富勤团体医疗保险-资料更改表格(2页).pdf
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Policy No.保单号码: Name of Policyholder
保单持有人名称:
Name of Associated Policyholder保单共同持有人名称:
(A) Addition of Employee(s)
新增僱员
(Maximum 31 days backdating of Effective Date
upon receipt of this change form is permitted
最多31天可追溯期)
Bank Account No.
(For claim settlement by Autopay only )
银行户口号码(只供医疗赔偿自动转帐之用)
Date of Birth
出生日期
Effective Date
生效日期
Date of
Employment
受僱日期
Ref. No.
参照号码
Name (Surname First)
姓名(姓氏先行)
(Same as HKID Card与香港身份证相同)
保单持有人名称:
Name of Associated Policyholder保单共同持有人名称:
(A) Addition of Employee(s)
新增僱员
(Maximum 31 days backdating of Effective Date
upon receipt of this change form is permitted
最多31天可追溯期)
Bank Account No.
(For claim settlement by Autopay only )
银行户口号码(只供医疗赔偿自动转帐之用)
Date of Birth
出生日期
Effective Date
生效日期
Date of
Employment
受僱日期
Ref. No.
参照号码
Name (Surname First)
姓名(姓氏先行)
(Same as HKID Card与香港身份证相同)