Dah Sing Insurance Company (1976) Limited

2703, 27/F Island Place Tower

510 King’s Road, North Point
Hong Kong
Tel: 852 2808 5699
Fax: 852 2232 5984
Email: dsiclaim@dahsing.com
Website: www.dahsinginsurance.com

Third Party Liability Insurance – Accident Report Form

第三者責任保險意外報告表
This form should be completed as fully and accurately as possible and returned to The Company immediately whether a claim has been
made on the Insured/Policyholder or not.
投保人／保單持有人不論是否被人要求賠償，請立即全面及並準確地填寫本表格，並遞交到本公司，以便處理。

Insured/Policyholder 投保人／保單持有人

Full Name 姓名 Policy No. 保單號碼

Home Address 住宅地址

Tel No. 電話

Business Address 公司地址

Tel No. 電話

Time and Place of Accident 發生意外之時間及地點

Date (DD/MM/YYYY) 日期 (日/月/年) Time 時間 A.M.上午 / P.M. 下午

Exact Place of Accident 發生意外之地點

When, and by whom was the accident reported to you? 意外事件在何時及由何人通知 閣下？

Are you the owner, lessee, tenant or contractor? 閣下是否物主、承租人、住客或承辦商？

Full Description of the Accident 發生意外之詳情

Cause and Manner of Occurrence

發生意外之起因及情況

Was the Accident due to want of care upon part of injured person? If so, how?

意外事件之發生是否由受傷者之疏忽引致？若是，如何發生？

What right did the injured party have on the premise? 受傷者在意外發生之屋宇有何權利？

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Person Injured 受傷者情況

Full Name 姓名 Address 地址

Nature and extent of Injuries 傷患之性質及程度

If medical aid was rendered, please provide the name and address of doctor. 如曾接受醫藥治療，請提供醫生之姓名及地址

Where were the injured taken? 受傷者現被送往何處？

Damage to Property of Others 損害第三者之財物情形

Name of Owner 物主姓名

Address 地址

Nature and Extent of Damage 損害之性質及範圍

Estimated Cost of Repair 估計修理費用若干

Has claim been made? 是否被要求賠償 ?

Is claimant insured? 要求賠償者是否有購買保險?

If yes, please provide the name of insurance company 如有者，請提供承保之保險公司名稱

Witnesses 證人
Whenever possible, please obtain names and addresses of witnesses, bystanders or people in the immediate vicinity who may have seen
the accident or heard statements made by any of the person involved. (Please use separate sheets if the space is insufficient.) 請盡可能提
供所有證人、旁觀者，或出事地點之目擊者及其他路經意外地點者之姓名及地址（如以下填寫之空間不敷應用，請另紙書寫）

