澳門保險勞工保險索償申請

勞工保險索償申請 Employees' Compensation Insurance Claim Application

請填寫以下資訊 Please complete the information below

步驟一 Step 1

填寫資料 Complete Info

步驟二 Step 2

確認資料 Confirmation

步驟三 Step 3

驗證 Authentication

填寫資料 Complete Info

確認資料 Confirmation

驗證 Authentication

帶星號(*)的欄位為必填項目 Fields with asterisk symbol (*) are required information

工作意外類別Work accident category*

非工程Non-Construction工程Construction

投保客戶資料 Policyholder Information

(PL) 保單編號(PL) Policy No.*

名稱Name*

電話號碼Phone No.*

傳真號碼Fax No.

電郵地址Email Address*

* 請填寫已登記的電郵地址，以接收驗證碼及作為聯絡用途 * Please enter the registered email address to receive the verification code and for contact purposes

地址Address

受傷僱員資料 Injured Employee Information

姓名Name*

性別Gender*

男Male女Female

出生日期Date of Birth*

國籍Nationality*

電話號碼Phone No.*

證件類別ID Type*

證件號碼ID Number*

地址Address*

開始受僱之日期Start Date of Employment*

受僱形式Type of Employment*

長工Regular散工Casual

受僱之職業或職責Employed Occupation*

意外發生時正從事該等受僱之工作或職責Engaged in this occupation when accident happened*

是Yes否No

由投保客戶直接僱用?Directly employed by policyholder?*

是Yes否No

意外詳情 Details of Accident

發生日期時間Date and Time of Accident*

發生地點Place of Accident*

事件詳細經過Details of Incident*

傷者在意外發生時是否受酒精或藥物所影響 Was the injured person under the influence of alcohol or drugs at the time of the accident *

是 Yes

否 No

傷者在意外發生時是否有違背指令或規則，或疏忽職守之行爲 Was the injured person in violation of any order or rule, or negligence of duty at the time of the accident *

是 Yes

否 No

傷者在意外發生時是否身體虛弱、有殘障或有疾病 Was the injured person suffering from any physical infirmity, disability or sickness at the time of the accident *

是 Yes

否 No

意外由機器引致Accident caused by machinery

是Yes否No

目擊者 (如有) Witnesses (If any)

姓名Name

身份Capacity

電話號碼Phone No.

地址Address

傷勢及康復情況 Details of Injury and Recovery

受傷部位Regions Injured*

受傷類型Nature of Injury*

醫院、診所或醫生名稱Name of Hospital, Clinic or Physician*

治療情況Treatment Status*

門診Outpatient仍然留醫Still hospitalized留醫後出院Discharged from hospital

出院日期Discharge date

康復情況Recovery Status

經已全面恢復工作Already resuming full duty僅能擔任部分原有工作Only able to resume partial duty

受傷僱員開始停工日期Date Injured Employee Ceases to Work

受傷僱員恢復工作日期Date Injured Employee Resumes Work

受傷僱員最近三個月之收入 Income of Injured Employee in Last Three Months

月/年Month/Year

基本薪金Basic Salary & Wages

津貼Allowances

雙糧及花紅Double Pay & Bonus

合計Subtotal

總計Total

受傷僱員在上列三個月內是否曾經停工? Has the injured employee been absent from work at any time during the 3 months above? *

是 Yes

否 No

請詳述停工時期及原因Please give details of period and reason

肇事之第三者 Third Party Causing Accident

受傷僱員是否有權向第三者追索? (例如肇事者之汽車保險、民事責任保險等) Any right of indemnity against third party? (e.g. motor or civil liability insurance of third party causing the accident)

是 Yes

否 No

第三者名稱Name of Third Party

車牌號碼License Plate No.

證件類別ID Type

證件號碼ID Number

地址Address

電話號碼Phone No.

保險公司名稱Name of Insurer

保險類型Type of Insurance