AXA China Region Insurance Company (Bermuda) Limited (Incorporated in Bermuda with limited liability)/AXA General Insurance H ong Kong Limited (“AXA”/“The Company”)
( ) ( ) (“AXA ”/“ ”)
23/F, One Kowloon, 1 Wang Yuen Street, Kowloon Bay, Kowloon, Hong Kong 1 23 Page 1/4
AXA China Region Insurance Company (Bermuda) Limited
AXA General Insurance Hong Kong Limited
23/F, One Kowloon, 1 Wang Yuen Street
Kowloon Bay, Kowloon, Hong Kong
(852) 2523 3061
(852) 2810 0706
www.axa.com.hk
Claim procedure: please (1) Complete and sign this form, (2) Prepare the relevant documents listed on
page 4, and (3) Mail them to AXA Office at address above as soon as possible.
TRAVEL INSURANCE CLAIM FORM
Description of Loss/Accident/ Nature of
Illness
*If space is insufficient, please give details in a
separate paper.
Total amount claimed (HKD)
Have you lodged any report with
Police/Airline/Hotel?
If yes, please provide
Name of the Police Station/Airline/Hotel
Date & Time
Reference Number
Do you have any other insurance covering this
loss?
If yes, please provide
Insurance Company
Policy Number
1. POLICYHOLDER INFORMATION
Full Name
Policy No.
3. TRAVEL AND LOSS DETAILS
Travel Period (dd/mm/yyyy)
From To
Date and Time of Loss/Accident
Location
Type of Loss/Accident
Medical Expense
Personal Accident
Baggage and Personal Effects/Personal Money and Travel Documents
Personal Liability/Rental Vehicle Excess
Baggage Delay
Travel Delay, Trip Re-routing, Missed Journey and Overbooking
Loss of Deposit or Cancellation and Curtailment
Others
2. INSURED PERSON/CLAIMANT INFORMATION
Full Name
Email
Correspondence Address
Mobile No.
C-CF-STS
-0318
AXA China Region Insurance Company (Bermuda) Limited (Incorporated in Bermuda with limited liability)/AXA General Insurance H ong Kong Limited (“AXA”/“The Company”)
( ) ( ) (“AXA ”/“ ”)
23/F, One Kowloon, 1 Wang Yuen Street, Kowloon Bay, Kowloon, Hong Kong 1 23 Page 2/4
4. CLAIM PAYMENT METHOD
1. If the claim payment method “Autopay to bank account” is chosen,
a) please provide Insured/Insured Person/Eligible Person/Claimant’s bank account proof showing account holder name and account number ( e.g. copy of bank
book, ATM card or bank statement etc).
b) For Insured/Insured Person/Eligible Person/Claimant who is an individual, only personal banking saving/current accounts will be accepted by AXA China Region
Insurance Company (Bermuda) Limited (Incorporated in Bermuda with limited liability)/AXA General Insurance Hong Kong Limited (“AXA”).
c) For Insured/Insured Person/Eligible Person/Claimant who is a corporate entity, only commercial banking saving/current accounts will be accepted by AXA.
d) AXA will only pay/transfer Hong Kong Dollars to the designated bank account.
e) If the bank transfer payment is rejected, declined or unsuccessful, a cheque will be issued to Insured/Insured Person/Eligible Person/Claimant and posted to
address stated on the claim form instead without further notice.
f) If the claim payment amount is over HKD 20,000, a cheque will be issued to Insured/Insured Person/Eligible Person/Claimant and posted to the address stated
on the claim form.
2. If the claim payments are settled in currencies other than the policy currency(ies), the payment amounts would be subject to change according to the prevailing
exchange rate determined by AXA from time to time. The fluctuation in exchange rates may have impact on the payment amounts. You are subject to exchange rate
risks. Exchange rate fluctuates from time to time. You may suffer a loss of your benefit values as a result of the exchange rate fluctuations.
3. AXA reserves the right to determine the claim payment method at its absolute discretion.
1.
a) ( )
b) ( ) ( ) ( AXA )
c) AXA
d) AXA
e)
f) 20,000
2. AXA
3. AXA
I/WE hereby request and authorize AXA China Region Insurance Company (Bermuda) Limited (Incorporated in Bermuda with limited liability)/AXA General Insurance Hong
Kong Limited to pay benefit due in respect of this claim by (Please “
” the appropriate box to indicate your choice):
( ) ( ) ( “
” )
Cheque (to be drawn in Hong Kong Dollar) ( )
Cheque (To be drawn in Policy Currency which is non-Hong Kong Dollar) ( )
Autopay* to bank account (By HKD and only apply to claim amount not over HKD 20,000) * ( 20,000 )
* Please fill in Part below
Bank Account Information
Name of Bank
Full Name in English of Account
Holder(s)
Bank Account No.
