qbe-hksi claim form - insur-unionqbe specialist insurance solutions qbe hongkong & shanghai...

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

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QBE-HKSI Claim Form �� !"

Travel Claim

�� !

Contents��

A. NOTES �� !

B. DETAILS OF THE INSURED �� !

C. INCIDENT / LOSS / ACCIDENT / ILLNESS DETAILS �� / �� / �� / �� !

D. MEDICAL EXPENSES / PERSONAL ACCIDENT / ADDITIONAL ACCOMMODATION

& TRAVELING EXPENSES �� ! / �� ! / �� !"#$%&

E. DEPOSITS & CANCELLATION CHARGES �� !"#$

F. CURTAILMENT EXPENSES �� !"#

G. BAGGAGE / PERSONAL EFFECTS / TRAVELING DOCUMENTS & PERSONAL

MONEY �� / �� ! / �� !"#$%&

H. TRAVEL DELAY �� !

I. BAGGAGE DELAY �� !

J. PERSONAL LIABILITY �� !

K. DECLARATION & AUTHORIZATION �� !"

Claims Hotline �� !": (852) 2877 8608

Claims Fax �� !": (852) 3607 0530

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A. NOTES �� !

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

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

Insurance Ltd.

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

additional pages.

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4. Please submit this claim form with copy of your ID card / passport. If this is a claim for your children,

please also submit copies of their birth certificates.

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5. If there is more than one claimant but not insured under family cover, please complete another claim form.

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COMPULSORY INFORMATION FOR ALL CLAIMS �� !"#$%

B. DETAILS OF THE INSURED �� !

1. Policy no. �� !: ...............................................................................................................................

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

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

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

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

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

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

Email ��: .............................................................................................................................................

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

6. Occupation / business �� / ��: .........................................................................................................

7. Name of claimant �� !": ...............................................................................................................

8. Relationship with the insured�� !": ..............................................................................................

9. Was / Were there any other insurance policy / policies covering this accident at the time of occurrence?

�� !"#$�%&$'()*+,-+. ? YES� ❑ NO� ❑

If "YES", please give details and amount recovered or recoverable.

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Name of Insurer Policy no. / Claim no. Amount Recoverable /�� !"# �� / �� ! Recovered

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10. Have you made any travel insurance claims previously?

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If "YES", please give details.

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Date of Total Claimed AmountName of Insurer Policy no. / Claim no. Claim and Amount Received�� !"# �� / �� ! �� ! �� !"#$

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If you are insured under an annual travel policy, please answer the following question and return the

form together with copies of boarding passes / air-tickets / e-tickets / passport / other supporting

documents.

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11. Date of departure�� !".........../ .........../ ........... Date of return�� !".........../ .........../ ...........

C. INCIDENT / LOSS / ACCIDENT / ILLNESS DETAILS

�� / �� / �� / �� !

1. Exact place where the incident / loss / accident / illness occurred:

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

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

2. Description of the incident / loss / accident / illness �� / �� / �� / �� !":

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

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

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

3. Any one witness, if any �� !"#$(��):

Name �� ..........................................................................................................................................

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

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

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

Tel. no. �� !" ........................................... Email �� ..............................................................

Relationship with the claimant �� !"#$ ......................................................................................

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ONLY COMPLETE RELEVANT SECTIONS PERTAINING TO YOUR CLAIM

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D. MEDICAL EXPENSES / PERSONAL ACCIDENT / ADDITIONAL

ACCOMMODATION & TRAVELING EXPENSES

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1. The following documents are required in support of your claim. Please tick ( ✓ ) when attached.

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❑ Original medical advice / certificate

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❑ Original admission and discharge slips

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❑ Original hospital / clinic bills and receipts with diagnosis and medicine receipts

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❑ Original additional accommodation and traveling expenses receipts

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❑ Copies of boarding passes / air-tickets / e-tickets / passport / other supporting documents, if you

have any follow-up treatment(s) incurred in Hong Kong

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❑ All other supporting documents, such as laboratory report, X-ray report, and so forth

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2. Nature of injury / illness �� / �� !" .............................................................................................

