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1、 General Documents Required 所需文件 : Certificate of insurance or premium receipt 保險憑證或保費收據 Travel proof, such as air-ticket, boarding pass, travel agent or airlines official receipt 旅遊證明，例如機票、登機証、航空公司或旅行社簽發的收據 Letter from employer/company regarding the nature and duration of trip, if claiming under a
2、corporate travel policy. 雇主發出的公幹證明(商務旅遊保單適用) Copy of bank passbook or card (applicable to HK Bank Transfer) 銀行存摺或提款卡副本 (適用於本地銀行過數)Name of Policyholder (English) 保單持有人姓名(英文)Policy/Certificate No. 保單號碼Name of Policyholder (Chinese) 保單持有人姓名(中文)Name of Insured (Chinese) 受保人姓名(中文)Name of Insured (English
3、) 受保人姓名(英文)Insureds HKID No/Passport No 受保人香港身份証/護照號碼Mobile Phone No. 手提電話號碼Acknowledgement will be sent to this mobile phone number via SMS upon receipt of this form. 本公司將會在收到此索償申請表後發送確認短訊至此手提號碼。E-mail Address 電郵地址 If yes, please provide your social security number 如是，請提供社會保障編號Are you a citizen of
4、the United States? 閣下是否美國公民？ Yes 是 No 否Yes 是 No 否If yes, please provide the details below 如是，請提供以下資料 Name of Insurer 保險公司之名稱Policy No. Policy Type Sum Insured 保單編號 保單類別 保額 Do you have any other insurance policies covering this loss or expenses incurred? 是項索償是否受保於其他保險合約？Yes 是 No 否Office / Home Contac
5、t No. 辦公室或家居電話號碼 Travel Guard Case reference number, if applicable. Travel Guard 檔案編號，如適用。Name of Parent/Legal Guardian (Chinese) Only applicable if the Insured is below the age of 18 父母/合法監護人姓名(中文) 只適用於受保人未滿18歲的情況Name of Parent/Legal Guardian (English) Only applicable if the Insured is below the ag
6、e of 18 父母/合法監護人姓名(英文)只適用於受保人未滿18歲的情況Mailing Address 通訊地址 Parent/Legal Guardians HKID No/Passport No 父母/合法監護人香港身份証/護照號碼Section I - General Information (REQUIRED)第一部份 受保人及一般資料 (必須填寫) 1Policy Category 保單類別 Single Trip Policy 單次旅遊保險單Annual Policy 全年旅遊保險單Journey Period 旅遊日期From由 DD MM YYYY日 月 年To至 DD MM
7、 YYYY日 月 年Bank Code 銀行號碼Branch Code 分行號碼Account Number 戶口號碼Bank Name 銀行名稱Account Holders Name (Must be the Insured or Insureds Parent/ Legal Guardian if the Insured is below the age of 18) 戶口持有人姓名 (必須為受保人或受保人之未滿18歲受保人的父母/合法監護人) :Hong Kong Dollar Cheque 港幣支票We must emphasize that this request is not
8、an admission of our liability. If the claim is eligible, the indemnity shall be payable to the relevant Insured only. 本公司特此聲明此項要求並不代表本公司承認賠償責任。如果索償成功，所有賠償均只可支付予此索償之相關受保人。Hong Kong Bank Transfer 本地銀行過數 We will facilitate payment by HKD cheque delivered to the mailing address if e-mail address is not
9、provided. 如果沒有填寫電郵地址，本公司會以港幣支票作為賠償方式並郵寄往通訊地址。Means of Claim Settlement (Please tick) 賠償支付方式 (請選擇)E-mail Address (if different from above) 電郵地址 (如跟上頁所填寫的不同)Foreign Currency Cheque 外幣支票(Not available for RMB or MYR 不適用於人民幣或馬幣)Please specify the currency preferred 請註明所需外幣 只限港幣戶口，如閣下選擇銀行過數，請填寫電郵地址及提供銀行存
10、摺或提款卡副本HKD account only. Please provide your E-mail Address 2) otherwise for the purpose of administering the insured(s) insurance policy (including pursuing recovery from reinsurers) and 3) for other purposes stated elsewhere in this form.(c) AIG HK may transfer the personal data to the following c
11、lasses of persons (whether based in Hong Kong or overseas) for the purposes identified in (b) above: i) third parties providing services related to the administration of the Insureds policy (including reinsurers); ii) financial institutions for the purpose of processing this application and obtainin
12、g policy payments; iii) loss adjustors, assessors, third party administrators, emergency providers, legal services providers, retailers, medical providers and travel carriers; iv) another member of the AIG group (for all of the purposes stated in (b) ) in any country; or v) other parties referred to
13、 in AIG HKs Data Privacy Policy for the purposes stated therein. (d) The Insured(s)/Claimant(s) may gain access to, or request correction of their personal data (in both cases, subject to a reasonable fee)at any time, by writing to the Privacy Compliance Officer of AIG Insurance Hong Kong Limited at
14、 GPO Box 456 or . The same addresses may be used to contact us with any comments on our service. The full version of AIG HKs Data Privacy Policy can be found at .hk. C. The Insured(s) / Claimant(s) hereby irrevocably authorize:(a) any organization, institution, or individual that has any information
15、, record or knowledge of the Insured(s) health and medical history or any treatment or advice rendered thereto to disclose to AIG HK such information, record and knowledge;(b) AIG HK or any of its approved medical examiners or laboratories to perform the necessary medical assessment and tests to und
16、erwrite and evaluate the Insured(s) health status in relation to the Claims therein and any matter arising therefrom. These tests may include, but are not limited to, tests for cholesterol and related blood lipids, diabetes, liver or kidney disorders, acquired immunodeficiency syndrome (AIDS), infection by any human immunodeficiency virus (HIV), immune disorder or the presence of medications, drugs, nicotine or their met
