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Tel 852 2827 1883 Fax 852 2802 0018 Web site www. pingan.com.hk TRAVEL INSURANCE CLAIM FORM By Furnishing this form the Company makes no admission of liability. China Ping An Insurance Hong Kong Co. Ltd Incorporated in Hong Kong 138 17 17/F. Allied Kajima Building 138 Gloucester Road Wanchai Hong Kong. A Photostat copy of this authorization shall be considered as effective and valid as original. Place and Date Claimant s Name and Signature CANCELLATION AND CURTAILMENT...
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