Model insurance claim application form 1 Applicant: XXXX Co., Ltd.
Domicile:
Respondent: China XXXX Insurance Co., Ltd.
Domicile:
Requested items:
1. The respondent paid the applicant's vehicle loss insurance premium of 209,509.438+03 yuan.
2. The respondent paid the applicant an indirect loss of 72,000 yuan.
Facts and reasons:
On May 13, 20xx, the applicant insured the motor vehicle traffic accident liability compulsory insurance policy and loss insurance for the company's concrete pump truck (using nature: other non-operating vehicles). The insurance policy numbers are: PDZA20xxXXXXXXX047245 and PDAA 20XXXXXXXXX 0612 respectively. The insurance coverage includes motor vehicle loss insurance, third party liability insurance, vehicle personnel liability insurance (driver (D 1 1)), extension clause for lifting, loading, unloading and excavating vehicles (K 1), extension clause for damage to special vehicle fixed equipment and instruments (K2), and a/b a/b/d1.
At about 20xx65438+123: 00 on October 6th 1 1 min, the heavy-duty special operation vehicle driven by the applicant xxX was driving from XXX town to XX village, and when driving to the incident site, it crashed into a stone pier beside the road, causing traffic accidents in which the vehicle was damaged. According to the Letter of Confirmation of Road Traffic Accidents (Summary Procedure) issued by XXX Traffic Management Brigade, XXX, the driver of the applicant company, is fully responsible for the accident.
At the time of the incident, the person in charge of the applicant company kept contacting the respondent company, but the respondent company kept coming to the scene of the accident under various excuses. Afterwards, the applicant company had no choice but to complain to the employees of the respondent company. Two hours later, two staff members arrived one after another. After the staff arrived at the site, their attitude was quite bad, that is, they did not take the initiative to understand the situation on the site, nor did they take the initiative to ask the applicant's company to issue relevant materials. Leave a sentence: your company's vehicle was a traffic accident caused by spontaneous combustion, and the insurance company "left without any compensation." Afterwards, the applicant company took the initiative to contact the insurance company and asked for cooperation in identifying the cause of the vehicle accident, but no one from the insured company came forward. The applicant company has no choice but to contact the automobile 4S shop and send the XXXXX concrete pump truck to be inspected.
According to the fault detection and analysis report of Jiangxi XXXXXXXXXXXX service center, the fault phenomenon of Jiangxi XXXXXXXX concrete pump truck is that the right side of the cab is severely burned due to short circuit, and the fault reason is analyzed as follows: the upper wiring harness is pulled off due to the collision and fracture of the left middle bumper, which leads to short circuit combustion. Solution: Replace and repair the burnt wire harness and module, and the maintenance cost is RMB * * * 2009+03. According to the insurance liability in the motor vehicle loss insurance clause, that is, in line with the permission of the insured, the insurer is responsible for compensation for the loss of the insured vehicle caused by fire, explosion and other reasons when the driver uses the insured vehicle. The XXX driver's license of the applicant company is B2, and it is the driver allowed by the insured.
Article 7 In motor vehicle loss insurance, the insurance company shall not be liable for the losses caused by spontaneous combustion or fire caused by unknown reasons. The definition of spontaneous combustion in this article refers to the fire caused by the failure of electrical appliances, wiring, oil supply and other systems of the insured vehicle or the fire of the goods itself without external fire source, collision and overturning. Spontaneous combustion emphasizes the fire and combustion that occurs due to its own reasons without any external force. The damage of the applicant's vehicle, although there is a phenomenon of short-circuit combustion, is not caused by it.
According to the test report, the precondition of the car damage accident is that the driver collides first when driving, and the left middle bumper breaks due to the collision with the stone pier, which leads to the tensile fracture of the upper harness and short-circuit combustion. In addition to motor vehicle loss insurance, the insured also purchased an extension clause on the damage of fixed equipment and instruments of special vehicles, clearly stating that this insurance contract extends to cover the self-loss of fixed equipment and instruments on the insured motor vehicle due to electrical reasons such as overload, overvoltage or induced current. The vehicle loss caused by the applicant's traffic accident fully conforms to the scope that the respondent company should bear.