Name 姓名 Address 地址

Policeman if any at the scene of accident 意外發生時有沒有警察在場，如有者，請填寫以下各項

Name of The Policeman 警察姓名

Identity Number of The Policeman 警員號碼

Attached to which police station 警員所屬警署

Dah Sing Insurance Company (1976) Limited 大新保險（1976）有限公司 20210726 Page 2 of 4

 Personal Information Collection Statement (“PIC”) 個人資料收集聲明
1. Purpose: Among the personal data collected from you to Dah Sing Insurance Company (1976) Limited (“Company”), it is collected for the purpose of:
目的： 大新保險（1976）有限公司（「大新保險」）就向 閣下收集之個人資料（「個人資料」）乃為以下目的使用：
i. processing, administering, implementing and effecting the requests indicated in this document or any documents that you may submit to the
Company from time to time; 處理、管理、落實及實行 閣下提交予本公司的本文件或不時提交的任何其他文件中所表明的申請；
ii. providing all services related to this document and the Policy, including promoting or improving such services or related services by the Company or
its subsidiaries and affiliates; 提供與本文件和本保單相關的一切服務，包括推廣或改善本公司或其關聯公司提供的有關本次申請的服務或相關
務；
iii. communicating with you in relation to the administrative purposes; 就行政目的與 閣下聯絡；
iv. investigating, processing and paying claims made under your insurance policy; 調查、處理及繳付 閣下保單的理賠申請；
v. co-operating with any investigation and meeting any disclosure requirements imposed by any legal, regulatory, governmental, tax, law enforcement
or other authorities, or self-regulatory or industry bodies within or outside Hong Kong Special Administrative Region (“HKSAR”);
依照在香港特別行政區境內或境外任何法律、監管、政府、稅務、執法或其他機關，或自律監管機構或行業組織的要求，配合調查及作出披
露；
vi. transferring your Personal Data to any federation or similar organisation of insurance companies (“Federation”) and any members of the Federation
to carry out its regulatory functions and/or in the interest of insurance industry or any members;
閣下的個人資料將發送給任何保險公司聯會或類似組織（「聯會」）以及聯會的任何成員，以供其履行其監管職能及／或為保險行業或聯會
的任何成員的合理利益所需的其他職能；
vii. statistical or actuarial research; 統計或精算研究；
viii. other ancillary purposes which are directly related to the purposes set above. 其他直接與以上目的相關的目的；
The failure of providing the Personal Data by you may result in the Company being unable to provide products and services, assess your policy application,
process claims under insurance policies issued by the Company, or process any other requests, enquiries, or complaints from you.
未能提供所需的個人資料可能導致本公司無法為 閣下提供產品及服務、評估 閣下的保單申請、處理保單索償、或處理任何 閣下提出的要求、
查詢或投訴。
2. Transfer: Personal data provided by you to the Company will be kept in confidential but it may be transferred to parties mentioned below for purposes set
above:
轉移： 閣下提供的個人資料將保密處理，惟會因以上所述之目的將此等資料轉移給以下各方：
i. any related company(ies), including subsidiaries or affiliates of the Company; 本公司的任何成員公司，包括附屬公司及聯屬公司；
ii. any other unrelated company carrying on insurance, financial services intermediaries or reinsurance related business;
任何其他從事保險、金融服務中介團體或再保險相關業務的非本公司成員公司；
iii. financial services intermediaries that are authorised by the Company for the distribution of products and services provided by the Company; 獲本公司
授權以分銷本公司所提供之產品及服務的金融服務中介團體；
iv. a claims, investigation or other services provider providing services relevant to your insurance policies;
提供與 閣下的保單有關 的索償、調查或其他服務的提供者；
v. relevant industry association and federation that exists or is formed from time to time; 現有或不時成立的相關行業協會及聯會；
vi. any person (including agents, contractors or third party service providers) who provides administrative, telecommunications, computer, payment, data
processing or other services in connection with the operation of the Company’s business and provision of products and services to you;

向 閣下提供與本公司產品及服務有關的行政、電訊、電腦、付款、數據處理或其他服務的任何人士（包括代理商、承包商或第三方服務提

供者；
vii. any legal, regulatory, governmental, tax, law enforcement or other authorities, or self-regulatory or industry bodies within or outside HKSAR; 於香港
境內或境外任何法律、監管、政府、稅務、執法或其他機關，或自律監管機構或行業組織；
viii. any third party in connection with a transfer or potential transfer of all or part of the business of the Company that some of the transferees may be
located within or outside of HKSAR; 與本公司業務的轉讓或擬議轉讓有關的任何第三方，當中部分受讓方 或位於香港境內或境外；
ix. Your insurance agents, intermediaries or referrer. 閣下的保險代理人或中介人或介紹人。
3. Access: You have the right to ascertain what type of personal data the Company holds, whether the Company holds your personal data and, if so, the right
to request access to and to request correction of any personal data concerning you held by the Company. Such request can be made to the Data Protection
Officer of the Company at 2703, 27/F, Island Place Tower, 510 King’s Road, North Point, Hong Kong. The Company has the right to charge a reasonable fee
for processing a request to access your personal data access request.
查閱： 閣下有權查明本公司持有個人資料的類別、本公司是否持有 閣下的個人資料，如持有， 閣下有權要求查閱本公司持有涉及 閣下的
個人資料以及要求對該等資料作出更正。 閣下可向本公司的資料保障主任提出要求，地址為香港北角英皇道 510 號港運大廈 27 樓 2703 室。本
公司有權為處理 閣下的個人資料查閱要求而收取合理費用。

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。

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 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 agreed that all personal information about me/us collected by the Company may be held and disclosed within or outside Hong
Kong.
本人／我們已細閱個人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 2703, 27/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 27 樓 2703 室）。
6. I/we hereby agree to authorise 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 authorise The Company or its representative to utilise such information and the like for the purpose of assessing my/our claim. A
photocopy of this authorisation 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 HKID No. Date (DD/MM/YYYY)

投保人簽署 香港身份證號碼
日期 (日/月/年)

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