太平财产保险有限公司claimform理赔申请表.pdfVIP

太平财产保险有限公司 TAIPING GENERAL INSURANCE CO., LTD CLAIM FORM 理赔申请表 This claim form is to be used only if your provider did not file claims directly to ICS on your behalf. Return this form along with fully itemized bills, receipts and diagnosis to the address below. International Claims Services must receive claims within one hundred eighty days (180) after first day of treatment. 仅当您的医疗服务机构未直接以您的名义向 ICS （国际理赔服务中心）申请赔理时，您才需要填写此表。将本申请表填妥后， 连同完整的收费清单及诊断证明寄往如下地址。ICS 必须在开始治疗之日起的（180 ）天内收到理赔申请。 GBG China Claim contact information GBG 中国理赔联系信息: Shanghai Claims Center ·Suite 3007, Sino Life Tower, 707 Zhangyang Road, Shanghai, 200120 P. R. China 中国上海张杨路707 号生命人寿大厦 3007 室 邮编200120 Tel: (86-21) 3126 9300 · Fax: (86-21) 5835 3368 · Email: eclaims@ Policy holder (Primary Insured) Information 持保人(主投保人) 资料 Name: 持保人姓名: Employer 雇主名称: Policy Number 保单号码: Telephone:联络电话: Current Resident Address and Country 当前居留国家及居住地址: E-Mail: 电子邮箱: Fax 传真: Section A 第一部分 Please check who this claim is for: 请勾选保险理赔申请人: Primary Insured 主投保人 Name 姓名: Date of Birth 出生日期: Male 男  Female 女  Married 已婚  Single 单身  Dependent Insured 附属投保人 Name 姓名: Date of Birth 出生日期: Male 男  Female 女 Relationship with Primary Insured 与主被保险人关系: Spouse 配偶  Child 子女 Current Country of Residence 当前居住国家: If dependent is a child 21 years and older, is child a full-time student? 如果附属投保人年龄大于21 岁，那么他/她是