汽车索赔表格 (挡风玻璃)
请耐心地填写这个问卷,提供最详细和正确的资料,我们才可以完善地处理您的索赔
Motor Accident Claim Form (Windscreen)
Kindly complete this form and provide detailed and accurate information, so that we can handle your claim effectively
填写表格前,请先准备好以下资料 Please have the following ready before completing the form
事故细节 Info about the incident
您的个人资料 Info about the insured
驾驶者的驾照(照片) Photos of all drivers' licenses
汽车的车牌/行车证 (照片)Photos of registration # / License disc
汽车损毁照片 Photos of all damages
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受保人的资料 Info about the insured
车主/投保人/投保公司的英文姓名 Full name of owner / insured
*
您的联络号码 Your contact number
*
-
您的电邮地址 Your email address
*
example@example.com
您的ID/护照号码 Your ID/passport number
*
汽车品牌和型号 Car make & model
*
汽车还能开,不会造成更多损毁?Can the car be driven without causing further damages?
*
是 Yes
不是 No
哪个窗户坏了 Which window is damaged ?
*
正面 Front
后窗 Back
前驾驶员侧 Front driver side
后驾驶员侧 Back driver side
前排乘客侧 Front passenger side
后乘客侧 Back passenger side
Other
现在汽车的所在地址 Current location of your car
*
行车证或注册证书照片 Photo of License Disc or Registration Certificate
*
上载 Upload
Cancel
of
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驾驶者的资料 Info about the driver
驾驶者的英文姓名 Full name of the driver
驾驶者的联络号码 Contact number of the driver
-
驾驶者的驾照 Driver's license
上载 Upload
Cancel
of
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事故资料 Info about the incident
事发日期 Date of the incident
*
事发时间 Time of the incident
*
事发地點 Place of the incident
*
道路状况 Road condition
*
晴天 Clear sky
下雨 Rainy
大雾 Misty
黑暗 Dark
事发经过的详细内容 Detailed description of the incident
*
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照片 Photos
汽车损毁照片(可以选择多个档案) Photo of damages (multiple selection allowed)
*
上载多个档案 Upload multiple files
Cancel
of
其他相关资料(例如维修报价) Other relevant info (e.g. repair quote)
上载多个档案 Upload multiple files
Cancel
of
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宣言和签名 Declaration & signature
我在此确认以上资料正确无误,如果还有其他对保障有影响的额外资料,我会尽快提供给我的保险顾问和公司。I hereby declare the foregoing particular to be true in every aspect. If there are additional information that may have a material impact on the policy, I will inform my advisor and insurer as soon as possible
受保人的签名 Signature by the insured
提交 Submit
Should be Empty: