意外和医疗保险索偿申请表.PDFVIP

Accident Health Insurance Claim Form 意外及醫療保險索償申請 表 This form must be completed truthfully and accurately. If the space is not enough or no applicable field available, please supplement information by attachment. 請正確填寫此申請表。如果表格空間不足或沒有適用之欄位，請以附件補充資料。 The list of documents required is not exhaustive and we reserve our right to request from you any additional information/documentation, as necessary. The submission of an incomplete form or insufficient information or supporting documents may delay the processing or result in the denial of your claim. 各部份之「所需文件」只是概括要求，本公司保留權利在有需要時要求閣下提供更多文件以處理有關的索償申請。如所遞交的索償申請表未填妥或有關資料或 文件不足，閣下的索償申請有可能會受延誤或被拒絕。 The completed form should be returned to us together with all supporting documents as soon as possible at the following address: 請填妥索償申請表並連同所有有關文件盡快寄回以下地址 : AIG Insurance Hong Kong Limited (Macau Branch) 美亞保險香港有限公司（澳門分行） Claims Department 賠償部 Unit 506, 5/F, AIA Tower, No 251A-301 Avenida Comercial de Macau 澳門商業大馬路251A-301號友邦廣場5樓506室 Facsimile: 853 2835 5299 傳真 : 853 2835 5299 Telephone: 853 2835 5602 / 6321 3633 電話 : 853 2835 5602 / 6321 3633 Email address: claim.mo@ 電郵地址 : claim.mo@ .hk/macau .hk/macau Section I – General Information (REQUIRED) 第一部份 受保人及一般資料 (必須填寫) Policy/certificate no. 保單號碼 : Name of Policyholder (English) 保單持有人姓名(英文) : Name of Policyholder (Chinese) 保單持有人姓名(中文) : Name of Insured (English) 受保人姓名(英文) : Name of Insured (Chinese) 受保人姓名(中文