招商信诺全球医疗理赔申请表(2页).pdf
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SECTION A : PATIENT’S DETAILS A
部分:病人详情
To be completed by the insured person or his/
her legal representative
由被保险人或其法定代表人完整填写
1 Full Name 全名
3 Membership Number 会员号
5 Patient’s Date of Birth 病人的出生日期
7 Full Name of Employer 雇主全称
8 State nature of illness (failure to
complete may delay claim settlement)
疾病名称(若不填写可能会延误理赔)
9 Are you eligible for full or partial
reimbursement for these
expenses from another insurer?
你是否有资格获得另一家保
险公司的全额或部 分费用理赔?
Yes/No 是/否
2 雇员姓名(如有不同)
4 Relationship to Employee
与雇员的关系
6 Full Mailing Address of Employee
雇员邮寄地址
Email address 电子邮箱
Tel No 电话号码Fax No 传真号码
10 I f you have answered yes in section 9,
please give details below (Full Name,
Address of Insurance Company and Policy number)
如果第9条的答案为“是”,请提供以下详细信息(该保险公司的全称、地址和保单号)
部分:病人详情
To be completed by the insured person or his/
her legal representative
由被保险人或其法定代表人完整填写
1 Full Name 全名
3 Membership Number 会员号
5 Patient’s Date of Birth 病人的出生日期
7 Full Name of Employer 雇主全称
8 State nature of illness (failure to
complete may delay claim settlement)
疾病名称(若不填写可能会延误理赔)
9 Are you eligible for full or partial
reimbursement for these
expenses from another insurer?
你是否有资格获得另一家保
险公司的全额或部 分费用理赔?
Yes/No 是/否
2 雇员姓名(如有不同)
4 Relationship to Employee
与雇员的关系
6 Full Mailing Address of Employee
雇员邮寄地址
Email address 电子邮箱
Tel No 电话号码Fax No 传真号码
10 I f you have answered yes in section 9,
please give details below (Full Name,
Address of Insurance Company and Policy number)
如果第9条的答案为“是”,请提供以下详细信息(该保险公司的全称、地址和保单号)