Annex I HSSEGME: SWDITAV-A~__ MS hee CER) (Px SBSH Ack AR ng (OD AASSCR EMEC Rane ORIEL ASD > LanAy eA A mERTAL « QO) EAB AOE AS: PRET ETHE EAS 210 SE CRRSEMRIMY BREET « CEPT BE RS Ta See + ROA AR} DE HR 201 He CPGILBAOSREON) » FEAR ACRE Ep anita + RASH RATS Alike eee 9A + ASS) + BR Wee AGE aa BE ONLOAD A ATE ALOTRMIERTET SO BETTE soe wa meen it DER CON EMER) BE GRU IR I Pe © + aR RMS Application received by. of *HKPF/SWD Lon ame of Officers Txparimenis CBG RIE) RN: Date: Time: Location of Accident: Vietim was treated at/admitted to Injured/Deceased was [) driver passenger [] pedestrian [-] others, please specify Was it a “road traffic accident’ under the Road Traffic Ordinance? ["] Yes. 1) No (For doubtful case, please give detailed circumstances of the traffic accident in the “Remarks” column) Vehicleis) involved: Type and No. Policy No. Insurer vi v2 v3 ve Remarks. if any: or Senior Superintendent, Traffic) Region Date