Insurance Department letter[2006]78No.

2006Years6Month19Day

Motor vehicle traffic accident liability compulsory insurance

Underwriting, claims practice rules points

First chapter Underwriting practice rules

 

The first section Explanation and informAn insurer to the insured, the provisions, fulfill the specific explanation obligation

(a) to the insured to the terms, including: the insurance liability, the limitation of compensation, liability exemption, the insured obligations, the insured obligations, claims processing etc..

Special exemptions to the responsibility, to explain it clearly to the applicant.

(two) clearly to the applicant for motor vehicle traffic accident liability compulsory insurance (hereinafter referred to as the compulsory insurance) sub limit of indemnity.

(three) explain it clearly to the applicant, insured in accordance with the health administrative department of the State Council shall formulate a traffic accident staff trauma clinical guidelines and national basic medical insurance for medical expenses standard audit.

(four) inform the insured do not duplicate insuranceCompulsory insurance,Even if the insured more than one can only get a guarantee.

(five) to remind the vehicle windshield policyholders will insurance mark affixed to the windscreen on the upper right corner; motorcycle, tractor driver to carry.

(six) inform the insured how to query the illegal behavior, traffic safety, traffic accident records.

Two, to remind policyholders to perform such obligation

(a) the applicant must provide the following information.

1For the first time, insurance compulsory insurance, insured shall provide the insured motor vehicle driving license and driving license copy.

2For the renewal, business, the applicant needs to provide the strong insurance to pay the original insurance policy or other proof of written documents last year has strong risk of the insured to pay. Before the establishment of the traffic accident responsibility compulsory insurance information platform area, the applicant cannot provide the motor vehicleThe previous year traffic safety violations,Traffic accidentRecordThe insurer is not given, the corresponding preferential rates; establishment of traffic accident liability compulsory insurance information platform area, the corresponding floating rate according to the information platform of recorded information.

(two) requirementsThe insured on important matters to perform such obligation.

Important issues include the following contents:

1Vehicle type, brand, model, identification code, the license plate number, the nature of the use of;

2, the motor vehicle owner or manager's name (name), gender, age, address, ID card or driver's license number (organization code);

3,Before the renewal of motor vehicleTraffic safety violations,Traffic accidentRecords and other matters affecting rate level (cross strong insurance to implement the first year need not provide);

4,The China Insurance Regulatory CommissionOther matters prescribed.

(three) request the applicant to provide telephone, address, zip code, to provide insurance services for the insurer.

(four) cross strong insurance contract, the insured shall timely return of insurance mark insurance, insurer verification (if signs of damage as long as identifiable, can write off.

The second section Application form fill in the

One, the insurer should guide correctly fill in the application form the applicant, insured single species, motor vehicle shall at least contain label type, identification code, number, the nature of the use, the insured motor vehicle owner or the manager's name (name), gender, age, residence, ID card or driver's license number (organization code), and renewed the insured motor vehicle traffic safety violations, traffic accident records and other matters affecting rate level.

Two, request the applicant to fill in all the information is true, cross strong insurance insured single accurately, and sign or seal in the proposalform.

Three, the applicant to provide data copy pasted on the application form on the back.

After four, during the period of insurance must be insured in the insurance application date, before the start of the insurer is not liable for compensation during the period of insurance.

During the period of insurance, compulsory insurance for the five1Years, but one of the following circumstances, the applicant may insure short-term insurance:

(a) the overseas motor vehicle temporary entry;

(two) the vehicle from the deadline less than a year;

(three) the vehicle traveling on the road temporarily (for example: a temporary license plate of motor vehicle, the temporary car, to use the registration of newly purchased motor vehicles);

(four) other circumstances stipulated by circ.

 

The third section The insurance fee calculation

One, the insurer must be in accordance with the motor vehicle traffic accident liability compulsory insurance premium of the China Insurance Regulatory Commission approval scheme (hereinafter referred to as the rate of compulsory insurance scheme), the premium calculation.

TwoShort term insurance, insurance premium, calculated according to short-term monthly rate.

Three, the premium must be a full charge, no stage charge.

Four, in addition toThe rate of compulsory insurance scheme CIRC approvalIn the approach to floating ratesThe provisions of the concessions, the insurer shall not give the insured any return, discount and extra benefits.