According to the obligations of the insurer in the Motor Vehicle Insurance Clause of China XXXX Insurance Co., Ltd., the insurer shall promptly accept the accident report of the insured and conduct an investigation as soon as possible. The applicant company informed the staff of the applicant company at the first time of the accident, but the insured company was so passive that the applicant company contacted the automobile 4S maintenance service center to detect the cause of the vehicle accident. According to Article 15 of China XXXXX Insurance Co., Ltd. Motor Vehicle Third Party Liability Insurance Clause, if the insurer fails to make an investigation within 48 hours after receiving the report and fails to put forward an acceptance opinion, resulting in uncertain property losses, the property damage photos, loss list, accident certificate and repair invoice provided by the insured shall be used as the basis for claim settlement. Therefore, the respondent company should take the maintenance cost assessed by Jiangxi Huace Economic and Trade Co., Ltd. entrusted by the applicant as the compensation basis.
The vehicle of the applicant's company, the concrete pump truck in XXXXX, Jiangxi, belongs to the heavy-duty operation vehicle. The applicant's company has signed the XX Ready-mixed Concrete Purchase and Sale Contract with more than a dozen companies in Ganzhou, and it is necessary to use a truck to fulfill the signed contract. Because the respondent company did not accept traffic accidents and actively carried out investigations, the applicant failed to identify the vehicle damage and repair the vehicle in time, which has caused the current project to be suspended. XX city
The price list of ready-mixed commercial concrete association clearly indicates that the daily running price of concrete pump truck is 3000 yuan. Since the accident occurred on June 65438+1October 65438+June 6, Jiangxi XXXX has been shut down for 24 days, so the applicant company should bear the losses caused by the applicant company's failure to perform the contract on the agreed time, * * * 72,000 yuan.
The provisions of article 15 of the judicial interpretation of traffic accident damage compensation; "If the following property losses are caused by traffic accidents, the people's court shall support them: First, the expenses incurred in repairing damaged vehicles, as well as the reasonable freight loss caused by the inability to continue to use commercial vehicles such as cargo transportation and passenger transportation according to law. Therefore, the respondent company shall bear the vehicle loss insurance premium paid by the applicant of 209,509.13 yuan, and the respondent shall pay the applicant the indirect loss insurance premium of 72,000 yuan, that is, 2,865,438 yuan+0,509.13 yuan.
Applicant: XXXX co., ltd
XX，XX，XX，XX
Model insurance claim application form Article 2 Claimant: xxx, male, 1970, born on February 24th, Han nationality. Address: Zhong Jia 127, Fuxi Village, xxxx Merrill Lynch Sub-district Office. Id number: xxxxxxxx, telephone number: xxxxxxxx.
Organ applying for compensation obligation: xx Municipal Public Security Bureau, legal representative: xxx.
Facts and reasons:
In 20xx, the West Village of xx City was included in the proposed "Administrative Center of xx City" by xx City, and later renamed as "Citizen Center". At the same time, the collective land of villagers Zhongjia and Xinshan in Fuxi Village was expropriated, and a drinking well owned by villager xxx was also expropriated. (This well was formed by villagers xxx who hired geological survey workers to dig and drill water sources at their own expense, and bought drinking water facilities such as motors to lead the water sources to daily drinking water. ) In June, 20xx, due to the need of land acquisition, the water well was requisitioned, and the village committee of Fuxi Village appointed Chen Wendian, a village cadre, and Wu, a villager, to xxx's house to negotiate with xxx about the compensation of the water well. Through consultation, both parties agree that the village committee will compensate the motor wells that xxx has expropriated, and draw up a compensation agreement on the spot. After xxx signed, the agreement was taken away by Chen Wendian on the grounds that the village committee kept it on file.
