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
SUN HUNG KAI PROPERTIES INSURANCE LTD
TRAVEL INSURANCE CLAIM FORM SECTION A
INSURED'S INFORMATION
Name
Correspondence Address
For Office Use Only Date Submitted
Claim Number :
!"#$
%
Mobile/Pager No.
")$%
Fax No.
Home Tel.
&'(
Office Tel.
*+,
E-mail Address
-$%
Policy No.
.
SECTION B
Remarks :
/0 CLAIMANT'S INFORMATION
0 (1
2)
Name of the Claimant (English)
456$%
I.D. Card No.
!"#$%
Mobile/Pager No.
Correspondence Address
7
SECTION C
Plan :
(3 2 )
(Chinese)
Home Tel.
&'(
Office Tel.
89/89:;/<=>
BAGGAGE/BAGGAGE DELAY/ PERSONAL MONEY
',?@ABCDEFGH
Date, time and place of incident
',?@AIJKL
State the occurrence of the incident
/MN
HKD
Amount Claimed
I O P Q Please give particulars of items claimed
R
ST EAUV
Item(s)
Original Cost (HKD)
SWBC
Date of Purchase
X Y R Z [ \ ] ^ _ ` a b (c d e A S Q f D g h i f ` a )
Any other insurance policy covering the items claimed? (e.g. credit card protection plan, householder all risk)
Z Yes
[ No
SUN HUNG KAI PROPERTIES INSURANCE LTD
If yes, please provide the following information.
jZklmno
p Name of insurance Company
q r Class of Insurance
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
- $ % Policy No.
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Please attach the relevant supporting documents to certify the expenses/losses and incident and items of claim e.g.
airlines irregularity report, original police report, original purchase receipts of the items claimed.
st
Remarks
Œ
SECTION D
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MEDICAL EXPENSES AND EMERGENCY SERVICE
',?@ABCDEFGH
Date, time and place of incident
•– / \—˜–
Diagnosis of conditions / Cause
of injury
XY RZ[\]^_`ab
Any other insurance policy covering the expenses involved?
If yes, please provide the following information.
jZklmno
p Name of insurance Company
q r Class of Insurance
Z Yes
[ No
- $ % Policy No.
/MN
™š
HKD
Amount Claimed
Currency
: u y z AŽ€G‡ˆ‰Šn6{/MN‹
st
Remarks : Please attach the relevant medical report and original medical expenses receipts to certify the expenses.
›
SECTION E
œž / Ÿ
œ
CANCELLATION OF TRIP / CURTAILMENT OF TRIP
/˜–
Causes of claims
/M N
HKD
Amount Claimed
8¡p D D $%G
Name, address, phone no. and contact person of Travel Agent
XY RZ[\]^_`ab
Any other insurance policy covering the expenses involved?
If yes, please provide the following information.
jZklmno
p Name of insurance Company
q r Class of Insurance
st
Remarks
:
:
Z Yes
[ No
- $ % Policy No.
u¢yzA2,n6{£¤¥¦A§ G¨©Aª– , c@€D«¬6D ‡ˆ‰Ši‹
Please attach the relevant supporting documents to certify the expenses and incident of claim. e.g. medical report,
death certificate, original receipts of amount claimed etc.
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
SUN HUNG KAI PROPERTIES INSURANCE LTD
­
SECTION F
œ:;
TRAVEL DELAY
BC / EF Date /
Time
® From
˜±EF
Original Schedule
:;²EF
Delayed Schedule
:;˜–
Reason of Delays
XY RZ[\]^_`ab
Any other insurance policy covering the expenses involved?
¯ To
:
:
¹
SECTION G
$% Flight No.
