死亡赔偿-医生报告模板.pdfVIP

Death Claim — Attending Physician’s Report 死亡賠償 — 醫生報告 Please print in BLOCK Letters 請以正楷填寫 (To be completed by the deceaseds last attending doctor without expenses to FWD Life 由最後診治死者之醫生填寫 ，本公司並不負責有關費用) Policy No. Deceased (Surname First) Sex Age I . D. No. 保單號碼 死者姓名 性別 年齡 身份證號碼 ( ) Residence at the time of Death Occupation prior to death 生前住址 生前職業 1. (a) Were you the last attending physician of the deceased? If not, please give details of the last attending physician. 閣下是否死者生前最後就診之醫生？如否 ，請詳列最後就診之醫生資料 。 (b) Date on which you f irst saw the deceased? 閣下首次診治死者之日期？ (c) Who referred the deceased to you? Please indicate his/her full name and address. 死者由誰人介紹到診？請提供該醫生之資料 。 (d) How long have you acquainted with the deceased? 閣下認識死者多久？ (e) Please give particulars of any illness or investigations for which he/she has consulted you: 請提供死者因任何疾病或檢查而曾求診之紀錄： Date Attended Complaints Abnormal Duration of Illness Diagnosis Describe Treatment (including name of 就診日期 Physical Findings