Floating mechanism five, insurance premium and the insured motor vehicle traffic violations, accident record linked after execution, the insurance company shall calculate upon completion of insurance premium, insurance certificate, issued by the "motor vehicle traffic accident liability compulsory insurance rate floating notification to the applicant" (Annex A), by the insured signature after the confirmation, and then issue insurance policy, insurance mark.

Traffic accidents including identified by the traffic administrative department of the public security traffic accident, and not by the traffic administrative department of the public recognition, but the insurer has in cross strong insurance under the liability accident.

 

The fourth section Insurance certificateOf insurance mark

One, the insurer must collect insurance before the insurance certificate, insurance mark.

Two, the policy must develop a separate insurance policy number and the business processing system issued by the.

Three, cross strong insurance must be separately issue insurance policy, insurance mark, invoice. The insurance policy, the insurance mark must use the CIRC producer cross strong insurance policy, insurance, commercial insurance documents shall not be used to replace.

Four, the applicant for insurance to pay strong insurance policy, insurance marks are damaged or lost to re submit the application, the insurer shall submit application and report after receiving the certificate of5The completion of the audit work days, the corresponding replacement cross strong insurance policy, insurance mark;And through the business system to print a policy of insurance, the insurance mark, printing water number new insurance policy, insurance mark with the original insurance policy number can through the system query to the corresponding relationship.

Five,For the distributed business motorcycle, farm tractor business can use the quota policy. The quota policy manual can be a single, but must be issued in the insurance policy after7Working days, accurate record to the business processing system.

The transport type tractor does not use the quota policy.

 

The fifth section Insurance contract modificationAnd termination

One, the insurer terminates the contract. The applicant fails to perform the duty of disclosure of important matters, the insurer to terminate the contract, shall notify the applicant, the insured shall, from the date of receipt of the notification5Days to perform such obligation; the insured in the period to fulfill the duty of disclosure, the insurer may not terminate the contract.

The insurer terminates the contract, the insurer shall recover the insurance, the insurance mark, and notify the administration departments of motor vehicles.

Two,Except the following circumstances, may not accept insured cancelling the contract application:

(a) the insured motor vehicle is in accordance with the cancellation of registration;

(two) the insured motor vehicle shall stop;

Three.The insured motor vehicle by public security authorities confirmed loss;

Four.Repeated insurance policy holders of compulsory insurance.

For the termination of the contract procedures, the applicant must provide proof of the corresponding materials, the insurer shall recover the cross strong insurance policy, insurance mark, may apply for compulsory insurance refund procedures, and notify the administration departments of motor vehicles.

 

Remove the insured because of duplicate insurance compulsory insurance contract, only to terminate the insurance during the period in the back of the insurance contract, the insurer refund insurance contract period at the back of the insurance fee, loss by up stage in front of the insurance contract for compensation.

Three, the following items, the insurer shall insurance policy in correcting, and according to the alterations to increase or decrease the insurance premium:

(a) the insured motor vehicle resell, transfer, gift for others;

(two) by change the use of the insurance of motor vehicles;

(three) to change other matters.

No correction of the insurance period.

The correction according to the daily rate of increase or decrease the insurance premium.

Four, any of the following circumstances, the insurer shall insurance policy in correcting, and in accordance with the policy year re approved insurance premium collection:

(a) the insured non disclosure of important matters,The insurance fee calculation influenceUnder the policy, and caused the annual re approved insurance premiums rise;

(two) in the duration of insurance contract, the insured motor vehicle for refitting, install, use nature changes lead to increase in the degree of risk, the insurer is not notice in a timely manner, and not to revise procedures.

 

The second chapter Claim practice rules

 

The first section Report of cases and claims to accept

One, from the insured or the victims of a report, should be asked about the situation, and immediately inform the insured or the matters related to the specific compensation procedures.

Involving casualties or accidents party failed to cover the risk of strong, should remind the parties involved in the accident report to the local traffic management departments to immediately.

A detailed record of two, the insurer shall report the situation, and a unified archive management.

Three, the insured motor vehicle traffic accidents, shall be borne by the insured to the insurer for the compensation insurance. The insurer shall, upon receipt of an application for compensation1Working days, to claim for writing and inform the insured need to provide insurance and compensation of the relevant proofs and materials. The insurer shall, after receiving the insured to provide evidence and information on the date of5Working days, making the decision of whether to liability insurance, and will notify the insured; do not belong to the insurance liability, it shall make a written explanation; on the part of the insurance liability, and the insured reached a compensation agreement10Working days to pay the insurance money.

