中文印件名称-HangSengBank.PDF

住院保障計劃賠償申請表 HOSPITAL CASH PLAN CLAIM FORM 呈遞此賠償申請表，並不表示公司承擔賠償責任。 日期 By furnishing this form the Company makes no admission of liability. Date: 如投保人因傷病不能書寫，投保人的家屬或負責人可代為填簽。 If the Insured is unable to write on account of disablement, this form should b e completed and signed by a close relative or other responsible person acting on behalf of the Insured for the time being. 辦妥以下各項，可免延緩索償進程： Unnecessary delay in claim process can be avoided by the following procedures: 1. 詳細填妥甲、乙兩項並簽署。 Sections A and B a re fully completed and signed. 2. 由主診醫生填妥表格背面丙項並簽署。 Section C is completed and signed by the attending Doctor. 3. 正本住院賬單、收據及醫生介紹書。 Original hospital bill, receipt and Doctor’s referral letter are submitted together with this form. 甲項 投保人資料 SECTION A INSURED’S INFORMATION 投保人姓名 職業 保單編號 Name of Insured Occupation Policy No. 地址 流動電話號碼 Address Mobile Phone No. 閣下是否願意以手機短訊(SMS )接收索償通知? 是 否 Do you agree to receive SMS claim notification via your mobile phone? Yes □ No □ 乙項 索償資料 SECTION B CLAIM INFORMATION 病人姓名 疾病／受傷之性質 Name of Patient Disease / Nature of Injuri