国寿康优全球团体医疗保险(B 型)理赔申请表讲述.pdfVIP

理赔申请表 国寿康优全球团体医疗保险(B 型) Claim Form China Life Goodhealth International Healthcare Plan (Type B) (2009 年10 月10 日版) (Version: Oct 10, 2009) 中国人寿保险股份有限公司 China Life Insurance Company Limited All claims under ￥1, 600 (or corresponding rates) per condition, please complete Section A, B and C and return this with the original receipt(s) showing the diagnosis and a full breakdown of costs for each condition being claimed for. ALL sections MUST be completed in full for hospitalization claims and all claims over ￥1, 600 (or corresponding rates). A referral letter from Your Specialist should be attached when You are claiming for diagnostic tests or covered alternative treatments. 索赔金额低于1,600 元人民币(或等值的其他货币),如原始发票已清楚写明病症并列明费用明细，请完整填写A,B,C 栏。 住院治疗或索赔金额高于或等于1,600 元人民币(或等值的其他货币) 的，请完整填写A, B, C, D, E 栏。填写完毕后请和 医疗费用收据原件、医疗费用明细清单原件、诊断病历原件一起提交。如索赔诊断性检验或非常规治疗的费用，请同时 提供您的治疗医师的书面介绍证明。不同的病症请分别填写理赔申请表。 保险单持有人 保险单号码 Policyholder Policy Number 栏目A ：出险人详细资料– 由被保险人/ 附带被保险人填写 Section A: Patient’s Details - To be completed by the Insured/Supplementary Insured 姓： 住址及邮政编码： Surname Address Post Code 名及英文字母简写： 身份证号/护照号码：如索赔为人民币付款且大于1 万元或外币 First Name Initials 付款且大于等值美元1 千元，请提供相关护照或身份证件复印件. ID No. / Passport No. : Please attach with your ID card/Passport copy if the claim amount is above RMB10,000 for RMB payment or above USD1,000 for Non-RMB payment 出生日期（日/ 月/年）：