The claim notice must be popular, easy to understand, and according to the actual case check the following and compensation of the relevant proofs and materials:

Claim letter, motor vehicle traffic accident liability compulsory insurance policy original, traffic accident responsibility confirmation, mediation, a simple accident, traffic accident processing agreement by negotiation, court rulings, the verdict, judgment, mediation, arbitration, vehicle damage, vehicle repair invoices, loss of property list, hospital to prove the diagnosis, medical fee reimbursement vouchers, prove that delays and income, disability certificate, death certificate, be dependent proof materials, household registration certificate, motor vehicle driving license, driving license, the insured person to receive indemnity proof of identity, identity.

 

The second section The survey and assessment

A,The motor vehicle insurance accident in a client report, the responsibility of surveying, the loss will be.

An estimated loss of two, more than any one accident compulsory insurance indemnity, should remind the parties for the division of responsibilities according to the law of accident.

Three, the accident involving multiple insurance people, but there are one or more insurers could not surveying cases,Failed to carry out surveying insurer, may entrust other insurers to surveying.Entrusted by the insurer, the insured shall submit to the client to provide survey report, accident/Confirmation loss of picture and losses.Loss of a vehicle a confirmation letter, signed by the parties and confirmed by accident.

 

The third section Advance and recovery

A,The conditions of rescue expenses paid in advance

(a) conforms to the "motor vehicle traffic accident liability compulsory insurance regulations" twenty-second article of the cases;

(two) receivedThe traffic control department of the public security organ for advance notice;

(three) the victim must rescue, and salvage cost has already occurred, rescue hospital rescue bill and the details of the project;

(four) is not by the road traffic accident social rescue fund pays rescue expenses.

Two,Advanced standard

(a)In accordance with theTraffic accident staff traumaClinical guidelinesAnd save the national basic medical insurance standards, in the strong insurance to pay for medical expenses limit or not responsible for medical expenses limit pays rescue expenses;

(two) the number of rescued treatment in different hospitals in one person and, in medical expenses limit or not responsible for medical expenses limit according to the number of capitation; can also according to the hospital and police advice, as appropriate, within limit adjustment.

Three,Pay the way

The traffic police department issued upon receipt of written notification, the medical advance/To prove the diagnosis, rescue expenses documents and detailed date, time to rescue the victim commitment issued by the hospital "pays rescue expenses guarantee", or the special account shall be transferred to the rescue cushion payment hospital opened in the bank, no cash payment.

Four, recovery

For all the cases in advance, the insurer has the right to advanceToHarmer recovery. Compensation income after deduction of the legal expenses (costs, legal fees, execution fees), to recover costs, reducing the payment in full.

 

The fourth section Treatment of claim

One, the principle of compensation

The insurer is liable to indemnify the damage to the victim caused by traffic accident of motor vehicle insurance in insurance liability within the scope of.

Two,The rescue expenses paid

The traffic accident to liability insurance, for rescuing the victims to the insurer to pay the rescue expenses, the insurer after receiving written notice and medical institutions the traffic administrative department of the public security organs issued by the rescue bill, payment standard and payment according to the provisions of section third of the second chapter two or three practical execution.

The traffic accident insurance does not belong to the responsibility or by the road traffic accident social rescue fund pays rescue expenses will be paid, the insurer is not.

Three, reparations computation

(a) the insured in the insurance to pay strong partial compensation within the limit of compensation to the victim, calculate casualties, property loss.

The basic formula for the:

Total loss=Sigma partial loss amount=The death and disability claims+The medical expenses claims+The loss to the property of reparations

Partial loss amount=Each approved the amount of loss

The partial loss exceeds the amount approved sub limit of indemnity, compensation according to the calculation of each sub limit of indemnity.

(two) the following cases, the insurer compensation calculated in the following way:

1More than two vehicles, two vehicles and motor vehicle traffic accident compensation.

(1Traffic management departments of uncertain) insurance accident vehicle borne by the parties in insurance liability under, compensation in the following manner.

