Date : 26 June, 2001

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1 Dah Sing Insurance Company Limited (Incorporated in Bermuda with limited liability) 20/F Island Place Tower 510 King s Road, North Point Hong Kong T F E [email protected] MOTOR ACCIDENT REPORT FORM 汽車失事報告表 It is important that a complete answer be given to every question. If insufficient space is provided for your answers, please continue on a separate sheet. 請詳細填報申請表格上每一項目, 若有需要, 請加附頁以完成各項 Insured or Policyholder 保險單持有人 Policy Number 保單號碼 Full Name 姓名 Private Address 住宅地址 Tel No. 電話 Business Address 公司地址 Tel No. 電話 Occupation/Business 商業 / 職業 Vehicle 汽車之細節 Cubic Capacity 馬力 Make/Model 廠名及款式 Year of Make 年份 Carry Capacity 載客人數 Is the vehicle under a hire purchase or loan agreement? 該車輛是否由分期付款或貸款合約下購買? Value before accident 意外前之價值 YES/NO* 是 / 否 If YES, state name of the finance or lending company, their address and agreement number 若是, 請提供有關財務或貸款公司名稱地址及合約號碼 State fully the purpose for which the vehicle was being used. 該車於意外時作為何種用途 Number of trailers attached to the vehicle 該車是否連接有拖車? 如是, 請詳述細節 Value of trailers before accident 意外前之拖車價值 Were goods being carried? 是否載有貨物? If YES, state (a) description 如是, 請 (a) 說明貨品種類 Weight of load on: (a) vehicle 該貨物總重量 : (a) 受保汽車上 (b) owner 物主 (b) trailers 拖車上 Additional Questions for Motor Cycles or Scooters only 如車輛是電單車, 請回答以下問題 Was a sidecar attached? 有否連接側車? Was a pillion passenger being carried? 有否載有乘客? * DELETE AS REQUIRED Page 1 of 4

2 Damage to insured vehicle 保單持有人之車輛損壞情形 What is the extent of damage to the insured vehicle? 保單持有人之車輛損壞情度 Repairer s name 修理廠名稱 Tel. No. 電話 Is the vehicle at the repairers premises? 現該車是否在修理廠? If not, when will it be taken in for repair? 如否, 將會在何時送往修理廠? In all cases where your vehicle is damaged and you are entitled to claim under the policy; please send an estimate for repairs to the Company immediately. 任何情形下, 如閣下打算從由保單獲得賠償, 請附上估價單 Driver 司機之細節 Note: All the questions should be answered, whether or not the Insured was driving. 注意 : 不論保單持有人是否駕駛遇事車輛, 必須回答以下各項問題 Name 姓名 Identity Card No. 身份証號碼 Occupation 職業 Date of Birth 出生日期 Tel. No. 電話 Is the driver employed by you? 司機是否受僱於閣下? Was the vehicle being driven with your permission? 在駕駛該車前, 司機有否徵求閣下同意 Has the driver been convicted for any offence in connection with any motor vehicle? 司機有否曾經觸犯交通條例? If YES, give details including dates 如有, 請寫上事情細節及日期 Has the driver ever been refused motor vehicle insurance or continuance thereof? 司機有否曾經被任何保險公司拒保? Does the driver own a motor vehicle? 該司機是否擁有任何車輛? If YES, give name and address of his insurer as well as the Policy No. 如是, 請寫上其保險公司名稱地址及保單號碼 Was the driver licensed to drive the vehicle? 該司機是否擁有駕駛車輛之執照? If YES, was the licence full / provisional*? 如是, 駕駛執照是正式 / 臨時? How long has the driver held a full licence? 司機擁有正式執照之時間? Licence No. 執照號碼 Expiry Date 到期日 Police 警方 Were particulars taken by or reported to the police? 當時有否警方到場處理此事? If YES, 如有, (a) give name of Station 請註明警署名稱 (b) attach a copy of Police Statement 請附上口供副本 (c) Policy Report No. 警署檔案編號 Has any person been or may any person be charged with any offence arising from the accident? 有否任何人因這次意外受到檢控? If YES, 如有, (a) give name of person 請提供其姓名 (b) offence 所受檢控 Was the driver of the Insured Vehicle tested for alcohol or drugs? 保單持有人之司機有否接受酒精測試? If YES, what was the result? 如有, 請提供測試結果 Page 2 of 4

3 Accident 意外發生情況 Date 日期 Time 時間 A.M./P.M. 上午 / 下午 Place 地點 Weather 天氣情況 Visibility 視野 What lights were lit on the vehicle? 汽車當時亮起何種燈光? Speed (a) before the accident 意外前之車速 Speed limit on the road 該段道路之時速限制為 : (b) at the moment of the accident 意外時之車速 Was the insured in or on the vehicle? 保單持有人是否在車上? YES/NO* 是 / 否 Condition and type of road surface 道路情況 Distance from the nearside at moment of accident 受保車輛與路邊之距離 Meters 米 State fully what happened 請詳述遇事經過 Please sketch below plans of the accident and indicate: 請在下面空白處畫一草圖, 包括 (a) the names and approximate widths of roads 街道名稱及闊度 (b) position and direction of progress (by means of arrows) of all vehicles and persons concerned. 意外中牽涉之車輛及第三者之位置及方向 ( 請用箭咀指明 ) Positions just before the accident 意外發生前之位置 State names and address of all 請在以下各項填上姓名及地址 Positions at the moment of the accident 意外發生時之位置 (a) Passengers 乘客 (b) Independent Witnesses 在場目擊證人 Page 3 of 4

4 Other vehicles involved 第三者之車輛損壞情況 Name 第三者之姓名 Insurers and Policy No. 保險公司名稱及保單號碼 Apparent damage 明顯之損壞情況 Name 第三者之姓名 Insurers and Policy No. 保險公司名稱及保單號碼 Apparent damage 明顯之損壞情況 Other property damaged (apart from vehicles) 第三者之財物損壞情況 Name and address of owner (if know) 物主之姓名及地址 Nature of damage 損壞情況 Name and address of owner (if know) 物主之姓名及地址 Nature of damage 損壞情況 Persons injured 受傷者之情況 Name and address (State whether driver or passenger and in which vehicle or pedestrian) 姓名及地址 ( 請註明是司機乘客或是行人 ) Apparent injuries 明顯受傷程度 Taken to hospital 有否被送往醫院 If a front seat passenger was injured, was he/she wearing a seat belt? 如車頭乘客受傷, 他 / 她有否配戴安全帶 If a motor cyclist or his passenger was injured, was he/she wearing a safety helmet? 如電單車司機或乘客受傷, 他 / 她有否配戴頭盔 Any communications you receive about the accident should not be answered but sent immediately to the Company 如接獲有關任何函件請勿作答, 必須先交來本公司以便採取適當行動 Declaration 聲明 I/We declare that these particulars are true to the best of my/our knowledge and belief. 本人 / 吾等聲明已盡一切能力保証上述各節均屬實情 Signature 保單持有人簽署 I/D No. 身份証號碼 Date 日期 Page 4 of 4

5 LETTER OF CONSENT Date : To Whom it may concern Dear Sir/Madam, Re : Traffic accident on : Involving Driver : Involving Vehicle(s) : I, the undersigned, would hereby give my consent and authorize you to release any relevant information and documentation pertaining to the captioned matter to Dah Sing Insurance Company Limited &/or their representative(s) for claims assessment and investigation. Yours faithfully, Signature : Driver Name : (In Block Letter) HKID / Passport No. : Vehicle Registration No. : Date

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