journeysure travel insurance plan 「智優遊」旅遊保障計劃 · travel delay/cruise...

Dah Sing Insurance Company (1976) Limited

20/F Island Place Tower 510 King’s Road, North Point Hong Kong Tel: 852 2808 5699 Fax: 852 2232 5984 Email:[email protected] Website: www.dahsinginsurance.com

* Please fill in if appropriate 如適用，請填寫

# Please delete as inappropriate 請刪除不適用之項目

Personal Details 個人資料

Certificate/Policy No. :

保險證書／保單號碼

Insured’s Name :

投保人姓名

Insured Person’s Name :

受保人姓名

Relationship with Insured Person*:

與受保人關係*

Ｇender

性別

M／F＃

男／女＃

Date of Birth :

出生日期

DD/ MM/ YY

日/ 月/ 年

Occupation :

職業

Contact Tel. No. :

聯絡電話

Email Address :

電郵地址

Correspondence Address :

通訊地址

Type of Claim 索償類別

Please tick and complete the relevant Section(s) overleaf :

請填妥背頁之索償項目

Basic supporting documents required

索償所需的基本文件

Personal Accident

個人意外

Credit Card Protection

信用咭保障

Itinerary, Boarding Pass or Travel Ticket, Medical Report, Police Report and/or where relevant

行程表、登機證或旅遊票據、醫療報告、警察報告及 /或相關事故報告

Medical Expenses

醫療費用

Itinerary, Boarding Pass or Travel Ticket, Medical Report, Medical Receipts, All Relevant Receipts

行程表、登機證或旅遊票據、醫療報告、醫療費用收據、所有相關的收據

Accidental Death / Compassionate Death Cash Benefit

意外死亡／身故恩恤金

Death certificate, coroner’s report, Police report and/or Incident Report where relevant, Letter of Administration, For disappearance: Supporting Document(s) for the Presumption of Death as proclaimed by court.

死亡證、驗屍報告、警察報告及／或相關事故報告、申請遺產管理書、失蹤個案: 由法庭頒令的推

定死亡證明文件

Personal Belongings

個人財物

Baggage Delay

行李延誤

Itinerary, Boarding Pass or Travel Ticket, Carrier’s /Airlines’/ Cruise’s Written Confirmation, Hotel bill / written confirmation, Police Report, Purchase & Replacement Receipts of the Loss / Damaged Items, Photos of the Damaged item(s), Repair Quotation

行程表、登機證或旅遊票據、客運公司／航空／郵輪公司發出的書面證明、酒店收據／書面確認

書、警察報告、損壞 /遺失物品之重置收據及購買收據、損毀項目的相片、維修報價單

Travel Delay

行程延誤

Itinerary, Boarding Pass or Travel Ticket, Carrier’s /Airlines’ /Cruise’s Written Confirmation, Receipt(s) of Additional Hotel Accommodation and Receipt(s) of Additional Transportation Costs

行程表、登機證或旅遊票據、客運公司／航空／郵輪公司發出的書面證明、額外酒店住宿收據、

額外交通收據

JOURNEYSURE TRAVEL INSURANCE PLAN – CLAIM FORM 「智優遊」旅遊保障計劃 – 索償表格

mailto:[email protected]

Dah Sing Insurance Company (1976) Limited 大新保險（1976）有限公司 of 7

Trip Cancellation

取消行程

Trip Curtailment

縮短行程

Cruise Interruption

中斷郵輪旅程

Itinerary, Boarding Pass or Travel Ticket, Travel Deposit / Payment Receipt, Carrier’s /Airlines’ /Cruise’s Written Confirmation

行程表、登機證或旅遊票據、旅費按金／旅費收據、客運公司／航空／郵輪公司發出的書面證明

Personal Liability

個人責任

Itinerary, Boarding Pass or Travel Ticket, Police Report and / or Incident Report where relevant

行程表、登機證或旅遊票據、警察報告及 /或相關事故報告

Rental Vehicle Excess

租車自負額

Itinerary, Boarding Pass or Travel Ticket, Police Report or Police Statement, Rental Agreement, Receipt from the Rental Car Company (both Rental Receipt & Compensation Receipt), International Driving Permit / Overseas Driving License

行程表、登機證或旅遊票據、警察報告或警方口供紀錄、租貸合約、租車公司發出之收據（租賃

及賠償收據）、國際駕駛執照或海外駕駛執照

Golfer “Hole-in-One”

