危疾賠償申請表-癌症-中國人壽保險(海外)股份有限公司.PDFVIP

危疾賠償申請表-癌症 CS-CLA05 Critical Illness Claim Form-Cancer 第一部份 PART I 此表格適用於「危疾」或「嚴重病症」附加保障的賠償申請。 This form is applicable for Dread Disease or Major Diseases benefit riders. 為使有關賠償申請能盡速辦理，此申請表必須由受保人/保單持有人填寫及簽署 。 In order to process your claim promptly, this form must be completed and signed by Insured/Policyholder. 甲) 受保人資料 A) Particulars of Insured 保單號碼 受保人姓名 年齡 及性別 身份證/ 護照號碼 Policy No. Name of Insured Age and Sex I.D. Card / Passport No. 聯絡電話 Contact phone no: □ 首次索償 New Claim □ 再度索償 Further Claim 通訊地址 Mailing Address 乙) 病症性質及有關資料 B) Nature of illness and related information 1. 病症名稱 Name of illness 2. 請描述症狀 Please describe symptoms 3. 症狀何時開始出現? When did these symptoms first appear? __________________________ 年/月/ 日YY/MM/DD 4. 初診醫生/醫院的資料: 求診日期 _________________________ The physician/hospital first consulted for this injury or illness. Date of consultation: 年/月/ 日YY/MM/DD 醫生/醫院名稱及地址 Name Address of Physician/Hospital 其他曾診治此症或過往類似病況的醫生/醫院資料: 求診日期 _________________________ . Date of consultation: 年/月/ 日YY/MM/DD Other physicians/hospital consulted for this or similar conditions: 醫生/醫院名稱及地址 Name Addres