Each approved the amount of loss=The traffic accident by each item all victims insurance vehicle outside the approved amount of loss and / (N-1)

NThe number of traffic accident of motor vehicle.

(2) traffic management departments have been identified in the motor vehicle insurance accident parties undertake compulsory insurance liability under, compensation in the following manner.

Each approved the amount of loss=To determine the traffic control department of the insured motor vehicle to bear all the victims of accidents in the partial loss and.

(3The motor vehicle) are uninsured, as the insured motor vehicle computing reparations.

2, motor vehicle and non motor vehicle, pedestrian traffic accident compensation.

(1The accident victim) partial all approved loss and within cross strong insurance sub limit of indemnity, compensation calculated according to the actual loss.

(2The accident victim) partial all approved loss and more than cross strong insurance sub limit of indemnity, compensation calculated according to the partial compensation limit.

(3) traffic management departments have been identified in the motor vehicle insurance accident parties undertake compulsory insurance liability under, compensation in the following manner.

Each approved the amount of loss=To determine the traffic control department of the insured motor vehicle to bear all the victims of accidents in the partial loss and

(4)A plurality of the insured motor vehicle collision of non motor vehicles or pedestrians, the insured motor vehicle insurance respectively bear the liability of compensation in insurance liability limit, ifTraffic management departments to determine the motor vehicle accident liability should bear,The insured motor vehicle insurance man on the victim's average share of each item loss, and calculate the compensation in the corresponding partial compensation limit.

3More than two vehicles, two vehicles and vehicles with a plurality of non motor vehicle, pedestrian traffic accident, calculation of compensation reference this section the above provisions.

For non motor vehicles, pedestrians, cars and property loss, reference1, (1The calculation formula, but the denominator)N.

4The property, loss to rescue, rescue expenses claims and property loss does not exceed the totalLimit of indemnity for loss of property.

5The main vehicle and the trailer, traffic accident when used in connection with people, cross strong insurance main vehicle and the trailer are liable for compensation in the respective liability limits. IfThe liability for traffic management department did not determine the main vehicle, trailer should undertake, the main vehicle, TrailerThe insurer of the victim's average share of each item loss, and calculate the compensation in the corresponding partial compensation limit. The main vehicle and the trailer by the insured, the traffic accident happened when used in connection with each other, according to the principle of the three.

6,The insured motor vehicle insurance more than one cross strong insurance, insurance during the period of liability in the insurance contract, in the later period of play does not assume liability to pay compensation.

Three.The standard for death and disability costs and the cost of medical care

According to "the Supreme People's court 'scope of compensation, on the relevant issues concerning the application of law in the trial of personal injury compensation case explanation'" items and standards, issued by the Ministry of public security "injured in road traffic accident" (evaluationGB18667-2002), andTraffic accident staff traumaClinical guidelinesThe amount of compensation for the basic medical standards and traffic accident of the approved human casualties.

(four) comfort on spirit damage the insured in accordance with the court judgment or mediation take gold, in principle, other compensation for the project in full compensation, the compensation for death and disability compensation limit.

 

The fifth section Payment of indemnity

One, pay reparations

Before the establishment of motor vehicle traffic accident liability compulsory insurance information platform, the insurer to pay the claims should be in the original insurance policy with the "x x months sunrise risks, negative * * (all, mainly, equal, minor) responsibility, * * (no)." chapter of the strip.

Two, document segmentation

If the compulsory insurance and commercial three party insurance in different insurance companies, such as the amount of loss more than cross strong insurance liability limit, by cross strong insurance underwriting company retained has compensation cost original invoice or credentials, will need to commercial insurance project original invoice or a copy of the invoice, the insurer claims dedicated seal, hand the insured for commercial insurance claim.

 

The sixth section Directly to the victim compensation processing of reparations

A bodily injury, occurrence, and one of the following conditions are met, the insurer may accept the claim:

(a) the insured issued a written authorization;

(two) the people's court judgment or enforcement;

(three) the death of the insured, missing, loss of ability to escape, claim or written waiver claim rights;

(four) other circumstances stipulated by law.

Two, the claim to the insurer shall provide the following materials:

(a) issued by the people's court judgment or execution of a book or the traffic police department traffic accident responsibility confirmation and reconciliation of book of the original;

(two) the proof of identity;

(three) bodily disability certificate and relevant list of losses and expenses documents;

(four) other and confirm the property of insurance accident, reason, loss and other material relevant to.

