11
QBE SPECIALIST INSURANCE SOLUTIONS CLM.VPCCF.V1-1.2.611 QBE HONGKONG & SHANGHAI INSURANCE LIMITED A member of the worldwide QBE Insurance Group 17/F, Warwick House, West Wing, Taikoo Place, 979 King's Road, Quarry Bay, Hong Kong Tel +(852) 2877 8488 Fax +(852) 3607 0300 www.qbe.com.hk !""#$%&'=!"#$%&'( !"#$% VTV !"#$%&'=NT= ==== +(852) 2877 8488 +(852) 3607 0300 =www.qbe.com.hk QBE-HKSI Claim Form !" Motor Accident Claim !"# Contents A. NOTES ! B. DETAILS OF THE INSURED ! C. DETAILS OF THE INSURED VEHICLE !"# D. DRIVER DETAILS ! E. DRIVING & INSURANCE HISTORY !"#$ F. DAMAGE TO THE INSURED VEHICLE !"#$% G. POLICE REPORT ! H. DETAILS OF THE INJURED PERSON(S) ! I. ACCIDENT DETAILS ! J. OTHER PROPERTY / VEHICLE(S) DAMAGED !"# / K. WITNESS(ES) DETAILS !" L. DECLARATION Claims Hotline !": (852) 2877 8608 Claims Fax !": (852) 3607 0529 CLM.VPCCF.V1-1.2.611

QBE-HKSI Claim Form - Insur-Union · 2011-08-15 · QBE HONGKONG & SHANGHAI INSURANCE LIMITED A member of the worldwide QBE Insurance Group 1 17/F, Warwick House, West Wing, Taikoo

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Page 1: QBE-HKSI Claim Form - Insur-Union · 2011-08-15 · QBE HONGKONG & SHANGHAI INSURANCE LIMITED A member of the worldwide QBE Insurance Group 1 17/F, Warwick House, West Wing, Taikoo

QBE SPECIALIST INSURANCE SOLUTIONS

CL

M.V

PC

CF.

V1

-1.2

.611

Q B E H O N G K O N G & S H A N G H A I I N S U R A N C E L I M I T E D A member of the worldwide QBE Insurance Group17/F, Warwick House, West Wing, Taikoo Place, 979 King's Road, Quarry Bay, Hong Kong Tel +(852) 2877 8488 Fax +(852) 3607 0300 www.qbe.com.hk

�� !""#$%&' =�� !"#$%&'(�� !"#$% VTV�� !"#$%&'=NT=�====�� +(852) 2877 8488 �� +(852) 3607 0300 =www.qbe.com.hk

QBE-HKSI Claim Form �� !"

Motor Accident Claim

�� !"#

Contents��

A. NOTES �� !

B. DETAILS OF THE INSURED �� !

C. DETAILS OF THE INSURED VEHICLE �� !"#

D. DRIVER DETAILS �� !

E. DRIVING & INSURANCE HISTORY �� !"#$

F. DAMAGE TO THE INSURED VEHICLE �� !"#$%

G. POLICE REPORT �� !

H. DETAILS OF THE INJURED PERSON(S) �� !

I. ACCIDENT DETAILS �� !

J. OTHER PROPERTY / VEHICLE(S) DAMAGED �� !"# / ��

K. WITNESS(ES) DETAILS �� !"

L. DECLARATION��

Claims Hotline �� !": (852) 2877 8608

Claims Fax �� !": (852) 3607 0529

CL

M.V

PC

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V1

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.611

Page 2: QBE-HKSI Claim Form - Insur-Union · 2011-08-15 · QBE HONGKONG & SHANGHAI INSURANCE LIMITED A member of the worldwide QBE Insurance Group 1 17/F, Warwick House, West Wing, Taikoo

QBE SPECIALIST INSURANCE SOLUTIONS

CL

M.V

PC

CF.

