(852) 2867 8555
Claims Service Hotline
(852) 2830 0481
To avoid any delay in the administration of your
MOTOR ACCIDENT CLAIM FORM claim, it is imperative that each question on this
claim form should be fully answered.
* Mandatory fields
Name Policy No & Cover
Occupation Contact No E-mail Address
Registration No Year of Manufacture Make Model Engine No Chassis No
Purpose of use at time of accident
: N.B. Please submit copies of vehicle registration document (Both sides)
Name Contact No E-mail Address
Correspondence Address Date of Birth
Occupation Relationship with The Owner Identity Card No
Licence No Expiry Date Date Test Passed
Has driver ever been convicted of any driving or motoring offence for the past 3 years? Yes No If "Yes", give details and dates
previously been involved in an accident for the past 3 years? Yes No If "Yes", give details and dates
taken any drugs during 12 hours prior to this accident? Yes No If "Yes", give details
: N.B. Please attach copies of identity card & driving licence
Time pm Speed of insured vehicle immediately prior to accident mph
Give clear account of what happened Diagram
AXA General Insurance Hong Kong Limited
23 21 21/F, Manhattan Place, 23 Wang Tai Road, Kowloon Bay, Kowloon, Hong Kong
(852) 2523 3061 (852) 2810 0706 firstname.lastname@example.org www.axa-insurance.com.hk Page 1/5
In Driver's opinion, who was at fault?
Immediately after the accident, did the insured driver pay or receive any payment to or from the third party?
Yes, paid/received an amount of $ to/from third party No
# delete where inapplicable
Immediately after the accident, did the insured driver has any verbal or written compromise agreement with the third party?
Yes, details No
N.B. Please also provide us with a copy of the written agreement, if any
DAMAGE TO INSURED VEHICLE
Description and extent of damage
Was the vehicle detained for inspection by the police after the accident? Yes No
IMPORTANT : If the vehicle is insured on comprehensive terms, an estimate of repair cost must be submitted to the company before repair are commenced.
Do you intend to claim the repair cost against the company? Yes No
If "Yes", where is the location of the vehicle
Garage/Person and Contact Telephone No
Estimate of Repair Costs $
Name Age Address Injury Name of Doctor/Hospital
DAMAGE TO PROPERTY OF OTHERS
Third Party Vehicle(s) No Vehicle Type
Name of Vehicle/Property Owner
Address Telephone No
Name of third party insurers if known
Give name and contact details of every witness and every other person who was present
In insured vehicle
Name/Number of Officer
Name of Police Station Date and Number of Report
Is any police action being taken against the driver?
SCREENING BREATH TEST RESULT
Yes, conducted. Please provide copy of the test result. Not conducted.
If you receive any communications in any way connected with the accident, please forward them UNANSWERED to the company IMMEDIATELY.
Repair work must NOT be carried out without our authorization.
Send all Summons Letters of Prosecution immediately upon receipt. Please do not answer by yourself.
PERSONAL INFORMATION COLLECTION STATEMENT
" " 486 " "
1. " "
AXA General Insurance Hong 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
Purpose: From time to time it is necessary for the Company to collect your personal data which may be used, stored, processed, transferred or disclosed or
shared by us for purposes, including:
1. offering, providing and marketing the products / services of the Company and / or other companies of the AXA Group ("our affiliates") to you, and
administering, maintaining, managing and operating such products / services. Such products / services may include insurance, banking, provident fund or
scheme, or other financial products / services or other related products / services;
2. processing and evaluating any applications or requests made by you for products / services offered by the Company and / or our affiliates;
3. providing subsequent services to you, including but not limited to administering the policies issued;
4. 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;
5. evaluating your financial needs;
6. designing products / services for customers;
7. conducting market research for statistical or other purposes;
8. matching any data which relates to you from time to time for any of the purposes listed herein;
9. making disclosure as required by any applicable law, rules, regulations, codes of practice or guidelines;
10. conducting identity and / or credit checks and / or debt collection;
11. complying with the laws of any applicable jurisdiction;
12. carrying out other services in connection with the operation of the Company's business; and
13. 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, 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
2. any person 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;
3. any agent, contractor or third party who provides administrative or other 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.
For our policy on using your personal data for marketing purposes, please see the section below "Use of data in direct marketing".
Transfer of your personal data will only be made for one or more of the purposes specified above.
Use of data in direct marketing: The Company intends to provide your personal data including your name and contact details to our affiliates, persons
associated with the Company, reinsurance companies, fund management companies, other financial institutions and third party providers of marketing and
technology in Hong Kong or elsewhere for sending you promotional materials and conducting direct marketing activities in relation to the financial products /
services offered by our affiliates, persons associated with the Company, reinsurance companies, fund management companies, and / or other financial
institutions. If you do not wish to receive direct marketing information or materials, please notify the Company at AXA General Insurance Hong Kong Limited,
21/F, Manhattan Place, 23 Wang Tai Road, Kowloon Bay, Kowloon, Hong Kong in a written form specified by us. The Company shall, without charge to you,
ensure that you are not included in future direct marketing activities.
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 it.
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 Protection Officer
AXA General Insurance Hong Kong Limited
21/F, Manhattan Place, 23 Wang Tai Road
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.
DECLARATION AND AUTHORIZATION
Date (dd/mm/yyyy) Signature of Driver Signature of Insured/Policyholder
with company chop, if any
Letter of Authorization 授權書
Incident on 事故日期: _____________________
Involving vehicle 牽涉車輛: _________________
I, _____________________________, HKID No. _____________ hereby
consent and authorize The Commissioner of Hong Kong Police and /or
other relevant authority(ies) to releasing the statements (including all
relevant parties involved whether rely on or not in respect of subsequent
prosecution), personal data, sketches, MVE Report, brief facts, notes of
proceeding, and all other relevant materials in relation to the subject
accident to the representatives of AXA General Insurance Hong Kong
Limited and/or _____________________________ Solicitors. The copy
of this is as valid as the original.
Signature of driver 司機簽署