From August 20xx to June 20xx, in the year of 65438+20xx 10, the village committee of Fuxi Village wanted to requisition xxx's house, but xxx refused. In order to teach xxx a lesson, Fuxi Village Committee forged materials and reported to the public security organ of xx City, claiming that xxx defrauded Fuxi Village Committee of 9000 yuan. On July 28th, 20xx, xxx was forcibly taken away by the public security organ for criminal detention on the grounds that xxx extorted 9000 yuan from Fuxi Village Committee in 20xx. In fact, the 9000 yuan received by xxx in 20xx is the compensation for the expropriation of motor wells voluntarily made by the village Committee after consultation with xxx. On the day of the consultation, Wu was appointed by the village Committee and attended the meeting with Chen Wendian, a village cadre. There was no extortion or fraud by xxx.
Application items:
20xx On July 28th, xx City Public Security Bureau wrongly detained xxx, a villager from Fuxi Village, Merrill Lynch Sub-district Office, and detained him in xx City. 20xx was released on bail from August 5th to August 1 day. As a result, xxx lost the right of personal freedom, unable to participate in the daily affairs of society, and the xxx family lost its owner. Economic sources. Xx City Public Security Bureau wrongfully detained for 8 days, and detained on bail for 30 days +3665438 brought huge economic losses and mental harm to xxx! According to Article 6, Section 2, Chapter 2 of the State Compensation Law of People's Republic of China (PRC), the claimant and the organ liable for compensation, the injured citizens, legal persons and other organizations have the right to claim compensation. In view of the fact of compensation in this case, xxx is the victim of this case and has the right to apply for compensation from xx Municipal Public Security Bureau. According to the first item of the first paragraph of Article 15 in Chapter III of the State Compensation Law of People's Republic of China (PRC), if there are no criminal facts or no facts to prove that there is a criminal suspect who has been wrongly detained, the victim has the right to receive compensation.
Xxx was wrongly detained by xx Public Security Bureau for 8 days (24 hours a day). Because the legal working hours of the country are 8 hours a day, every day of detention is counted as three days ***24 days, and the bail pending trial is 36 1 day, both of which are counted as 385 days. According to the provisions of the State Compensation Law, the xx Municipal Public Security Bureau (the organ liable for compensation) should face up to the facts and compensate xxx for lost time every day 162. 25 yuan/day ×385 days (***62466 yuan), compensation for mental loss of 65438+ ten thousand yuan, reputation loss of 50000 yuan, xx City Public Security Bureau should compensate xxx for a total of 2 12466 yuan.
I am here to convey
Xx municipal public security bureau
Applicant: xxx
Xx，xx，XX，XX
Insurance claim application model essay 3 China xx Company:
My name is. }
I hereby entrust the insured's mother, XXX, female, who is a villager in Group 5, XX Village, XX Town, XX County. Her ID number is XXX ×××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××
Applicant: ×××
Xx year xx month xx day
Model application for insurance claim Article 4 Applicant: XXXX Co., Ltd.
Domicile:
Respondent: China XXXX Insurance Co., Ltd.
Domicile:
Requested items:
1. The respondent paid the applicant's vehicle loss insurance premium of 209,509.438+03 yuan.
2. The respondent paid the applicant an indirect loss of 72,000 yuan.
Facts and reasons:
On May 13, 20xx, the applicant insured the motor vehicle traffic accident liability compulsory insurance policy and loss insurance for the company's concrete pump truck (using nature: other non-operating vehicles). The insurance policy numbers are: PDZA20xxXXXXXXX047245 and PDAA 20XXXXXXXXX 0612 respectively. The insurance coverage includes motor vehicle loss insurance, third party liability insurance, vehicle personnel liability insurance (driver (D 1 1)), extension clause for lifting, loading, unloading and excavating vehicles (K 1), extension clause for damage to special vehicle fixed equipment and instruments (K2), and a/b a/b/d1.
At about 20xx65438+123: 00 on October 6th 1 1 min, the heavy-duty special operation vehicle driven by the applicant xxX was driving from XXX town to XX village, and when driving to the incident site, it crashed into a stone pier beside the road, causing traffic accidents in which the vehicle was damaged. According to the Letter of Confirmation of Road Traffic Accidents (Summary Procedure) issued by XXX Traffic Management Brigade, XXX, the driver of the applicant company, is fully responsible for the accident.