V1

-1.2

.611

Q B E H O N G K O N G & S H A N G H A I I N S U R A N C E L I M I T E D A member of the worldwide QBE Insurance Group17/F, Warwick House, West Wing, Taikoo Place, 979 King's Road, Quarry Bay, Hong Kong Tel +(852) 2877 8488 Fax +(852) 3607 0300 www.qbe.com.hk

�� !""#$%&' =�� !"#$%&'(�� !"#$% VTV�� !"#$%&'=NT=�====�� +(852) 2877 8488 �� +(852) 3607 0300 =www.qbe.com.hk

A. NOTES �� !

1. All questions must be answered. If not applicable, write "n/a".

�� !"#$%&'()*+,-./�� !"�

2. The issue of this claim form is not an admission of liability by QBE Hongkong & Shanghai

Insurance Ltd.

�� !"#$%&'(%)*+,--./0123456758

3. If there is insufficient space or further comment on any area is considered necessary, please use

additional pages.

�� !"#$%&'()�*+,-./0

4. Please return this claim form together with the following documents:

�� !"#$%&$'()�*+,-.

a) Original letter of authorization duly signed by the driver

�� !"#$%&' (

b) Copy of the insured's (if an individual) HK identity card

�� (�� !) �� !"#$%

c) Copy of driver's HK identity card & driving license

�� !"#$%&'()*+,

d) Copy of vehicle registration documents (both sides)

�� !"#$%(�� !�)

e) Copy of police statement

�� !

5. Any communication including letters, claims, writs, summons and process which the insured and / or

the insured driver receive in any way connected with this accident must be notified and forwarded to

QBE Hongkong & Shanghai Insurance Ltd. immediately upon receipt. You must not respond to any of

them without the written consent of QBE Hongkong & Shanghai Insurance Ltd.

�� / �� !"#$%&'()*+,-./012034056�789:;/<=>?@AB

�� !"#$%%&'()*+,-./!"#$%%&'()*0123456789:-

6. No admission, offer, payment or indemnity shall be made in respect of liability for property damage,

bodily injury or death without the written consent of QBE Hongkong & Shanghai Insurance Ltd.

�� !"#$$%&'()*+,-./0123456789:;<=>?=@ABCD@EF=

�� !"#$

B. DETAILS OF THE INSURED �� !

1. Policy no. �� !" .............................................................................................................................

Cover�� !"

❑ Comprehensive �� !

❑ Third party fire & theft �� !"#$%&

❑ Third party only �� !"#$

❑ Property damage (commercial vehicle) �� !"#$%

2. Name of the insured�� !" ............................................................................................................

1

Page 3: QBE-HKSI Claim Form - Insur-Union · 2011-08-15 · QBE HONGKONG & SHANGHAI INSURANCE LIMITED A member of the worldwide QBE Insurance Group 1 17/F, Warwick House, West Wing, Taikoo

QBE SPECIALIST INSURANCE SOLUTIONS

CL

M.V

PC

CF.

V1

-1.2

.611

Q B E H O N G K O N G & S H A N G H A I I N S U R A N C E L I M I T E D A member of the worldwide QBE Insurance Group17/F, Warwick House, West Wing, Taikoo Place, 979 King's Road, Quarry Bay, Hong Kong Tel +(852) 2877 8488 Fax +(852) 3607 0300 www.qbe.com.hk

�� !""#$%&' =�� !"#$%&'(�� !"#$% VTV�� !"#$%&'=NT=�====�� +(852) 2877 8488 �� +(852) 3607 0300 =www.qbe.com.hk

3. Address�� ......................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

4. Home tel. no. �� !" .................................. Office tel. no. �� !"# ........................................

Mobile tel. no. �� !" ................................. Contact person �� !"# ....................................

Email �� ..........................................................................................................................................

5. Occupation / business �� / �� ......................................................................................................