-
-
Bank Code
Branch Code
Account No.
5. PERSONAL INFORMATION COLLECTION STATEMENT
AXA China Region Insurance Company (Bermuda) Limited (Incorporated in Bermuda with limited liability)/AXA General Insurance H ong Kong Limited (referred to hereinafter
as the “Company”) recognises its responsibilities in relation to the collection, holding, processing, use and/or transfer of personal data under the Personal Data (Privacy)
Ordinance (Cap. 486) (“PDPO”). Personal data will be collected only for lawful and relevant purposes and all practicable steps will be taken to ensure that personal data held
by the Company is accurate. The Company will take all practicable steps to ensure security of the personal data and to avoid unauthorised or accidental access, erasure or
other use.
Please note that if you do not provide us with your personal data, we may not be able to provide the information, products or services you need or process your request.
Purpose: From time to time it is necessary for the Company to collect your personal data which may be used, stored, processed, transferred, disclosed or shared by us for
purposes (“Purposes”), including:
1. processing and evaluating any applications or requests made by you for products/ services offered by the Company and our affiliates; 2. providing subsequent services to
you, including but not limited to administering the policies issued; 3. any purposes in connection with any claims made by or against or otherwise involving you in
respect of any products/services provided by the Company and/or our affiliates, including investigation of claims; 4. evaluating your financial needs; 5. designing
products/services for customers; 6. conducting market research for statistical or other purposes; 7. matching any data held which relates to you from time to time for
any of the purposes listed herein; 8. making disclosure as required by any applicable law, rules, regulations, codes of practice or guidelines or to assist in law
enforcement purposes, investigations by police or other government or regulatory authorities in Hong Kong or elsewhere; 9. conducting identity and/or credit checks
and/or debt collection; 10. complying with the laws of any applicable jurisdiction; 11. carrying out other services in connection with the operation of the Company’s
business; and 12. other purposes directly relating to any of the above.
Transfer of personal data: Personal data will be kept confidential but, subject to the provisions of any applicable law, may be provided to:
1. any of our affiliates, any person associated with the Company, any reinsurance company, claims investigation company, your br oker, industry association or federation,
fund management company or financial institution in Hong Kong or elsewhere and in this regard you consent to the transfer of your data outside of Hong Kong; 2. any
person (including private investigators) in connection with any claims made by or against or otherwise involving you in respe ct of any products/services provided by
the Company and/or our affiliates; 3. any agent, contractor or third party who provides administrative, technology or other services (includi ng direct marketing services)
to the Company and/or our affiliates in Hong Kong or elsewhere and who has a duty of confidentiality to the same; 4. credit reference agencies or, in the event of default,
debt collection agencies; 5. any actual or proposed assignee, transferee, participant or sub-participant of our rights or business; and 6. any government department or
other appropriate governmental or regulatory authority in Hong Kong or elsewhere.
AXA China Region Insurance Company (Bermuda) Limited (Incorporated in Bermuda with limited liability)/AXA General Insurance H ong Kong Limited (“AXA”/“The Company”)
( ) ( ) (“AXA ”/“ ”)
23/F, One Kowloon, 1 Wang Yuen Street, Kowloon Bay, Kowloon, Hong Kong 1 23 Page 3/4
6. DECLARATION AND AUTHORISATION
1. I/WE HEREBY DECLARE AND AGREE that (1) all statements and answers to all questions whether or not written by my/our own hand are to the best of my/our knowledge
and belief complete and true; (2) AXA China Region Insurance Company (Bermuda) Limited (Incorporated in Bermuda with limited liability)/AXA General Insurance Hong
Kong Limited (the “Company”) is not bound by and is not required to rely on any statement which I/We may have made to any person if not written or printed here.
2. I/WE, HEREBY AUTHORIZE (1) any employer, medical practitioner, paramedical examiners, hospital, clinic, insurance company, bank, financial institution, police,
government institution, or other organization, institution or person, that has any records or knowledge of me/us to disclose such information to the Company; (2) the
Company or any of its appointed medical examiners, paramedical examiners or laboratories to perform the necessary medical ass essments and tests to evaluate in
relation to this claim. This authorization shall bind the successors of and remains valid notwithstanding death or incapacity. A photocopy of this authorization shall be
as valid as the original.