At the time of the incident, the person in charge of the applicant company kept contacting the respondent company, but the respondent company kept coming to the scene of the accident under various excuses. Afterwards, the applicant company had no choice but to complain to the employees of the respondent company. Two hours later, two staff members arrived one after another. After the staff arrived at the site, their attitude was quite bad, that is, they did not take the initiative to understand the situation on the site, nor did they take the initiative to ask the applicant's company to issue relevant materials. Leave a sentence: your company's vehicle was a traffic accident caused by spontaneous combustion, and the insurance company "left without any compensation." Afterwards, the applicant company took the initiative to contact the insurance company and asked for cooperation in identifying the cause of the vehicle accident, but no one from the insured company came forward. The applicant company has no choice but to contact the automobile 4S shop and send the XXXXX concrete pump truck to be inspected.
According to the fault detection and analysis report of Jiangxi XXXXXXXXXXXX service center, the fault phenomenon of Jiangxi XXXXXXXX concrete pump truck is that the right side of the cab is severely burned due to short circuit, and the fault reason is analyzed as follows: the upper wiring harness is pulled off due to the collision and fracture of the left middle bumper, which leads to short circuit combustion. Solution: Replace and repair the burnt wire harness and module, and the maintenance cost is RMB * * * 2009+03. According to the insurance liability in the motor vehicle loss insurance clause, that is, the driver who meets the requirements of the insured shall be responsible for compensation for the loss of the insured vehicle caused by fire, explosion and other reasons during the use of the insured vehicle. The XXX driver's license of the applicant company is B2, and it is the driver allowed by the insured.
Article 7 In motor vehicle loss insurance, the insurance company shall not be liable for the losses caused by spontaneous combustion or fire caused by unknown reasons. The definition of spontaneous combustion in this article refers to the fire caused by the failure of electrical appliances, wiring, oil supply and other systems of the insured vehicle or the fire of the goods itself without external fire source, collision and overturning. Spontaneous combustion emphasizes the fire and combustion that occurs due to its own reasons without any external force. The damage of the applicant's vehicle, although there is a phenomenon of short-circuit combustion, is not caused by it.
According to the test report, the precondition of the car damage accident is that the driver collides first when driving, and the left middle bumper breaks due to the collision with the stone pier, which leads to the tensile fracture of the upper harness and short-circuit combustion. In addition to motor vehicle loss insurance, the insured also purchased an extension clause on the damage of fixed equipment and instruments of special vehicles, clearly stating that this insurance contract extends to cover the self-loss of fixed equipment and instruments on the insured motor vehicle due to electrical reasons such as overload, overvoltage or induced current. The vehicle loss caused by the applicant's traffic accident fully conforms to the scope that the respondent company should bear.
According to the obligations of the insurer in the Motor Vehicle Insurance Clause of China XXXX Insurance Co., Ltd., the insurer shall promptly accept the accident report of the insured and conduct an investigation as soon as possible. The applicant company informed the staff of the applicant company at the first time of the accident, but the insured company had a negative attitude and neglected management, so the applicant company contacted the automobile 4S maintenance service center to detect the cause of the vehicle accident. According to Article 15 of China XXXXX Insurance Co., Ltd. Motor Vehicle Third Party Liability Insurance Clause, if the insurer fails to make an investigation within 48 hours after receiving the report and fails to put forward an acceptance opinion, resulting in uncertain property losses, the property damage photos, loss list, accident certificate and repair invoice provided by the insured shall be used as the basis for claim settlement. Therefore, the respondent company should take the maintenance cost assessed by Jiangxi Huace Economic and Trade Co., Ltd. entrusted by the applicant as the compensation basis.