C. DETAILS OF THE INSURED VEHICLE �� !"#

1. Registration no. �� !"#: ..........................

2. Make of vehicle ��: .................................................... Model ��: ....................................................

3. Engine no. �� !: ..................................................... Engine capacity �� !: ..............................

4. Year of manufacture�� !: ......................................

5. Purpose of use at the time of accident �� !"#$%&'():

Private �� ❑ Commercial �� ❑ Hire �� ❑ Others �� ❑ ..................................................

6. Has the car been modified or altered from the manufacturer's standard specification?

�� !"#$%&'()*+,-./012? YES� ❑ NO� ❑

If "YES", please give details.

��� �� !"#$

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

D. DRIVER DETAILS �� !(Please give details even if the driver is the insured �� !"#$%&'()*+,)

1. Name�� ..........................................................................................................................................

2. Address�� ......................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

3. Home tel. no. �� !" .................................. Office tel. no. �� !"# ........................................

Mobile tel. no. �� !" ................................. Email �� ..............................................................

4. Date of birth �� !"................ / ............... / ............... Gender ��: Male � ❑ Female � ❑

5. Occupation / business �� / �� ......................................................................................................

Position held �� ................................................ Year of service �� !" ...................................

Employer's name �� !" .................................................................................................................

6. Date of the first driving license issued �� !"#$%&'(........... / .......... / ..........

Place of issue �� !" ......................................................................................................................

2

Page 4: QBE-HKSI Claim Form - Insur-Union · 2011-08-15 · QBE HONGKONG & SHANGHAI INSURANCE LIMITED A member of the worldwide QBE Insurance Group 1 17/F, Warwick House, West Wing, Taikoo

QBE SPECIALIST INSURANCE SOLUTIONS

CL

M.V

PC

CF.

V1

-1.2

.611

Q B E H O N G K O N G & S H A N G H A I I N S U R A N C E L I M I T E D A member of the worldwide QBE Insurance Group17/F, Warwick House, West Wing, Taikoo Place, 979 King's Road, Quarry Bay, Hong Kong Tel +(852) 2877 8488 Fax +(852) 3607 0300 www.qbe.com.hk

�� !""#$%&' =�� !"#$%&'(�� !"#$% VTV�� !"#$%&'=NT=�====�� +(852) 2877 8488 �� +(852) 3607 0300 =www.qbe.com.hk

7. Relationship with the insured �� !"#$

❑ Myself �� !"#$% ❑ Friend �� ❑ Employee ��

❑ Relative �� (Relationship ��) .......................................................................................................

❑ Others �� .......................................................................................................................................

8. Did the driver obtain permission from the insured to use the vehicle?

�� !"#$%&'()*+,? YES� ❑ NO� ❑

9. Was the driver under the influence of intoxicating liquor or drugs?

�� !"#$%&'()*+,? YES� ❑ NO� ❑

10. Has the driver paid to / or received from any third party vehicle owner, driver, passenger and / or other

person(s) as compensation to the damaged property and / or bodily injury?

�� !"#$% / �� !"#$%&'()*+),-. / �� !"#$%&'() / �� !

�� !" YES� ❑ NO� ❑

If "YES", please state the amount involved and whom it was paid to / received from, together with a

copy of the relevant receipt / agreement.

��� �� !"#$%&'() / �� !"#$%&'()* / �� !"#$

❑ The driver has paid compensation to the third party �� !"#$%&

Amount �� .......................................

❑ The driver has received compensation from the third party �� !"#$%&'(

Amount �� .......................................

E. DRIVING & INSURANCE HISTORY�� !"#$

1. Was the insured or the driver convicted of any motoring offence or faced with any prosecution pending

during the 3 years immediately before the present accident (except illegal parking) ?

�� !"#$%&'()*+,-./0�123456789:;<.=>?@ABCDEF(�

�� !")�

The insured�� Yes� ❑ No� ❑

Driver�� Yes� ❑ No� ❑

If "YES", please give particulars (including the offence involved and date).

