住院赔偿申请表HOSPITALIZATION.PDFVIP

住院賠償申請表 HOSPITALIZATION CLAIM FORM 保單持有人姓名Name of Policyholder 受保人姓名Name of Insured 保單編號Policy No. 受保人身份證/ 護照號碼 I.D. / Passport No. of Insured 保險中介人資料INSURANCE INTERMEDIARY INFORMATION 保險中介人姓名Name of Insurance Intermediary 保險中介人代碼Insurance Intermediary Code 聯絡電話Contact No. 重要須知 IMPORTANT NOTE - 請以正楷填寫本申請表。任何資料如有更改，受保人/保單持有人/索償人必須在更改的位置簽署作實。Please complete this form in BLOCK LETTERS. All amendments should be endorsed by the Insured / Policyholder / Claimant in full sign