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This form is to be completed in block letter by the Insured 

Employee / Member and separate forms must be used for 

different claimants (i.e. patients).

此申请表由受保僱员 / 成员以正楷填写，每表祇限一位赔偿申请人（即病者）使用。

* Please complete all the information below, otherwise, 

it cannot be processed. 

请填妥以下资料，否则阁下之赔偿申请将不能处理。

** Please provide contact information. It will be 

updated to our record in accordance with the 

arrangement with your employer. 

请提供联络资料，我们将

根据与您的僱主所订下的安排更新该等资料。

1. Group Policy No. 团体保单编号：* 6. 

Name of Employer / Group Policyholder

僱主 / 团体保单投保公司名称：

2. Name of Insured Employee / Member 

受保僱员 / 成员姓名：* 7. HK / Macau ID No. of the Insured Employee

受保僱员香港 / 澳门身份证：*

3. Mobile number of Insured Employee 

受保僱员手提电话：** 8. Claimant Member ID 

(10 digits no. shown in the medical card)

(Compulsory)

赔偿申请人成员号码（医疗卡上显示的十位数字）（必须填写）：*

4. E-mail Address of Insured Employee 受保僱员电邮地址：**

9. Relationship to Insured Employee / Member

与受保僱员 / 成员之关係：*

5. Name of Claimant / Patient 赔偿申请人 / 病者姓名：*

*** Please complete items 10 to 11 if item 8 cannot be provided.

如未能提供第八项之资料，请填妥第十至十一项。

10. Certificate No. of the Insured Employee 

受保证书号码：*** 11. Employee No. of the Insured Employee 僱员编号：***