住院赔偿申请表-中国人寿保险.PDFVIP

住院賠償申請表 CS-CLA02 HOSPITALIZATION CLAIM FORM 第一部份PART I 為使此賠償能盡速辦理，此申請表必須由受保人/保單持有人填寫，並需於出院後三十天內連同有關之單據及出院證明書之正本呈交本公司。In order to help us process your claim promptly, this form must be completed by Insured/Claimant and returned to the Company within 30 days from date of discharge with original receipts and discharge note. 受保人資料 Insured’s Particulars 本表格需由受保人填寫，如受保人為十八歲以下，應由受保人之家長或合法監護人填寫此申請表。 To be completed by Insured. If the insured is under age 18, this form should be completed by the insured’s parent/ legal guardian. 保單號碼Policy No. 受保人姓名Name of Insured 年齡/性別Age/Sex 身份證/ 護照號碼I. D.Card / Passport No. 索償保障類別(請劃上剔號) Claimed Benefit(s) (please tick) □首次索償New Claim □ 再度索償Further Claim □ 住院醫療 Hospital Benefit □ 住院入息 Hospital Income 通訊地址Mailing Address : 聯絡電話Contact Phone No. : 閣下是否因同一事故向其他保險公司索償? 如是, 請提供該保險公司名稱及保單號碼 □ 是Yes □ 否No Are you making a claim against any other insurance company for the 保險公司名稱Name of Insurance Company ： same incident? If yes, please indicate the name of insurance company 保單編號Policy number ： and policy number. 因意外住院For hospitalization due to Accident 1. 意外發生時間/ 日期Date/Time of the accident 2. 意外發生地點Location of accident: At _____________________ on ________________________________ 上午/下午AM/PM 年/月/ 日YY/MM/DD 3. 請詳述意外發生經過及受傷情況Please describe the occurrence of the accident and the circumstances of injury in details. 因疾病住院For hospitalization due to Illness 4. 請描述病徵/ 病狀Please describe the symptoms