责任险索赔申请表（3页）.pdf

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