By the written authorization of the insurer, the insured shall provide written authorization.

Three, reparations computation

Insurance accident involving multiple victims, in all the victim claim application, also the victim of all materials are submitted, the insurer can be calculated.

(a) the accident victim item all approved loss and within cross strong insurance sub limit of indemnity, compensation calculated according to the actual loss.

Two.Insurance accidentEach limit of indemnity under the approved loss andMore than cross strong insurance sub limit of indemnity, the insurer shallThe approved amount of loss total loss amount of approved all the victims of the victims of the sub limit of indemnity, multiplied by the corresponding compensation limits, calculationThe amount of compensation for each victim of the breakdown of the insured.

A victim of the insured insurance to pay strong subentry compensation under the=Partial compensation limit * (sub a victim in the accident and the loss amount/The accident victim item all approved the amount of loss and)

 

The seventh section Closed and archiving

One, the claim documents

The insured person or the victim to pay reparations, will claim all documents are filed according to the claim. The necessary documents including:

(a) a copy of the policy;

(two) the report,The insured person writtenThe claim;

(three) the survey report, photos and pictures, loss loss project confirmation, medical expenses of the original bills and expenses list, adjustment of claims. The original bill, by surveying company retained;

(four) driving license and driving license copy, the insured and the victim's identity proof (such as direct payment to the victim);

(five) the accident issued by legitimate traffic management departments of public security organs or institutions such as courts of the proof, the relevant legal documents and other evidence, the parties to negotiate agreement;

(six) the other to confirm the insurance accident, reason of nature, the extent of the loss of the relevant evidence, protocol and written records;

(seven) payment receipt, to receive reparations authorization. Two, the payment should be on compensation3Working days to upload to the motor vehicle accident liability compulsory insurance information platform.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Annex A

 

Motor vehicle traffic accident liability compulsory insurance premium rates notice

 

Dear applicant:

Motor vehicle insurance your basic information as follows:

License plate numbers:                             Identification code (frame number):                      

The nature of the use of:                             Vehicle type:              

During the period of insurance:Years Month From midnight to     Years Month Day twenty-four

According to the approved Chinese Insurance Regulatory Commission insurance rates, the benchmark premium your vehicle is RMB         Element.

Following your vehicle in the previous year to violations of road traffic safety record, road traffic accident records:

Violations of road traffic safety record:

	Behavioral categories	The number of
1	The first kind of illegal behavior
2	Second kinds of illegal behavior
3	Third kinds of illegal behavior
4	Other illegal acts

Due to road traffic safety violations of premium floating coefficient:    %

Road traffic accident record:

	Categories of accidents	Not involving personal injury accidents	Not involving personal injury accidents
1	The main negative accident responsibility for the above
2	The same negative accident responsibility
3	Secondary liability accident

Due to the road traffic accident insurance floating coefficient:      %

Or:

Your vehicle at  There was no responsibility of traffic accident insurance year, the insurance premium is floating coefficient  %

Insurance premium = benchmark premium * (1+ road traffic safety violations floating coefficient () *1And the road traffic accident floating coefficient)

The insured shall pay the insurance fee: RMB       Yuan (capitalized:       )

Above that, if there was no objection, please signature (signature) confirmation.

 

Applicant Signature (Gai Zhang):            

Date:     Years   Month   Day

Note:

1      The illegal traffic information please refer to the traffic control department of the public security.

2      The traffic accident records please traffic management departments of public security and to issue an insurance policy insurance company.

The first kind of illegal activities including:1.Drunk driving a motor vehicle;2Bus manned exceed the approved number20Above.3Driving without a license or driving a motor vehicle driving license was suspended during the period of;4Motor vehicles traveling at speeds in excess50%;5Escaping after causing a traffic accident, do not constitute a crime. Includes second kinds of illegal behavior:1The normal road conditions, less than the prescribed minimum speed on the freeway;2Truck load that exceeds the ratified load more than30%The;3Continuous driving motor vehicles more than4Hours of no parking or parking rest time is less than the rest20Minute.4Vehicle driving after drinking;5Reversing on the highway, retrograde, crossing the central median U-turn;6Test and learn to drive a motor vehicle on the highway;7On the highway is not in accordance with the provisions of parking;8Vehicle malfunction, on the highway accidents after parking, no lights or set warning used in accordance with the regulations sign;9Violation of traffic signal, red light running, running the test lamp. Includes third kinds of illegal behavior:1Motor vehicle driving and quasi driving type does not match;2Motor vehicles traveling at speeds in excess50Following.3In violation of regulations on the highway towing vehicle, the vehicle fault;4Low visibility weather conditions on the highway driving is not required;5Not according to the provisions of the carriage of dangerous goods.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Annex two

 

 

Failing to perform the duty of Disclosure Notice

 

Policy-holder.          