��� �� !"# (�� !"#$!%&)�

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

2. Did the insured or the driver have any accident(s) / loss(es) in connection with any motor vehicle during

the 3 years immediately before the present accident?

�� !"#$%&'()*+,-./$0123456789:&' / ��?

The insured�� Yes� ❑ No� ❑

Driver�� Yes� ❑ No� ❑

If "YES", please give details of the accident, car registration no. and name of insurance company involved.

��� �� !"#$%�&'()*+,-./0123(456

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

3

Page 5: QBE-HKSI Claim Form - Insur-Union · 2011-08-15 · QBE HONGKONG & SHANGHAI INSURANCE LIMITED A member of the worldwide QBE Insurance Group 1 17/F, Warwick House, West Wing, Taikoo

QBE SPECIALIST INSURANCE SOLUTIONS

CL

M.V

PC

CF.

V1

-1.2

.611

Q B E H O N G K O N G & S H A N G H A I I N S U R A N C E L I M I T E D A member of the worldwide QBE Insurance Group17/F, Warwick House, West Wing, Taikoo Place, 979 King's Road, Quarry Bay, Hong Kong Tel +(852) 2877 8488 Fax +(852) 3607 0300 www.qbe.com.hk

�� !""#$%&' =�� !"#$%&'(�� !"#$% VTV�� !"#$%&'=NT=�====�� +(852) 2877 8488 �� +(852) 3607 0300 =www.qbe.com.hk

3. Did any insurance company ever cancel or refuse to renew your motor car insurance, increase your

premium, impose compulsory deductibles, or decline your proposal in the last 3 years?

�� !"#$%&'()*+,-./01234-56789-6:;-<6=;>?@ABCD

�� !?

The insured�� Yes � ❑ No� ❑Driver�� Yes� ❑ No� ❑

If "YES", please state the name of the insurance company and the information of the driver concerned.

��� �� !"#$%&'(%)*+,

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

F. DAMAGE TO THE INSURED VEHICLE�� !"#$%

1. Details of damage�� !

❑ Slight �� ❑ Serious �� ❑ Left� ❑ Right �

❑ Front � ❑ Rear � ❑ Others�� ..................................................

2. For comprehensive cover vehicle, please state �� !"#$%&'(

a) Estimated repair cost �� !"#

(Attach repairer's quotation, if obtained �� !"#$%&'() Amount ��: ...............................

b) Repairer's name, address, tel. no., email address, contact person and reference no.

�� !"#$%#&'#&(# �� !"#$%&

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

c) Is the vehicle at the repairer's premises�� !"#$%? YES� ❑ NO� ❑

If "NO", please state its location.

��� �� !"#$%&'

..........................................................................................................................................................

3. Has the vehicle been detained by the government vehicle examination centre for inspection?

�� !"#$%&'(�)*(�? YES� ❑ NO� ❑

If "YES", please state the centre’s location.

��� �� !"#$%&'(

...............................................................................................................................................................

G. POLICE REPORT�� !

1. At which police station was the accident reported�� !"#$%? ...................................................

2. Police report no. �� !"#: .................................. Date of report�� !: ............./ .........../ ..........

3. Officer's name or his / her no. �� !"#$: ......................................................................................

4. Have you lodged a complaint to the police against the other party / parties?

�� !"#$%&'()%? YES� ❑ NO� ❑

If the other party was at fault, you must lodge a complaint to the police within 10 days of the accident.

�� !"#$%&'() 10�� !"#$%&'

4

Page 6: QBE-HKSI Claim Form - Insur-Union · 2011-08-15 · QBE HONGKONG & SHANGHAI INSURANCE LIMITED A member of the worldwide QBE Insurance Group 1 17/F, Warwick House, West Wing, Taikoo

QBE SPECIALIST INSURANCE SOLUTIONS

CL

M.V

PC

CF.

