.
2.
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State exactly how accident occurred.
3.
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Describe the nature of injury
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GENERAL INFORMATION
1.
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Give name and address of Doctor who is or has been in attendance for this injury.
Name
Address
2.
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Is he the Insured's usual medical attendant.
3.
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(Name and address of insurance company and policy number)
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Yes
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No
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I hereby warrant the truth of the above statements and declare that I have not withheld any material information connected with this claim.
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Date
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Signature of Claimant
SUN HUNG KAI PROPERTIES INSURANCE LTD
Rm2309-16 Sun Hung Kai Centre,
30 Harbour Road, Wanchai, Hong Kong.
Telephone : 2827 8111 Facsimile : 2827 0622
Web Site:http://www.shkpinsurance.com.hk
E-Mail: shkpi@shkp.com.hk
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AUTHORIZATION
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I hereby authorize any hospital, physician, or other person who has attended or examined me, to furnish to Sun Hung Kai Properties
Insurance Limited or its authorized representative, any and all information with respect to any illness or injury, medical history, consultation,
prescriptions or treatment, and copies of all hospital or medical records. A Photostat copy of this authorization shall be considered as
effective and valid as the original.
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Place and date
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Signature of Claimant
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ATTENDING PHYSICIAN'S STATEMENT
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Injured Name
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I HEREBY CERTIFY that I personally examined the injuries sustained by the above named in Accident described herein and that the said
injuries are as follows:
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2.
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6.
7.
8.
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Date of treatment
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Date of Admission
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Totally disabled from
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Partial disabled from
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Permanent Disablement (Percentage %)
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Regions injured (please state precisely) *
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Date of Discharge
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Nature and extent of injuries. (If fracture or dislocation state whether complete or incomplete. Was it confirmed by X-ray?)*
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Signature of Attending Physician
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Medical Degree(s)
Address
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(The Attending Physician may issue his own certificate to state the nature and extent of injury)
SUN HUNG KAI PROPERTIES INSURANCE LTD
Rm2309-16 Sun Hung Kai Centre,
30 Harbour Road, Wanchai, Hong Kong.
Telephone : 2827 8111 Facsimile : 2827 0622
Web Site:http://www.shkpinsurance.com.hk
E-Mail: shkpi@shkp.com.hk
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Personal Information Collection Statement
The information you provide to us is collected to enable us to carry on insurance business and bay be used for the purpose of :any insurance or financial related product or service or any alterations, variations, cancellation or renewal of them;
any claim or analysis of it; and
may be transferred to:
any related company or any other company carrying on insurance or reinsurance related business or an intermediary or a claims or
investigation or other service provider providing services relevant to insurance busimess or any association or federation of insurance
companies that exists or is formed from time to time.