3. Have you ever suffered from this or similar condition or a recurrence of a previous injury or illness?

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If "YES", please give full details.

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

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

4. Your usual attending physician �� !"#$%&'

Name �� ..........................................................................................................................................

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

Tel. no. �� .................................................. Patient no. �� !" ...............................................

5. Were you hospitalized overseas as a result of this injury or illness?

�� !"#$%&'()*+,-./01 YES� ❑ NO� ❑

If "YES", please state:

�� !:

Date of admission �� !: ........../ ........../ .......... Date of discharge �� !: ........../ ........../ ..........

6. Are you fully recovered? �� !"#$%&'( YES� ❑ NO� ❑

If "NO", please state what treatment(s) that you are now receiving.

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

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

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7. Amount claimed �� !"#$

Medical expenses paid by you �� !"#$%&' HK$ �� ....................................

Additional accommodation and traveling expenses paid by you

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Total amount claimed �� !"#$% HK$ �� ....................................

E. DEPOSITS & CANCELLATION CHARGES �� !"#$


�� !"�#$%&'()*+,-./0� ✓ �� !"#$%&'()

❑ Original tour fare receipt and / or air-ticket fare receipt and / or accommodation expenses receipt

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❑ Original letter from travel agency and / or airline company confirming your trip had been

cancelled and the amount had been refunded by them

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❑ If the cancellation is due to the insured / relative / traveling companion's death or sickness or

injury, please provide us with copies of death certificate or medical advice / certificate with

diagnosis and supporting documents proving the relationship

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2. When was the trip booked? �� !"#$............/ ............/ ............

3. Scheduled departure date �� !"#$............/ ............/ ............

4. Date of trip cancelled �� !"#$............/ ............/ ............

5. Why was the trip cancelled? �� !"#$ .........................................................................................

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

6. Amount claimed �� !"#:

Amount paid by you �� !"#$% HK$ �� ....................................

Amount recoverable from all sources �� !"#$%&' HK$ �� ....................................


F. CURTAILMENT EXPENSES �� !"#


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

❑ Original tour fare receipt and / or air-ticket fare receipt and / or accommodation expenses receipt

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❑ Original additional traveling and accommodation expenses receipt

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❑ If the early return is due to the insured / relative / traveling companion's death or sickness or

injury, please provide us with copies of death certificate or medical advice / certificate with

diagnosis and supporting documents proving the relationship

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❑ Copies of boarding passes / air-tickets / e-tickets / passport / other supporting documents

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2. Scheduled return date �� !"#: ............/ ............/ ............

3. Actual return date �� !"#: ............/ ............/ ............

4. Reason for your early return �� !"#: ...........................................................................................

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

5. Amount claimed �� !"#:

Amount forfeited �� !" HK$ �� ....................................

Additional accommodation and traveling expenses paid by you

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G. BAGGAGE / PERSONAL EFFECTS / TRAVELING DOCUMENTS &

PERSONAL MONEY

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

❑ Original police report or property irregularity report / damage report from the airline company or

hotel confirmation

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❑ Original purchase receipt and replacement receipt

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❑ Copies of bank statement(s) and / or exchange rate slip(s) indicating the withdrawal of cash

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❑ Original repair quotation and / or receipt for the damaged item

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❑ Photo(s) depicting the extent of the damage

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2. Did you report it to the police at the place of loss? �� !"#$%&'()* YES� ❑ NO� ❑

If "YES", please state:

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Address and contact no. of the police station �� !"#$%&'()*

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

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

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

Report no.�� !: .............................................................

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3. Have you lodged a claim or complaint against any carrier / airline or other authority for the loss or

damage to your property?

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If "YES", please give details and attach copies of correspondence.

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

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

Name of carrier / airline �� / �� !"#: .....................................................................................

Claim no. �� !: .................................................

