团体意外伤害保险索赔申请书

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1、团体意外伤害保险索赔申请书GroupPersonalAccidentInsuranceClaimForm所有问题均须由被保险人/索赔申请人完全回答保单号码AllquestionsmustbeansweredbyInsured/applicantPolicyNo.__________________1.保单持有人名称英文/中文NameofPolicyHolderinfull(English/Chinese)_____________________________________________________________事故人员姓名英文/中文年龄Nameo

2、fPerson(s)involvedintheaccidentinfull(English/Chinese)____________________________________Age_______事故人员地址AddressofPerson(s)involvedintheaccident_______________________________________________________联络电话(日间固定电话)联络电话(手机)Tel.no.(Daytime)_________Mobile_______职业（请详述）身份证号码Occupation(de

3、scribefully)__________________________________________________IdentityCardNo.___2.意外在何时何地发生Whenandwheredidtheaccidentoccur?(a)Date日期______________________________________(b)Time时间___________________________________________________(c)Place地点___________________________________________

4、_______________________________________________________3.请详述意外事故发生经过Howdidtheaccidentoccur?(Pleasestatefully)______________________________________________________________________________________________________________________________________________________________________________

5、___________________________________________________________________________________________________4.受伤部位受伤性质PartofbodyinjuredNatureofinjuryß手handß脚legß扭伤sprainß折骨fractureß烧伤burnß头headß眼eyeß撞伤contusionß割伤lacerationß其它others_______________________ß其它others____________________(请说明plea

6、sespecify)(请说明pleasespecify)5.病假结束后是否复诊?是/否Afterthesickleaves,doyouneedtoattendfollowuptreatment/consultation:Yes/No若然，何时Ifyes,when____________________________________________________________________________________________________6.估计何时完全康复并可继续工作?Whendoyouanticipatebeingabletorecov

7、ercompletelyandresumeyourdutiesorattendtoyourbusiness?___________7.意外发生后首诊医生/医院之名称及地址GivenameandaddressoftheDoctorwhoattendedyou/Hospitalwhichyouwentimmediatelyaftertheaccident___________________________________________________________________________________________________________

8、___8.对本次意外有否向其它保险/社