富勤医疗索赔文件提交单（英文版）（1页）.pdf
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To : Falcon Insurance
Company (Hong Kong) Limited
Claim No.: 120
From: Policyholder:
Policy No.:
Date:
SUBMISSION OF MEDICAL CLAIMS DOCUMENTS
1. Total Number of Claim Forms Attached:
2. Total Amount Claimed:
3. Remarks:
Name & Title Authorized Signature
For Office Use Only Date
Overall Status: Date Entered By
Date Claim Processed: C h e c k e d B y :
Company (Hong Kong) Limited
Claim No.: 120
From: Policyholder:
Policy No.:
Date:
SUBMISSION OF MEDICAL CLAIMS DOCUMENTS
1. Total Number of Claim Forms Attached:
2. Total Amount Claimed:
3. Remarks:
Name & Title Authorized Signature
For Office Use Only Date
Overall Status: Date Entered By
Date Claim Processed: C h e c k e d B y :
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