MED_团体住院及手术索赔申请书_Draft02.PDFVIP

MED_團體住院及手術索賠申請書_Draft 02 Sign:________________ Name:____________________ Date:__________ 索償編號 (公司專用) Claim No. (for office use) 香港中環德輔道中71 號永安集團大廈九樓 9/F., Wing On House, 71 Des Voeux Road Central, Hong Kong. 查詢熱線Enquiry Hotline ：3187 5100 傳真 Fax ：3906 9906 HOSPITALISATION SURGICAL CLAIM FORM 住院及手術索賠申請書 Please complete and sign this claim form and make sure the original copies of invoices and receipts are attached 請填妥本申請書及簽署後連同有關單據正本一併遞交。 Note : ORIGINAL DOCUMENTS submitted would be retained by our company. You are advised to keep a copy for reference. Our Company reserve the right to return the CERTIFIED TRUE COPY only upon request. 注意 ：所遞交之正本文件將會存留於本公司 ，請自備副本參考 。如要求退回文件 ，本公司保留只退還文件之核實正本之權利 。 Please tick the box if certified true copy of receipt is required.  如需索取收據之核實副本 ，請於空格內畫上 「」號。 PART I – CLAIMANT’S STATEMENT (IN BLOCK LETTER) 第一部份 – 索償人資料 (請用正楷填寫) For Group Account Only 團體醫療保險適用 Group Policy No. Name of Employer 團體保單號碼 僱主名稱 Employee Name Employee/Staff No. 員工姓名 員工編號 For Individual Policy only 個人保單適用 Individual Policy No.