赔款收据及权益转让书

赔款收据及权益转让书

RECEIPT AND SUBROGATION FORM

保险单号码：Policy/Certificate No.

保险金额：Insured Amount:

赔案号：Loss No.

致：中国平安财产保险股份有限公司分公司

To: Ping An Property & Casualty Insurance Company of China Ltd Branch

贵公司赔付有关上述保险单项下由轮承运自

港/地至港/地的（货物）索赔案的赔款

（大写）（小写）已收到。立书人同意接受上述赔款，从而结束上述保险单项下的全部索赔。

Received from Ping An Property & Casualty Insurance Company of China Ltd.

Branch, the sum of ( ) in full and final settlement of the claim under the above mentioned Policy/Certificate Shipped per M/V. “” from to .

鉴于收到该款，立书人同意将已取得的上述赔款部分保险标的的一切权益转让给贵公司，并同意贵公司以贵公司或立书人的名义向责任方追偿或诉讼，立书人并将提供一切必要的协助，以利贵公司实现该项权益。

In consideration of having received this payment, we hereby agree to assign, transfer and subrogate to you, to the extent of your interest, all our rights and remedies in respect of the subject matter insured, and to grant you full power and give you any assistance you may reasonably require of us in the exercise of such rights and remedies in our or your name and at your own expense.

Date at（地点）this（日）day of（月）（年）20

立书人（签章）

Signed：