V1

-1.2

.611

Q B E H O N G K O N G & S H A N G H A I I N S U R A N C E L I M I T E D A member of the worldwide QBE Insurance Group17/F, Warwick House, West Wing, Taikoo Place, 979 King's Road, Quarry Bay, Hong Kong Tel +(852) 2877 8488 Fax +(852) 3607 0300 www.qbe.com.hk

�� !""#$%&' =�� !"#$%&'(�� !"#$% VTV�� !"#$%&'=NT=�====�� +(852) 2877 8488 �� +(852) 3607 0300 =www.qbe.com.hk

H. DETAILS OF THE INJURED PERSON(S) �� !

1. Did the accident involve bodily injury or death?

�� !"#$%&'(? YES� ❑ NO� ❑

If "YES", please state details of all injured persons.

��� �� !"#$%&'(

a) Name �� ....................................................................................................................................

Age �� ........................................................................ Gender ��: Male � ❑ Female � ❑

Position of injury �� !" .............................................................................................................

Extent of injury �� !"❑ Slight�� ❑ Serious �� ❑ Dead��

❑ Coma �� ❑ Fracture�� ❑ Bleeding��

Name of hospital�� !" .............................................................................................................

Relationship with the driver: such as passenger on board of the insured vehicle / other vehicle; pedestrian

�� !"#$%&'() / �� !"#$%&

..........................................................................................................................................................

b) Name �� ....................................................................................................................................

Age �� ........................................................................ Gender ��: Male � ❑ Female � ❑

Position of injury �� !" .............................................................................................................

Extent of injury �� !"❑ Slight�� ❑ Serious �� ❑ Dead��

❑ Coma �� ❑ Fracture�� ❑ Bleeding��

Name of hospital�� !" .............................................................................................................

Relationship with the driver: such as passenger on board of the insured vehicle / other vehicle; pedestrian

�� !"#$%&'() / �� !"#$%&

..........................................................................................................................................................

c) Name �� ....................................................................................................................................

Age �� ........................................................................ Gender ��: Male � ❑ Female � ❑

Position of injury �� !" .............................................................................................................

Extent of injury �� !"❑ Slight�� ❑ Serious �� ❑ Dead��

❑ Coma �� ❑ Fracture�� ❑ Bleeding��

Name of hospital�� !" .............................................................................................................

Relationship with the driver: such as passenger on board of the insured vehicle / other vehicle; pedestrian

�� !"#$%&'() / �� !"#$%&

..........................................................................................................................................................

2. Was / Were the injured person(s) sent to hospital by ambulance?

�� !"#$%&'()* YES� ❑ NO� ❑

3. Was the injured able to walk to the ambulance on his / her own?

�� !"#$%&'() YES� ❑ NO� ❑

The above information is entirely in the opinion of and based only on the observations of the driver

and / or witness of the accident.

�� !"#$%&'( / �� !"#$�%&'()*+

5

Page 7: QBE-HKSI Claim Form - Insur-Union · 2011-08-15 · QBE HONGKONG & SHANGHAI INSURANCE LIMITED A member of the worldwide QBE Insurance Group 1 17/F, Warwick House, West Wing, Taikoo

QBE SPECIALIST INSURANCE SOLUTIONS

CL

M.V

PC

CF.

V1

-1.2

.611

Q B E H O N G K O N G & S H A N G H A I I N S U R A N C E L I M I T E D A member of the worldwide QBE Insurance Group17/F, Warwick House, West Wing, Taikoo Place, 979 King's Road, Quarry Bay, Hong Kong Tel +(852) 2877 8488 Fax +(852) 3607 0300 www.qbe.com.hk

�� !""#$%&' =�� !"#$%&'(�� !"#$% VTV�� !"#$%&'=NT=�====�� +(852) 2877 8488 �� +(852) 3607 0300 =www.qbe.com.hk

I. ACCIDENT DETAILS�� !

1. Date �� ............../ ............../ .............. Time�� .........................................am �� / pm ��

2. Location �� ......................................................................................................................................

