遗失声明

本人（单位）拥有的一辆： 车，（车牌： 车架号： ，发动机号码： ） 因该车的： 已遗失，故此，在现申请办理该车报废手续时，未能将相关牌证交回车管所，本人（单位）反映情况属实，否则愿意承担相应法律责任。

特此声明

声明人签名（盖章）：

年 月 日

———————————————————————————————————————

遗失声明

本人（单位）拥有的一辆： 车，（车牌： 车架号： ，发动机号码： ） 因该车的： 已遗失，故此，在现申请办理该车报废手续时，未能将相关牌证交回车管所，本人（单位）反映情况属实，否则愿意承担相应法律责任。

特此声明

声明人签名（盖章）：

年 月 日

 

第二篇：保单遗失声明

American International Assurance

Company (Bermuda) Limited

This is to certify that I (Owner's/Assignee's/Trustee's Name) have lost the abovementioned policy issued by the AMERICAN INTERNATIONAL ASSURANCE COMPANY (BERMUDA) LIMITED coveringassurance on the life of the above insured.

茲證明本人(權益人/受讓人/信託人姓名) 遺失由美國友邦保險(百慕達)有限公司發出以上保單號碼之保單，該保單承保上述受保人之保險。

I hereby apply for the following document being marked ( X ). 我謹在此申請下列填寫(X)之文件:

A policy certificate 保單證書

A duplicate policy copy 保單的復製本 (Please attach receipt copy of policy fee 請附上保單費用收據副本)

I agree that the original policy copy and any issued duplicate policy copy before this declaration have been void. I further agreethat in case of a claim arising through the above insured's death, the AMERICAN INTERNATIONAL ASSURANCE COMPANY(BERMUDA) LIMITED shall be liable for the amount covered by the original policy only and this policy certificate / duplicate policywill not cover any additional assurance.

本人同意在此聲明訂立前，原先之保單及任何巳復製保單之副本均視為無效。此外，本人亦同意若因以上受保人身故而索償，美國友邦保險(百慕達)有限公司將只會根據原有保單中的承保數額作出賠償，而此保單證書/復製副本將不包括任何附

加保險。

Declaration & Authorization聲明及授權

I/We DECLARE and AGREE that any personal data and other information relating to me/us or my/our policy(ies) or investments contained in this application or collected, obtained, compiled or held by the Company by any means from time totime may be used, maintained, processed, stored, transferred, disclosed and/or shared by the Company for the purposes of processing, administering, implementing and effecting the requests or transactions contemplated in this application orany other applications made by me/us from time to time, promoting or providing subsequent or other services or products to me/us, direct marketing, data matching and/or communicating with me/us. I/We further DECLARE and AGREE that theCompany may transfer, disclose, grant access of or share such personal data and other information to or with individuals, entities and/or organizations associated with the Company and/or to or with third parties (including, without limitation,reinsurance companies, claims investigation companies, industry associations or federations, fund management companies, financial institutions, or service providers) selected by the Company, in each case whether within or outside of HongKong, for any of the aforesaid purposes and/or for the purposes of providing administrative, data processing, data maintenance or storage, telecommunications, computer, payment or other services to the Company in connection with theoperation of its business. I/We understand that I/we have the right to obtain access to and to request correction of my/our personal data held or controlled by the Company. Such request can be made to any of the Company's Customer ServiceCentres. If I/we do not wish to receive marketing information or materials, I/we will send an opt-out notice to the Company, in which case my/our personal data and other information would be included in a centralized customer opt-out list thatmay be shared amongst the Company's associated partners for reference.

本人/我們現聲明並同意貴公司可使用、保留、處理、儲存、轉交、透露及/或共用貴公司所收集、索取、整理或保留在此申請表所載或從其他途徑取得之任何有關本人/我們的個人資料或其他有關本人/我們的保單或投資資料，用作處理、管理、落實及實行在此申請表所載或本人/我們從任何其他申請表所提出之要求，及介紹或提供其稍後或其他的服務或產品予本人/我們、直接促銷、資料核對及/或聯絡本人/我們之用途。本人/我們再聲明並同意貴公司可向與貴公司有關的本港或海外的人士、團體及/或機構及/或任何被選的第三機構(包括並不限於再保險及賠償調查公司，及有關的行業協會/聯會、基金管理公司、金融機構或提供有關服務之公司)轉交、透露、授權取得或共用本人/我們之個人或其他資料，用作以上列明之用途及/或貴公司業務運作之用，包括行政、資料處理、資料保存或儲存、通訊、電腦、付款或其他服務。本人/我們明白到本人/我們有權向貴公司查閱及申請更改貴公司儲存或管理與本人/我們有關的個人資料。有關的申請可於貴公司任何一間客戶服務中心辦理。若本人/我們不想收到貴公司的銷售資料或刊物，本人/我們會發出信函通知貴公司，而本人/我們的個人或其他資料會存於貴公司之中央資料檔內的非聯絡客戶名單，並會供貴公司

及有關人士/機構作參考。??

_______________________________ on ___________________

Signature of Owner/Trustee 於 MM月/DD日/YYYY年

持有人/信託人簽名______________________________ on ___________________Signature of Assignee 於 MM月/DD日/YYYY年受讓人簽名

(if applicable 如適用)

PLEASE RETURN WITHIN 14 DAYS 請請請請14請請請請

PLEASE DO NOT SIGN ON BLANK FORM 請勿在空白表格上簽署OPPOSF06.0709