3. I/WE ACKNOWLEDGE AND CONFIRM that I/we have read and understood the Personal Information Collection Statement (“PI CS”). I/We confirm that I/we have been
advised to read carefully the PICS, and I/we have read it carefully its effect and impact in respect of my/our personal data collected or held by the Company (whether
contained in this application or otherwise). Based on the foregoing, I/we hereby give my/our acknowledgement and agree to the use and transfer of my/our personal
data by the Company in accordance with the PICS.
1. (1) (2)
( ) ( ) (
)
2.
3.
Signature of Insured Person/Claimant Or Signature of Policyholder (if claimant in under 18 years old)
Date (DD/MM/YYYY)
Transfer of your personal data will only be made for one or more of the Purposes specified above.
Access and correction of personal data: Under the PDPO, you have the right to ascertain whether the Company holds your personal data, to obtain a copy of the data, and
to correct any data that is inaccurate. You may also request the Company to inform you of the type of personal data held by i t.
Requests for access and correction or for information regarding policies and practices and kinds of data held by the Company should be addressed in writing to:
Data Privacy Officer
AXA China Region Insurance Company (Bermuda) Limited (Incorporated in Bermuda with limited liability)/AXA General Insurance
Hong Kong Limited
23/F, One Kowloon, 1 Wang Yuen Street, Kowloon Bay, Kowloon, Hong Kong
A reasonable fee may be charged to offset the Company’s administrative and actual costs incurred in complying with your data access requests.
486 (“ ”
1. 2. 3.
4.
5. 6. 7. 8.
9.
10. 11. 12.
1.
2.
3.
4. 5.
6.
AXA China Region Insurance Company (Bermuda) Limited (Incorporated in Bermuda with limited liability)/AXA General Insurance H ong Kong Limited (“AXA”/“The Company”)
( ) ( ) (“AXA ”/“ ”)
23/F, One Kowloon, 1 Wang Yuen Street, Kowloon Bay, Kowloon, Hong Kong 1 23 Page 4/4
(852) 2523 3061
www.axa.com.hk (Claims Section)
axag[email protected]m.hk
7. DOCUMENT CHECKLIST
Below is a list of documents required to proceed with your claim. In certain circumstances, more information may be required to
substantiate the claim.
Type of Claim
Documents Required (Please
against the documents you have submitted)
Basic for all types
Boarding passes, air tickets etc. that confirm the departure and return dates
(Plus) As applicable below
Medical Expenses
Medical Certificate/Medical Report
Original Hospital and Medical Bills/Receipts that show the period of hospitalization
Personal Accident
Medical Certificate/Medical Report
Death Certificate (for death claim)
Baggage and Personal
Effects/Personal Money
and Travel documents
Loss or Damage Report from relevant authorities e.g. police, airline or hotel
Photos showing the extent of damaged
All original Receipts/Warranties
All Exchange Slip/Withdrawal Records
The original replacement receipts for the lost Travel Documents
Personal Liability
Any Correspondence, Summons, Writ in relation to the incident UNANSWERED
Incident report from the relevant authority (e.g. Police report)
Rental Vehicle Excess
A copy of the Insured Person’s International Driving License
Incident Report from the Relevant Authority (e.g. Police report)
Original Payment Receipt for the Rental Vehicle
Original Payment Receipt for the Loss/Damage Charges/Rental Vehicle’s Policy Excess
A copy of the Comprehensive Motor Insurance Policy covering the damaged rental vehicle
Baggage Delay
Confirmation from the Airline/Carrier certifying the number of hour of delay & the reason
of delay
Original Receipts for purchase of essential items
Travel Delay, Trip re-routing,
missed journey and overbooking
Confirmation from the Airline/Carrier certifying the number of hour of delay & the reason
of delay
Loss of Deposit or
Cancellation and Curtailment
Original Receipt for the prepaid of transport cost and accommodation
Confirmation from the Hotel/Travel agent/Airline/Carrier/Certifying the amount of refund
on the unused expenses
8. TRACK YOUR CLAIM STATUS
Once your claim is registered, you will be updated through Email. If you have any query on your claim, please reach us at
AXA is committed to making your Travel insurance claim process as easy and stress-free as possible. Thank you for insuring with us.
We are always glad to be of service.