You in    Years   Month   In the                The company insured        (motor vehicle license number, policy number)                        , not on               To perform such obligation. In order to ensure you can get insurance, please5Days with my company, to perform such obligation. The reason for your failure to5Days to perform such obligation, according to the "motor vehicle traffic accident liability compulsory insurance regulations", our company will terminate the insurance contract.

 

The insurer shall:

 

      Years     Month     Day

 

Contacts:

 

Contact telephone number:

 

 

Annex three

 

 

Motor vehicle traffic accident liability compulsory insurance contract termination notice

 

Policy-holder.           

You in   Years Month In the                   The company insured        (motor vehicle license number, policy number)                        , failure to perform the duty of disclosure, according to the "motor vehicle traffic accident liability compulsory insurance regulations" provisions, the company will terminate the insurance contract with you.

 

 

 

The insured:                   The insurer (signature):

 

Date:    Years  Month  Day         Date: Years  Month Day

 

 

 

 

 

 

Annex four

 

Motor vehicle traffic accident liability compulsory insurance contract rescission application

 

The insurer:                            

I insured                      (motor vehicle license number, policy number)                             , because                    

                                    (the reason), to your company to apply for relief of motor vehicle traffic accident liability compulsory insurance contract.

    Hereby apply for

 

 

                                   Applicant signature:

 

                                  Years   Month   Day

 

 

 

 

 

 

 

Annex five

 

 

Motor vehicle traffic accident liability compulsory insurance contract termination notice

 

             (motor vehicle management department):

               (name of applicant/Name), in       Years   Month   In the                  The company insured        (motor vehicle license number, policy number)                      , because                     

                (cause), terminate the compulsory motor vehicle traffic accident liability insurance contract has been handled.

    Are hereby notified

 

 

 

The insurer shall:

 

                           Years     Month     Day

 

 

 

 

 

Annex six

 

 

Insurance declinature letter vehicle compulsory traffic accident liability

 

The insured:           

We regret to inform you that, in accordance with the provisions of relevant laws and the contract of insurance, our company policy                       Under cover (number)         (license number) in the vehicle    Years   Month   In the              (out of place) accident loss does not belong to the scope of insurance liability. We can't pay, please understand.

 

    Welcome your comments on our work.

 

    Yours sincerely

 

 

 

The insured:                 The insurer (signature):

 

Date:    Years  Month  Day      Date:   Years  Month  Day

 

 

Annex seven

 

 

Promise to pay/Advance medical expenses guarantee

 

             (the name of the medical institution):

    Our company                    (the number of motor vehicle insurance) under cover         (license number), in    Years  Month  The accident caused by day         (the victim) injured, rescue in your institution. Our company promises, will be in accordance with the "motor vehicle traffic accident compulsory insurance regulations", "motor vehicle traffic accident liability compulsory insurance clause" provisions, according to"Road traffic accident trauma approved personnel guidelines" and national basic medical insurance standards, according to the damage caused by the negative's responsibility in the accident,In the limit of indemnity (medical expenses       Element) or is not responsible for medical expenses limit (       Yuan), just pay/Advance         (the victim) rescue costs.

 

 

The insurer shall:

 

                           Years     Month     Day

 

 

Annex eight

 

 

The victim receive indemnity authorization

 

The insurer:                            

    I hereby authorize             (the name/Name), to your company for                   (under the insurance policy number)              

(motor vehicle brand models, the license plate number) to              (out of time) the accident occurred insurance claim indemnity procedures, please handle. "The payee name on the cheque" please fill in for:          .

 

    Yours sincerely

 

The insured person signature:

The signatory identity card number:

Date:   Years  Month  Day

 

The signature:

The victim identity card number:

Date:   Years  Month  Day