:;³E
Hours Delayed
Z Yes
[ No
If yes, please provide the following information.
jZklmno
pName of insurance Company
q rClass of Insurance
st
Remarks
°
- $ % Policy No.
u¢yzA2,n6{:;EFG˜–, ´c, µ 6G/! ¶·¸ŠD|}!8¡6{di
Please attach the relevant supporting documents to certify the expenses and incident of claim. e.g. boarding pass,
air ticket or certificate issued by the Airline Company or Travel Agent etc.
4¨©
PERSONAL ACCIDENT
',?@ABCDEFGH
Date, time and place of incident
',?@AIJKL
State the occurrence of the
incident
/MN
HKD
Amount Claimed
º€»¼½¾‹Please give particulars of the next of kin(s) of the Insured Person
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zÁ
Name
Age
Address
Relationship
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SECTION H
ÂÃ456$%
HK ID No.
<ÅÆ
PERSONAL LIABILITY
ÇÈ0/A'É
Circumstances of third party
claim
/ M N
HKD
Amount Claimed
XY RZ[\]^_`ab
Any other insurance policy covering the expenses involved?
/0
Name of Claimant
If yes, please provide the following information.
jZklmno
pName of insurance Company
q rClass of Insurance
Z Yes
[ No
- $ % Policy No.
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
SUN HUNG KAI PROPERTIES INSURANCE LTD
Ê
SECTION I
^Ë
OTHER CLAIMS
',?@AIJKL
State the occurrence of the
incident
/MN
Amount Claimed
Ì { G Í Î Ï DECLARATION AND AUTHORIZATION
Š / Ð i Ì { X Y Ñ Ò G ‰ Ó Ô Õ ‹ Š / Ð i Ö Ô × Ø Æ Ù Ú Û ‹ Š /Ð i { Ü ÝÛÞßà‹
I/We declare that the above information is true and complete to the best of my / our knowledge and belief and I / we have not
withheld any material information connected with this claim. I / We understand that the Company can request for more
information.
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^ò lmó5!ôóyzŠAŽåõ€
† G ö ƒ i ‹÷ Í Î Ï G ^ · ¸ Š ø ù
i A ú û‹
I/We 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.
/0ü ý
Signature of Claimant
BC
Date :
ü ý (Ö þ ÿ k c )
Signature of Insured (With company stamp
if appropriate)
BC
Date :
SUN HUNG KAI PROPERTIES INSURANCE LTD
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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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Sun Hung Kai Properties Insurance Limited (the "Company")
Circular to Customers relating to the Personal Data (Privacy) Ordinance
Use of Personal Data
We hereby give you notice that the personal data supplied or to be supplied by you to us in connection with this Policy will be used for:(a)
(b)
(c)
(d)
(e)
(f)
our daily operation, and for our provision of insurance, financial or other services;
processing applications for the issue of insurance policies and their renewal;
providing subsequent services for any insurance policies and other financial products or services;
processing, analyzing and investigating any claim under any insurance policy;
designing and marketing to you or otherwise our products and services; and
facilitating communication between you and us.
The personal data in respect of you and the Insured Person(s), whether supplied by you or collected by us through other means, will be treated with the strictest
level of confidence but may be disclosed to:
(a)
(b)
(c)
(d)
(e)
our employees, agents and intermediaries;
any of our associated, holding, subsidiary or related companies, and any other companies carrying on insurance or reinsurance business;
any of our claims investigation companies, legal advisors, accountants or other service providers;
any association, federation or other organization of the insurance industry; and
any law enforcement agencies under any law binding on us.
Pursuant to the Personal Data (Privacy) Ordinance, you and the Insured Person(s) are entitled to have access to your or the relevant Insured Person's own personal
data which are held by us and/or to correct such data on payment of a reasonable fee to cover our administrative charges and expenses. Such request should be
made in writing with 7-days advance notice to :
Data Privacy Compliance Officer,
Sun Hung Kai Properties Insurance Limited,
2309-16, Sun Hung Kai Centre,
30 Harbour Road,
Wanchai,
Hong Kong.
Thank you for your attention.
March 2000