人身保险理赔申请书正面-平安保险.docVIP

团体人身保险理赔申请书（正面） Group Life Insurance Claim Application Form (face) 为了维护您的正当权益，请于填写《人身保险理赔申请书》前详尽阅读此申请书背面的申请须知。 in order to protect your legitimate rights, please carefully read the notice on the back of the application form before filling in the Life Insurance Claim Application Form. 索赔类型 Claim Type 住院医疗（ ） 意外医疗（ ） 住院安心（ ） Hospitalization( ) Accidental medical treatment( ) Hospital allowance( ) 死 亡（ ） 残 疾（ ） 重大疾病（ ） 其 它（ ） Death ( ) Disability( ) Dread disease( ) Others( ) 单位名称 Company Name 保险单号码 Policy NO. 被保险人姓名 Name of the Insured 性别 Gender 年龄 Age 身份证号码 ID No. 理赔通知送达地址 Address for the Claim Notice 联系电话 Contact Phone 保险事故经过 Process of the Insurance Accidents 保险事故发生时间、地点及经过： Time, place and details of the insurance accident： 被保险人现状： Current status of the insured:□已痊愈Recovery□治疗中In treatment□死亡或残疾Death or disability□其他Others 保险事故是否报公安/交警/劳动或卫生部门处理 □是（请附材料）□否 Whether reported to Police/Traffic Police/Labor or Heath Dept? □Yes（Pls provide documents）□No 保险事故者如身故，是否已验明死因 □是（请附报告）□否 If the Insured in the accident died, whether the death cause was found out? □Yes（Pls attach report）□No 被保险人有否正在申请或已获得其它保险公司、其它福利保障计划等其它途径的给付及补偿，如有，请详述： If the insured is applying for or has obtained the payment and compensation through other ways such as other insurance companies, other welfare protection schemes, etc.; if yes, please describe them in details: 保险金领取方式Benefit receiving methods：□委托 （单位/个人）Commit（Institution/Individual） □自领Receive by self □银行转帐Bank transfer（银行帐户仅限被保险人本人帐户，死亡给付不提供银行转帐；银行转帐需详细填写开户银行、户名、帐号）(The bank account must be the insured’s own account; The death benefit can not be paid through bank transfer; Name of the bank, username and account number should be provided particularly if choosing bank transfer.） 开户银行 Name of Bank 户名 Username 帐号 Account No. 理赔申请人与被保险人关系 Relationship between claim applicant and the insured □配偶Spouse□本人Self □父母Parent□子女Children□其他Other 本人郑重声明：