高爾夫球「一桿入洞」

Itinerary, Boarding Pass or Travel Ticket, Signed Hole-in-one Scorecard / Certificate

行程表、登機證或旅遊票據、已簽署的高爾夫球「一桿入洞」記分卡／證書

Loss of Home Contents

家居物品損失

Itinerary, Boarding Pass or Travel Ticket, Police Report and/or Incident Report where relevant, Colour photo(s) showing the Damaged Properties, Purchase & Replacement Receipts of the Loss / Damaged Items, Repair Quotation

行程表、登機證或旅遊票據、警察報告及／或相關事故報告、顯示財物損毀情況之彩色照片、損

壞／遺失物品之購買及重置收據、維修報價單

If necessary, our Claims representative may ask for additional documents. 如有需要，賠償部代表可能會向閣下要求額外的文件。

Personal Accident/Medical Expenses/Compassionate Death Cash Benefit/Credit Card Protection

人身意外／醫療費用／身故恩恤金／信用咭保障

Amount claimed (please state the currency) 本節總索償額為（請註明貨幣）

1. Date of sickness / injury 患病／受傷日期 DD 日/ MM 月/ YY 年

Time of sickness / injury 患病／受傷時間 DD 日/ MM 月/ YY 年

Place of sickness / injury 患病／受傷地點

2. Diagnosis of sickness / Nature of injury

所患為何種疾病／受傷性質

3. When does the sickness / symptom first appear? / Please describe

how you got injured. 何時首次出現疾病／病徵？／請描述受傷經過

4. Have you ever had such sickness / injury before? If yes, please

state when. 以前有否患過該種疾病／受過同樣傷患？如有，請提供

患過該種疾病／傷患日期

5. Name and address of medical practitioner who attended you immediately following the sickness / injury

於患病／受傷後首次為閣下診治的醫生姓名及地址

6. If hospitalisation is required, please state 如需留院治療，請提供

Date of admission 入院日期 DD 日/ MM 月/ YY 年

Date of discharge 出院日期 DD 日/ MM 月/ YY 年

7. Can you get compensation from other sources for the sickness now you suffered? If “yes”, please state where and how

閣下可否從其他途徑獲取是次患病的醫療費用的賠償？如答案為

「可以」，請提供索取有關醫療費用賠償的途徑及如何取得賠償


8. Name and address of your attending medical practitioner in Hong

Kong 日常替閣下診治的醫生姓名及地址

9.. Further follow up treatment in Hong Kong is required?

是否還需要於香港覆診呢？ Yes 需要 No 不需要

Personal Belongings/Baggage Delay/Loss of Home Contents 個人財物／行李延誤／家居物品

Amount claimed (please state the currency) 本節總索償額為（請註明貨幣）

1. Date of loss/damage 財物遺失／損毀日期 DD 日/ MM 月/ YY 年

Time of loss/damage 財物遺失／損毀時間 a.m. 上午 / p.m.下午

Place of loss/damage 財物遺失／損毀地點

2. Please describe how the loss/damage occurred

請詳述財物遺失／損毀的經過

3. Loss/Damaged Item(s)

遺失／損毀項目

Model No.

型號

Date of Purchase

購買日期

Purchase Value

購入價

Conditions immediately after

the loss/damage

該財物遺失／損毀時之狀況

.

4. Date of loss reported 向警方報告遺失財物日期 DD 日/ MM 月/ YY 年

Time of loss reported 向警方報告遺失財物時間 a.m. 上午 / p.m.下午

Reference No. of the loss reported to the police

警方檔案編號

5. Please give details if you have lodged complaint against any

carriers/airlines/hotels/other parties concerning the

damage/lost 如有就財物遺失／損毀一事向任何客運公司/航

空公司／酒店／有關人士作出投訴，請提供詳情

Travel Delay/Cruise Interruption 行程延誤／中斷郵輪旅程

Amount claimed (please state currency) 本節總索償額為（請註明貨幣）

1. The relevant flight no. and/or tour reference no.

航班編號及／或行程編號

2. Scheduled date of departure 計劃離境日期

Scheduled departure DD 日/ MM 月/ YY 年

Scheduled time of departure 計劃離境時間 a.m. 上午 / p.m.下午

Scheduled place of departure 計劃離境地點

3. Actual departure

Actual date of departure 確實離境日期 DD 日/ MM 月/ YY 年

Actual time of departure 確實離境時間 a.m. 上午 / p.m.下午

4. Reason for the delay/missed departure

行程延誤／啟程誤點的原因

5. Additional Accommodation / Transportation

額外住宿／交通費用

6. Forfeited Travel Expense 損失的旅遊費用


* IMPORTANT – Please furnish us with all correspondence directly relating to the third party claim and do not admit any liability to the third party.