The vehicle of the applicant's company, the concrete pump truck in XXXXX, Jiangxi, belongs to the heavy-duty operation vehicle. The applicant's company has signed the XX Ready-mixed Concrete Purchase and Sale Contract with more than a dozen companies in Ganzhou, and it is necessary to use a truck to fulfill the signed contract. Because the respondent company did not accept traffic accidents and actively carried out investigations, the applicant failed to identify the vehicle damage and repair the vehicle in time, which has caused the current project to be suspended. XX city
The price list of ready-mixed commercial concrete association clearly indicates that the daily running price of concrete pump truck is 3000 yuan. Since the accident occurred on June 65438+1October 65438+June 6, Jiangxi XXXX has been shut down for 24 days, so the applicant company should bear the losses caused by the applicant company's failure to perform the contract on the agreed time, * * * 72,000 yuan.
The provisions of article 15 of the judicial interpretation of traffic accident damage compensation; "If the following property losses are caused by traffic accidents, the people's court shall support them: First, the expenses incurred in repairing damaged vehicles, and the reasonable loss of stopping freight transportation caused by the inability to continue using commercial vehicles such as cargo transportation and passenger transportation according to law. Therefore, the respondent company shall bear the vehicle loss insurance premium paid by the applicant of 209,509.13 yuan, and the respondent shall pay the applicant the indirect loss insurance premium of 72,000 yuan, that is, 2,865,438 yuan+0,509.13 yuan.
Applicant: XXXX co., ltd
XX，XX，XX，XX
Model insurance claim application form 5 _ _ _ _ _ _ branch of insurance company limited:
I (our company) have _ _ _ _ insurance with your company. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Now I (our company) file a claim in _ _ _ _ _ _ _ _.
Our company agrees to use _ _ _ _ _ _ _ _ _ _ _ _ _ (currency) as the final claim amount. After you pay the above amount, you shall be relieved of your liability for compensation for the above insurance accident according to law.
Please ask your company to pay it.
Bank of deposit: _ _ _ _ _ _ _ _ _ _ _
Account name: _ _ _ _ _ _ _ _ _ _ _
Account number: _ _ _ _ _ _ _ _ _ _ _
Claimant: _ _ _ _ _ _ _
Claim date: _ _ _ _ _ _ _ _ _
Application for Insurance Claim Model Wen 6 Applicant: Cheng * *, female,197165438+February 23rd, address: No.77, Jiuqiupai, Meilin Town, Gan County, ID number: * * * *, telephone number: * * *. Application items: …
Insurance claim application
Applicant: Cheng * *, female, born on February 23rd, 197 165438, address: No.77, Jiuqiupai, Meilin Town, Ganxian County, ID number: * * * *, and telephone number: * * *.
Application items:
Pay 30 1600 yuan to the insured.
Facts and reasons:
At 9 o'clock in the morning of 20xx 1 17 17, the applicant got permission from Tu Quannan, the owner of Jiangxi B 16333, to drive Zhong Xiumei (rural hukou, living in this city for more than 1 year). After the Ganxian Public Security Bureau filed the case, it rejected the applicant on the grounds that the circumstances were obviously minor and the harm was not great, and it was not considered a crime. Afterwards, the applicant reached a compensation agreement with Zhong Xiumei's parents in accordance with relevant laws and regulations, and compensated Zhong Xiumei's parents for various expenses totaling 30 1600 yuan. According to the Compulsory Insurance Contract for Motor Vehicle Traffic Accident Liability and Shen Xing Vehicle Insurance Series Insurance Contract signed by Jiangxi B 16333 owner Tu Quannan, your company should undertake the compensation obligation of the applicant to compensate Zhong Xiumei's parents for the above expenses within the insurance compensation limit. The applicant now submits a written application to your company in accordance with the law, requiring your company to fulfill its compensation obligations.
I am here to convey
Applicant: XXX
date month year
Model Application for Insurance Claims Article 7 xxx Insurance Company:
My name is. }
I hereby entrust the insured's mother, XXX, female, who is a villager in Group 5, XX Village, XX Town, XX County. Her ID number is XXX ×××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××
I am here to convey
Applicant: ×××