3. Speed of the insured vehicle at the time of accident

�� !"#$%&'()*+ ................................ km / hour�� / ��

4. In the driver's opinion, who was at fault�� !"#$%&'()*?

...............................................................................................................................................................

5. Other vehicle(s) involved is / are�� !"#$:

(Please state if there are more than one in the same type of vehicle �� !"#$%&'!, ��

�� )

a) ❑ Private car ��

No. of vehicle �� ............ Make & model �� !"# ...............................................................

Registration no.(s) �� !"#$ ...................................................................................................

b) ❑ Commercial vehicle ��

No. of vehicle �� ............ Make & model �� !"# ...............................................................

Registration no.(s) �� !"#$ ...................................................................................................

c) ❑ Motor cycle ��

No. of vehicle �� ............ Make & model �� !"# ...............................................................

Registration no.(s) �� !"#$ ...................................................................................................

d) ❑ Taxi ��

No. of vehicle �� ............ Make & model �� !"# ...............................................................

Registration no.(s) �� !"#$ ...................................................................................................

e) ❑ Public light bus �� !"#

No. of vehicle �� ............ Make & model �� !"# ...............................................................

Registration no.(s) �� !"#$ ...................................................................................................

f) ❑ Hire ��

No. of vehicle �� ............ Make & model �� !"# ...............................................................

Registration no.(s) �� !"#$ ...................................................................................................

g) ❑ Bus ��

No. of vehicle �� ............ Make & model �� !"# ...............................................................

Registration no.(s) �� !"#$ ...................................................................................................

h) ❑ Tram ��

No. of vehicle �� ............ Make & model �� !"# ...............................................................

Registration no.(s) �� !"#$ ...................................................................................................

i) ❑ Vehicle operated by H.M. Armed Forces ��

No. of vehicle �� ............ Make & model �� !"# ...............................................................

Registration no.(s) �� !"#$ ...................................................................................................

j) ❑ Vehicle operated by HK Government ��

No. of vehicle �� ............ Make & model �� !"# ...............................................................

Registration no.(s) �� !"#$ ...................................................................................................

k) ❑ Others �� .............................................................

No. of vehicle �� ............ Make & model �� !"# ...............................................................

Registration no.(s) �� !"#$ ...................................................................................................

6

Page 8: QBE-HKSI Claim Form - Insur-Union · 2011-08-15 · QBE HONGKONG & SHANGHAI INSURANCE LIMITED A member of the worldwide QBE Insurance Group 1 17/F, Warwick House, West Wing, Taikoo

QBE SPECIALIST INSURANCE SOLUTIONS

CL

M.V

PC

CF.

V1

-1.2

.611

Q B E H O N G K O N G & S H A N G H A I I N S U R A N C E L I M I T E D A member of the worldwide QBE Insurance Group17/F, Warwick House, West Wing, Taikoo Place, 979 King's Road, Quarry Bay, Hong Kong Tel +(852) 2877 8488 Fax +(852) 3607 0300 www.qbe.com.hk

�� !""#$%&' =�� !"#$%&'(�� !"#$% VTV�� !"#$%&'=NT=�====�� +(852) 2877 8488 �� +(852) 3607 0300 =www.qbe.com.hk

6. Please describe how the accident happened �� !"#$%&'(

(This part must be completed even if police statement is attached �� !"#$%&'()*+,-./

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

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...............................................................................................................................................................

...............................................................................................................................................................

7

Page 9: QBE-HKSI Claim Form - Insur-Union · 2011-08-15 · QBE HONGKONG & SHANGHAI INSURANCE LIMITED A member of the worldwide QBE Insurance Group 1 17/F, Warwick House, West Wing, Taikoo

QBE SPECIALIST INSURANCE SOLUTIONS

CL

M.V

PC

CF.

