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Claim Notification Form - Insurance

Được đăng lên bởi mr-duong
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To

: BAOMINH INSURANCE CORPORATION

Attn

: ……………………………………

Tel

: 848 - 8294180 / Fax: 848 - 8213653

CLAIM NOTIFICATION FORM
Type of Loss

: Please tick appropriate box
Own Property Damage
Bodily Injury of Third Party.
Third Party Property Damage.
Other: ..........................

The Insured

: .........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................

Policy No.

: .........................................................................................................................
.........................................................................................................................

Date and time of Loss

: .........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................

Location of Loss

: .........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................

Person to contact

: .........................................................................................................................
.........................................................................................................................
............................................
To : BAOMINH INSURANCE CORPORATION
Attn : ………………………
Tel : 848 - 8294180 / Fax: 848 - 8213653
CLAIM NOTIFICATION FORM
Type of Loss : Please tick appropriate box
Own Property Damage
Bodily Injury of Third Party.
Third Party Property Damage.
Other: ..........................
The Insured : .........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
Policy No. : .........................................................................................................................
.........................................................................................................................
Date and time of Loss : .........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
Location of Loss : .........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
Person to contact : .........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
Description of : .........................................................................................................................
damage/injury .........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
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Claim Notification Form - Insurance - Trang 2
Claim Notification Form - Insurance - Người đăng: mr-duong
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2 Vietnamese
Claim Notification Form - Insurance 9 10 272