全球团体医疗保险理赔申请表.PDFVIP

Insured by 承保方 Administered by 管理方 International Company Plan – Claim form 全球团体医疗保险理赔申请表 重 要 信 息 I M P o R t a N t I N f o R M a t I o N 重 要 信 息 Return this form with original invoices to: Bupa International, Russell House, Russell Mews, Brighton BN1 2NR, United Kingdom. 请将本表格连同原始发票寄回：Bupa International, Russell House, Russell Mews, Brighton BN1 2NR, United Kingdom. Please ensure that all sections of the claim form are fully completed. Note that claims payment may be delayed if all sections of the claim form are not completed in full. The form should be returned to us within six months of the initial treatment date. 请确保理赔申请表填写完整。请注意，如果理赔申请表没有填写完整，可能会延误支付赔款。本表格必须在接受最初治疗后的6个月内寄回。 Always enclose the original invoices - photocopies, receipts and credit card vouchers are not acceptable. Please write clearly in English in black ink and BLOCK CAPITALS. 请务必附上原始发票 - 复印件、 收据及信用卡凭单均不予接受。 请用黑色墨水以英文大写字母填写本表 。 Please complete a new / separate claim form for: 请就以下各项分别填写一份新的理赔申请表： •each patient •each in-patient / day-case stay •each medical condition •each currency 每位患者 每次住院治疗/日间住院 每项病情 每种货币 If you have more invoices, you do not need to send a further claim form. Just send the invoices with a covering letter stating the condition and payment instructions. If the condition continues for more than six months, we may request a new claim form to be completed. 如果有多张发票，您无需再邮寄额外的理赔单。只需连同发票邮寄一封说明信函，注明病情和支付方法即可。如果病情持续超过6个月，我们可能会要求您填 写一张新的理赔申请表。 We are unable to return original documents, but we will be happy to provide certified copies on request. 我们无法归还原始文件，但是，我们很乐意根据要求为您提供认证的副本。 1 Patient’s details - to b