OutpatientClaimForm门诊保障索偿表格.PDFVIP

MSIG Insurance (Hong Kong) Limited 9/F., Cityplaza One, 1111 King’s Road, Taikoo Shing, Hong Kong Tel +852 2894 0555, Fax +852 2890 5741 .hk Outpatient Claim Form 門診保障索償表格 H746 1. Please complete and submit this Claim Form to us within 30 days from the date of accident, together with relevant supporting documents. Further information may be needed in the future. Post: MSIG Insurance (Hong Kong) Limited, Claims Division, 9/F Cityplaza One, 1111 King’s Road, Taikoo Shing, Hong Kong OR Email: claimin@ 請將填妥之索償表格連同有關證明文件，並於事發後30 天內呈交本公司。稍後可能需要提供進一步資料。 郵寄地址：香港太古城英皇道1111 號太古城中心一期9 樓三井住友海上火災保險（香港）有限公司理賠部或 電郵：claimin@ 2. For all medical reports and original medical receipts, please provide the treatment date, patient’s name, diagnosis and countersigned by the attending physician with stamp on it. 請提供治療日期、病者姓名、病症及由主診醫生之印鑑及簽署在所有醫療報告及醫療費用之正本收據上。 3. Doctor’s referral letter is required for medicines/drugs/prescription purchase, and/or X-ray examination, laboratory test, physiotherapy treatment, specialist treatment, etc. Please also submit the original bills/receipts from the pharmacist, laboratory, physiotherapist or specialist. 如欲申請藥物費用或X-光、化驗、物理治療、專科等費用索償 ，請提供主診醫生之處方或轉介信及藥房或有關醫療機構之賬單/收據正本。 4. For inquiry, please call our Claims Services Hotline at 2894 0660 or email at claimin@ 如有任何查詢，請致電我們的賠償服務熱線2894 0660 或電郵claimin@ Policyholder 保單持有人資料 Policy No. 保單編號 Surname in English