4. a) Please provide details of amount claimed and attach receipt(s):

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Item / Description Place of Date of Original Amount Claimed�� ! Purchase Purchase Purchase Price �� !"#

�� ! �� ! ��

Total �� HK$��

b) Please provide details of amount claimed for replacing traveling documents and attach receipt(s):

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Replacing Traveling Documents Amount Claimed�� !"#$% �� !"#


c) Amount of additional accommodation and traveling expenses

�� !"#$%& HK$ �� ....................................

d) Amount of loss of cash�� !�" HK$ �� ....................................


H. TRAVEL DELAY �� !


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

❑ Original letter from airline confirming the total no. of hours delayed and reason for the delay

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2. Original time, date and place of departure �� !"#$%&'()*

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

Place �� ..........................................................................................................................................

3. Original flight number and airline of departure �� !"#$%&"'()*

Flight no. �� !" ........................................ Airline �� !" ...............................................

4. Actual time, date and place of departure �� !"#$%&'()*

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

Place �� ..........................................................................................................................................

5. Actual flight number and airline of departure �� !"#$%&"'()*


I. BAGGAGE DELAY �� !


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

❑ Original letter from airline confirming the total no. of hours baggage delayed and reason for the delay

�� !�� !"#$%&'��

❑ Original purchase receipt(s) of the essential item(s)

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�� / �� / �� ! / �� / �� !"#$%

2. Original time, date and place of departure �� !"#$%&'()*

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

Place �� ..........................................................................................................................................

3. Original flight number and airline of departure �� !"#$%&"'()*


4. Actual time, date and place of departure �� !"#$%&'()*

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

Place �� ..........................................................................................................................................

5. Actual flight number and airline of departure �� !"#$%&"'()*


6. Please provide details of amount claimed and attach receipt(s):

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Item / Description Place of Date of Original Amount Claimed�� ! Purchase Purchase Purchase Price �� !"#

�� ! �� ! ��


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J. PERSONAL LIABILITY �� !

1. Name of the injured person / third party property owner�� / �� !"#$%

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

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

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

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

3. Tel. no. �� ..................................................

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

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

6. Relationship with the insured�� !"#$%&' .............................................................................

7. Nature and extent of injury �� !"#$% ........................................................................................

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

8. Nature and extent of damage�� !"#$% ....................................................................................

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

9. Is the injured person or owner of the damaged property under your employment, or a relative of you?

�� !"#$$%&'()*+, -./ YES� ❑ NO� ❑

If "YES", please give full details.

�� !"#$

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

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

10. Particulars of witness(es) �� !":

Name Address Tel. no.��

11. Whose negligence caused the accident? �� !"#$%&'( .......................................................

12. Has any claim been made upon you? �� !"#$%&'()* YES� ❑ NO� ❑

If "YES", state detail and attach with this form together with all communication received.

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

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

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

No admission, offer, promise, payment or indemnity shall be made or given by or on behalf of the

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

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COMPULSORY INFORMATION FOR ALL CLAIMS �� !"#$%

K. DECLARATION & AUTHORIZATION�� !"

I declare that the answers given above are true and complete to the best of my knowledge. I understand and agree

that the furnishing of this form to me shall not constitute a waiver by QBE Hongkong & Shanghai Insurance Ltd. of

any of the conditions under the policy.

�� !�� !"#�� !�� !�� !"#$%&�'�� !"#$%

�� !""#$%&'�� !"#$%&'

I hereby authorize any physician, hospital, clinic, insurance company or organization (including my employer),

that has any records or knowledge of the insured person or his / her health, to disclose and make available to

QBE Hongkong & Shanghai Insurance Ltd. or its authorized representative all information and / or documents

about the insured person with reference to the accident, his / her health and medical history and any hospitalization,

advice, treatment, disease or ailment, or attendance record. Such authorization shall survive me and be binding

on my estate in any event even if I may be suffering from any kind of mental incapacity in so far as legally

possible. A photostatic copy of this authorization shall be as effective and valid as the original.

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Signature of the insured / insured person

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Date

...................................................................................................................... ��: ............ / ............ / ............

HK I.D. no.

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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)

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