* 重要事項 – 如收到第三者的索償信件，請勿私下向第三者作出任何承擔責任回覆。閣下必須將該等信件呈交本公司。

Rental Vehicle Excess 租車自負額


1. Date of incident 事故發生日期 DD 日/ MM 月/ YY 年

Time of incident 事故發生時間 a.m. 上午 / p.m.下午

Place of incident 事故發生地點

Trip Cancellation/Trip Curtailment 取消行程／縮短行程


1. Name and address of your travel agent 旅行社名稱及地址

2. The relevant flight no. and / or tour reference No.

航班編號及/或行程編號

3. Date of travel arrangement made 訂妥行程日期 DD 日/ MM 月/ YY 年

Date of deposit paid 支付按金日期 DD 日/ MM 月/ YY 年

4. Scheduled departure 預計離境

Scheduled date of departure 預計離境日期 DD 日/ MM 月/ YY 年

Time of departure 預計離境時間 a.m. 上午 / p.m.下午

Place of departure 預計離境地點

5. Actual departure 確實離境

Actual date of departure 確實離境日期 DD 日/ MM 月/ YY 年

Actual time of departure 確實離境時間 a.m. 上午 / p.m.下午

6. Reason for trip cancellation or trip curtailment

取消或縮短行程的原因

7. Can the pre-paid amount be recovered from other sources? If “yes”, please state where and how

已支付的金額可否從其他途徑獲得發還？如答案為「可

以」，請提供要求發還按金的途徑及如何獲得發還按金。

Personal Liability 個人責任

1. Amount claimed (currency) 本節總索償額為（請註明貨幣）

Date of incident 事故發生日期 DD 日/ MM 月/ YY 年

Time of incident 事故發生時間 a.m. 上午／p.m.下午

Place of incident 事故發生地點

2. Full description of incident 請詳述事故的始末

3. Name & address of the third party claimant and other

involved parties 要求索償的第三者或有關人士的姓名及地址

4. Extent of injury/damage caused with estimate on quantum if

possible 請提供第三者的受傷／損失程度。在可能情況，請提

供第三者索償的約數。

5. Please state your own view on liability

請闡述閣下對是次事故責任問題上的意見

6. Has formal claim been received from the third party

claimant? 閣下有否正式收到第三者之索償要求？ Yes 有 No 沒有


2. Full description of incident 請詳述事故的始末

3. Please state your own view on liability

請說閣下對是次事故責任問題上的意見

* Please attach a copy of the police report or police statement (if any) and accident record from rental car company.

* 請附上警察報告記錄或口供紙副本（如有）及租車公司的意外記錄。

General Questions 一般事項

1. Any other insurance covering this incident/loss?

有否其他保險承保是次事件／損失？ Yes 有 No 沒有

If yes, please state name of insurance company

如有，請列明保險公司名稱

Policy No 保單編號

Benefit Type 保障類別

2. Has the claimant ever claimed on any insurance company

for property loss of the same nature?

索償人有否因同樣性質的財物損失向任何保險公司索償？

Yes 有 No 沒有

If yes, please state name of insurance company

如有，請列明保險公司名稱

Golfer “Hole-in-One” 一桿入洞


Date of achievement 獲取成就日期

Time of Celebration 慶祝日期

Place of Hospitality 接待地點


Personal Information Collection Statement (“PICS”) 個人資料收集聲明

The Company will collect, use and disclose my/our personal information (including [credit information and claims history]) for the purposes necessary to

process my/our application, investigate and settle claims and detect and prevent fraud (whether or not relating to the policy issued in respect of this

application).

The Company will transfer personal information to the following persons who may collect and use this information only as reasonably necessary to carry

out the purposes described above: [insurance adjusters, agents and brokers; employers; health care professionals; hospitals; accountants; financial

advisors; solicitors; organisations that consolidate claims and underwriting information for the insurance industry; fraud prevention organisations; other

insurance companies (whether directly or through fraud prevention organisation or other persons named in this paragraph), the police and databases or

registers (and their operators) used by the insurance industry to analyse and check information provided against existing information.]

