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1、HSI85-R5(YX) 1-4 12/15 E 頁次 Page 1/4 信用卡購物保障計劃賠償申請表 CREDIT CARD PURCHASE PROTECTION PLAN CLAIM FORM 根據保單條款，此賠償申請表應詳細填妥並簽署，及遞上表格背面所列之相關索償文 件，以免延緩索償進程。 According to Policy Conditions, this form should be fully completed and signed, and the relevant claim documents listed overleaf be furnished, to avoi
2、d delay in claim process. 任何失物必須於四十八小時內向警方報案並索取警方報告書。 Any loss of property must be reported to the Police within 48 hours and a report obtained. 呈遞此賠償申請表，並不表示公司承擔賠償責任。 By furnishing this form the Company makes no admission of liability. 日期 Date: 甲項甲項 持卡人資料持卡人資料 SECTION A CARDHOLDERS INFORMATION 姓名 N
3、ame: 性別 Sex 職業 Occupation 香港身份證護照號碼 HKID Card/Passport No. 信用卡號碼 Credit Card No. 流動電話號碼 Mobile Phone No. 地址 Address 電郵地址 E-Mail Address 乙項乙項 索償資料索償資料 SECTION B CLAIM INFORMATION 失物損毀日期 Date of Loss/Damage 時間 Time 地點 Place 失物損毀之詳細經過 Detailed Circumstances of Loss/Damage 1. 有否向警方報案 Has Police been rep
4、orted? 是 Yes 否 No 若然，何區警署 If yes, which Police Station 報案日期 Date reported 案件編號 Case No. 2. 持卡人是否失物損毀物品之唯一主人 Is Cardholder the sole owner of lost/damaged property? 是 Yes 否 No 3. 是否有其他保險保障該物品 Are there any other insurances upon the same property? 是 Yes 否 No 若有，請列明其他保險公司名稱 If yes, please state name of
5、insurance company 4. 持卡人過去有否遭遇同樣性質之損失 Has Cardholder sustained losses of the same nature before? 是 Yes 否 No 若有，請詳述之 If yes, please give full particulars 5. 持卡人過去有否因同樣性質之損失向任何保險公司索償 Has Cardholder ever claimed on any insurance company for loss/damage of same nature? 是 Yes 否 No 若有，請列明保險公司名稱 If yes, pl
6、ease state name of insurance company 6. 持卡人是否已經重新購置失物損毀物品 Has Cardholder already replaced the lost/damaged property? 是 Yes 否 No 7. 索償數目 港幣 Amount claimed HK$ HSI85-R5(YX) 1-4 12/15 E 頁次 Page 2/4 丙丙項項 收取賠償款項方式收取賠償款項方式 SECTION C PAYMENT MODE 在保單條款許可情況下，閣下可選擇以銀行轉賬或支票方式收取賠償款項。一般情況下，選擇銀行轉賬收取賠償款項較支票快 3-5
7、個工作天。如閣下沒有選擇收取賠償款項方式，將會視作選擇以支票收取賠償款項。 Subject to the terms and conditions of your policy, you may select to receive the claim payable amount by way of direct credit or cheque. Normally, you will receive payment 3 5 working days earlier if you choose the direct credit option. If you do not provide pa
8、yment preference, a cheque will be issued for any claim payment. 銀行轉賬重要事項 Important Note for Direct Credit a. 有關之賠款將按其保單條款，存入該受保人名下之銀行賬戶。請確保賬戶號碼及賬戶持有人名稱正確，以免引致不必要 之延誤。 The claim payment shall be credited to the bank account in the name of the Insured Person in accordance with the terms and condition
9、 of your policy. To prevent any unnecessary delay, please make sure the bank account number and account holder name are correct. b. 如索償人提供之銀行賬戶號碼及 / 或戶口持有人名稱不正確，而導致本公司錯誤將賠款存至第三者戶口，無論有關賠款 能否取回，本公司無任何責任再支付該賠款及其引致之相關銀行手續費用。 If the claim payment is remitted to a third party as a result of your provision
10、 of incorrect bank account number and/or account holder name, we shall not be liable to make any further payment and any other additional banking handling charges regardless of whether the claim payment can be recovered. 選擇(一） Option (1) 銀行轉賬 By direct credit 只限港幣戶口 for HKD account only 請提供相關銀行資料 Pl
11、ease provide your bank account details 銀行名稱 Bank Name : 恒生銀行 Hang Seng Bank 其它，請列明 Others, please specify 賬戶持有人姓名(英文及大楷寫) Name of Account Holder (in English 2. administering your insurance policy and providing services in relation to your insurance policy; 3. any alterations, variations, cancellatio
12、n or renewal of any insurance and related services; 4. investigating, analyzing, processing and paying claims made under your insurance policy; 5. invoicing and collecting premiums and outstanding amounts from you; 6. exercising any right under the insurance policy including right of subrogation, if
13、 applicable; 7. complying with the requirements under any law and regulation, industry codes, guidelines, requests from regulators, industry bodies, government agencies and court order. 8. contacting you for any of the above purposes; 9. other ancillary purposes which are directly related to the abo
14、ve purposes; The information you provide to the Company may be provided or transferred to the following parties in Hong Kong or overseas for the purposes set out in the above paragraph: a. any agent, advisor, contractor or third party service provider who provides administrative, telecommunications,
15、 computer, payment, debt collection, security, data processing or storage or related services or any other company carrying on insurance or reinsurance related business, or an intermediary, or a claim or investigation or other service provider providing services relevant to insurance business, for a
16、ny of the above or related purposes; b. any association, federation or similar organization of insurance companies (“Federation“) that exists or is formed from time to time for any of the above or related purposes or to enable the Federation to carry out its regulatory functions or such other functions that may be assign