V1

-1.2

.611

Q B E H O N G K O N G & S H A N G H A I I N S U R A N C E L I M I T E D A member of the worldwide QBE Insurance Group17/F, Warwick House, West Wing, Taikoo Place, 979 King's Road, Quarry Bay, Hong Kong Tel +(852) 2877 8488 Fax +(852) 3607 0300 www.qbe.com.hk

�� !""#$%&' =�� !"#$%&'(�� !"#$% VTV�� !"#$%&'=NT=�====�� +(852) 2877 8488 �� +(852) 3607 0300 =www.qbe.com.hk

7. Sketch�� !

Prior to accident�� !"

After accident�� !"

8

Page 10: QBE-HKSI Claim Form - Insur-Union · 2011-08-15 · QBE HONGKONG & SHANGHAI INSURANCE LIMITED A member of the worldwide QBE Insurance Group 1 17/F, Warwick House, West Wing, Taikoo

QBE SPECIALIST INSURANCE SOLUTIONS

CL

M.V

PC

CF.

V1

-1.2

.611

Q B E H O N G K O N G & S H A N G H A I I N S U R A N C E L I M I T E D A member of the worldwide QBE Insurance Group17/F, Warwick House, West Wing, Taikoo Place, 979 King's Road, Quarry Bay, Hong Kong Tel +(852) 2877 8488 Fax +(852) 3607 0300 www.qbe.com.hk

�� !""#$%&' =�� !"#$%&'(�� !"#$% VTV�� !"#$%&'=NT=�====�� +(852) 2877 8488 �� +(852) 3607 0300 =www.qbe.com.hk

J. OTHER PROPERTY / VEHICLE(S) DAMAGED �� !"# /��

1. Name of owner�� !: .......................................................................................................................

2. Address ��: .........................................................................................................................................

...............................................................................................................................................................

.......................................................................................................... Tel. no. ��: .................................

3. Other damaged vehicle / property and name of owner �� !"# / �� �!"#$

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

❑ Registration no. �� !"#: ...............................................

❑ Government property �� !: ......................................

❑ Personal property �� !: ...........................................

4. Please specify the details of damage�� !"#$% ........................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

K. WITNESS(ES) DETAILS �� !"

1. Was / Were there any witness(es) �� !"#$%& YES� ❑ NO� ❑

If "YES", please state the following information.

��� �� !"#$%&

a) Name �� ....................................................................................................................................

Age �� ........................................................................ Gender ��: Male � ❑ Female � ❑

Address�� .................................................................................................................................

..........................................................................................................................................................

Tel. no.�� .................................................. Email�� ...............................................................

Relationship with the driver: such as passenger on board of the insured vehicle / other vehicle; pedestrian

�� !"#$%&'() / �� !"#$%&

..........................................................................................................................................................

b) Name �� ....................................................................................................................................

Age �� ........................................................................ Gender ��: Male � ❑ Female � ❑

Address�� .................................................................................................................................

..........................................................................................................................................................

Tel. no.�� .................................................. Email�� ...............................................................

Relationship with the driver: such as passenger on board of the insured vehicle / other vehicle; pedestrian

�� !"#$%&'() / �� !"#$%&

..........................................................................................................................................................

9

Page 11: QBE-HKSI Claim Form - Insur-Union · 2011-08-15 · QBE HONGKONG & SHANGHAI INSURANCE LIMITED A member of the worldwide QBE Insurance Group 1 17/F, Warwick House, West Wing, Taikoo

QBE SPECIALIST INSURANCE SOLUTIONS

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Q B E H O N G K O N G & S H A N G H A I I N S U R A N C E L I M I T E D A member of the worldwide QBE Insurance Group17/F, Warwick House, West Wing, Taikoo Place, 979 King's Road, Quarry Bay, Hong Kong Tel +(852) 2877 8488 Fax +(852) 3607 0300 www.qbe.com.hk

