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Dismemberment Claim Form (Hong Kong) Mobile App

Use this digital document for filing Dismemberment Claims against the insurance company. Simply fill out all the required details such as the policy number, claimant information, employment particulars, accident particulars, treatment particulars, and more.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Dismemberment Claim Form (Hong Kong) Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Policy Number

  • Ico textbox

    Name of Proposed Insured/Insured

  • Ico textbox

    I.

  • Ico textbox

    Area Code

  • Ico textbox

    Agency/Broker Name

  • Ico textbox

    Agent/Broker Code

  • Ico textbox

    Operations Team

  • Ico textbox

    Agent/Broker’s Name

  • Ico textbox

    Agent/Broker’s Tel.

  • Ico textbox

    Correspondence Address

  • Ico textbox

    Contact Phone No.

  • Ico statictext

    This is a:

  • Ico checkbox

    New Claim

  • Ico checkbox

    Further Claim

  • Ico checkbox

    Review/ Appeal

  • Ico textbox

    Occupation (if more than one, state all) and exactnature of occupational duties before disability.

  • Ico textbox

    Name and address of business or employer.

  • Ico statictext

    Did you file a sick leave certificate with youremployer?

  • Ico checkbox

    Yes

  • Ico checkbox

    No

  • Ico statictext

    Did you submit a claim for workmen’scompensation for this accident?

  • Ico checkbox

    Yes

  • Ico checkbox

    No

  • Ico date

    5. Date you last worked:

  • Ico date

    Date you returned to work (If no, then giveexpected date of return.

  • Ico date

    7.a) Date of accident:

  • Ico time

    Time of Accident

  • Ico textbox

    b) Where and how did it happen?

  • ...and More!

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