GroupInsuranceClaimForm团险索赔申请表SectionAGeneral.pdfVIP

Group Insurance Claim Form 团险索赔申请表 Section A General Information A. 基本信息 Primary Insured Information 主被保险人信息 Name Employer Name 姓名 投保单位名称 ID/Passport# Employee# 证件号码 员工号 Insured Telephone# Email Information 电话号码 电子邮箱 *If this is the claim for primary insured, dependent information can be skipped. 被保险人信息 *若理赔仅涉及主被保险人，则无需填写附属被保险人信息。 Dependent Information 附属被保险人信息 Name Relationship with Primary □Spouse 配偶 □Parent 父母 姓名 Insured 与被保险人关系 □Child 子女 □Guardian 监护人 ID/Passport# Telephone# 证件号码 电话号码 *If claim amount exceeds RMB10,000 or other currencies in equivalent, copy of beneficiarys identification (i.e. ID or passport...) is required. *若索赔金额超过人民币10,000元或等值外币，请提供被保险人的有效身份证件（如身份证、护照等）。 Expenses for Which Reimbursement is Claimed 申请报销费用明细及金额 Date Description of Injury, Illness or Treatments Currency Amount 日期 受伤、疾病或治疗描述 货币种类 金额 Payment Information 给付信息 □ I, the beneficiary, authorize Generali China Life Insurance Company to transfer reimbursement into the bank account designa