�� !""#$%&' =�� !"#$%&'(�� !"#$% VTV�� !"#$%&'=NT=�====�� +(852) 2877 8488 �� +(852) 3607 0300 =www.qbe.com.hk

PERSONAL INFORMATION COLLECTION STATEMENT �� !"#$%The information you provide to us is collected to enable us to carry on insurance business and may be used for the purpose of any insurance orfinancial related product or service or any alterations, variations, cancellation or renewal of such product or service; any claim or investigation oranalysis of such claim; and exercising any right of subrogation, and may be transferred to 1) any related company or any other company carryingon insurance or reinsurance related business or an intermediary or a claims or investigation or other service provider providing services relevant toinsurance business for any of the above or related purposes; 2) 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 itsregulatory functions or such other functions that may be assigned to the Federation from time to time and are reasonably required in the interest ofthe insurance industry or any member(s) of the Federation, and 3) any members of the Federation by the Federation for any of the above or relatedpurposes. Moreover, we are hereby authorized to obtain access to and/or to verify any of your data with the information collected by the Federationfrom the insurance industry. You have the right to obtain access to and to request correction of any personal information concerning yourself heldby us. Requests for such access can be made in writing to the General Administration Officer, QBE Hongkong & Shanghai Insurance Limited,17/F, Warwick House, West Wing, Taikoo Place, 979 King’s Road, Quarry Bay, Hong Kong (Telephone: 2877 8488, Fax: 3607 0300)

�� !"#$%&'() !*+,-./%0123456789*+:;-<=">?:@-%:AB>?:@-"78CDEFCE�� !"#$!%&'()!*+'(,-.!/0$!12%&3456789:;<)=>?@ABCNF=�� !"#$%&��'(�� !"#$!"%&'()*+,# !"%&'()-./#01#23#456&789:;<=>?@A#'(B)COF=�� !�� !"#$%&'()*+)*,-./=E��F�� !"#$%&'()*�&�+,-./01234�&056789:&"#,��� !"#$%&'()*+,-.� /012=PF=�� !"#$%&'!"(")*+,-&'./�012(345*6789:�� !"#$%&'()*+,-./012 L�� !"#$%&'!"()*+,-./012345((6!"789%&':(;-�� !"#$�� !"#$%&VTV�� !"#$%&'NT�=E�� OUTT=UQUU�� !"#PSMT=MPMMF=�� !"#$%&'()*

c) Name �� ....................................................................................................................................

Age �� ........................................................................ Gender ��: Male � ❑ Female � ❑

Address�� .................................................................................................................................

..........................................................................................................................................................

Tel. no.�� .................................................. Email�� ...............................................................

Relationship with the driver: such as passenger on board of the insured vehicle / other vehicle; pedestrian

�� !"#$%&'() / �� !"#$%&

..........................................................................................................................................................

L. DECLARATION ��

I / We hereby declare that the foregoing particulars are true in all respects, that I / we have not withheld from

QBE Hongkong & Shanghai Insurance Ltd. any information within my / our knowledge connected with the

accident and that I / we have no other policy indemnifying me / us in respect of this accident. I / We also

understand and agree that the furnishing of this form to me / us by QBE Hongkong & Shanghai Insurance Ltd.

does not constitute a waiver of their rights entitled under the terms and conditions of the policy.

�� / �� !"#$%&'()*+,-./012 / �� !"#$%&''()*+,-./0 / ��

�� !"#$%&'()*+,- / �� !"#$%&'()*+,-./0&'123 / �� !"#

�� ! / �� !"#$%&'()*+,--./01234-567897:;<6=>?@A

Signature of the insured

�� !"

Date

......................................................................................................................�� ............ / ............ / ............

(Please apply stamp if incorporated�� !"#$)

Signature of driver

�� !"

Date

......................................................................................................................�� ............ / ............ / ............

10