本公司將收集、使用和披露本人/我們的個人資料（包括[信用資料和以往申索紀錄]），以用作處理本人/我們的申請、調查和結清申索、以及偵測和防止

欺詐行為（無論是否與就此申請而發出的保單有關）所需的目的。

本公司將把個人資料轉移給以下人士，而他們只能在有合理需要履行上述目的之情況下才可收集和使用這些資料：[保險理算人、代理和經紀；僱主；醫護專業人士；醫院；會計師；財務顧問；律師；整合保險業申索和承保資料的組織；防欺詐組織；其他保險公司（無論是直接地，或是通過防欺詐組織

或本段中指名的其他人士）；警察；和保險業就現有資料而對所提供的資料作出分析和檢查的數據庫或登記冊（及其運營者）。]

Amendment to the PICS 個人資料收集聲明的修訂

The Company reserves the right at any time, with or without notice, amends this PICS which will be found in our website or in writing to notify you how

the Company will collect, use and transfers your personal data. Should there be any amendment to this PICS in the future, such amendment will

become effective with immediate effect.

本公司保留權利可隨時且在無須通知的情況下，修訂本個人資料收集聲明，本公司亦可在本公司的網站或以書面形式知會閣下，閣下因而能得悉本公司如何收集閣下的個人資料、如何使用該資料及轉移該資料的情況。任何有關修訂將在刊登後即時生效。


Declaration & Authorisation 聲明及授權

1. I/we hereby declare that the information given above is true and correct to the best of my/our knowledge and believe that all material facts affecting

the assessment of this claim have been disclosed.

本人／我們聲明在本表格內所填報的資料均盡本人／我們所知為屬實及正確，並確信已披露所有足以影響評估本索償的重要事項。

2. I/we have been duly authorised by the person mentioned in this form to make the following declarations for and on his/her behalf.

本人／我們已獲列於本表格上的人士授權代他／她作出以下聲明。

3. I/we have read the PICS and agree that all personal information about me/us collected by the Company may be held and disclosed within or outside

Hong Kong.

本人／我們已細閱個資料收集聲明並同意所有貴公司所收集有關本人/我們的個人資料可在香港或香港以外地區持有及披露。

4. I/we understand that providing the personal data requested on this form is mandatory, and failure to provide all the requested data may mean the

Company is unable to process my/our claim.

本人／我們明白提供本表格上要求的個人資料是必需的，未能提供所需資料可導致貴公司不能處理本人／我們的申請。

5. I/we understand that I/we have the right to seek access to and to request correction of any personal information about me/us held by the Company

by writing to the Data Privacy Officer of the Company at 20/F Island Place Tower, 510 King’s Road, North Point, Hong Kong.

本人／我們明白本人／我們有權查閱及更正任何貴公司持有有關本人／我們的個人資料，並以書面形式通知貴公司的資料私隱主任（地址為香港北角英皇道 510 號港運大廈 20 樓）。

6. I/we hereby agree to authorize any regulator or authority as required or permitted by law, police, Fire Services Department, insurance companies,

any hospitals, physicians, medical practitioners to disclose to The Company or its representative any and all information with respect to the accident

and/or my/our loss. I/we also authorize The Company or its representative to utilize such information and the like for the purpose of assessing

my/our claim. A photocopy of this authorization shall have the same legal effect as the original; and ;

本人／我們現同意授權任何法定的監督或管理機構、警方、消防處、保險公司、任何醫院、醫療專業人士、內外科醫生向貴公司或其代表提供任何一切本人／我們於上述意外及／或本人／我們於上述損失有關的資料記錄。本人／我們亦授權貴公司或其代表可就本人／我們索償的事宜而處理上述資料。本授權書的副本跟正本具有同等法律效力；及

7. I/we understand the issuance or completion of this Claim Form does not constitute admission of liability or guarantee payment of the claim on behalf

of The Company.

本人／我們明白此索償表之發出及填寫並不代表貴公司確認責任或保證賠償。

In the event of any discrepancy between the Chinese and English versions, the English version shall prevail.

如中文版與英文版之間有任何差異，一概以英文版為準。

Signature of Insured 投保人簽署 HKID No. 香港身份證號碼 Date 日期

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