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To be completed by the Policyholder/Insured Person 

由保单持有人/受保人填写

Important note :

1. This form is to be filled by the Policyholder/Insured 

Person. Please do not sign on blank form and use the 

same signature as policy record.

2. No fees, commission or charges of whatever nature 

are payable to Authorized Agents or Employees of the 

Company in respect of this claim.

3. To enable us to process your claim promptly, please 

answer all questions in this form as fully and 

accurate as you can.

4. Please submit a copy of the identification document 

of the Insured Person &/or Insured Dependent, unless 

submitted before, together with this form.

5 This claim application will be processed by our 

authorized third party claims administrators

1. 此申请表应由受保人/受保家属填写。请勿在空白申请书上签署，而签名式样须与保单的记录相符。

2. 有关本索偿，客户无需支付任何手续费、佣金或其他任何性质的费用予本公司的获授权代理或其他僱员。

3. 请回答此申请书上的所有问题，以供我们批核 阁下的索偿申请。

4. 如在之前未有递交保单持有人/受保人的身份证明文件，请随此申请表一併递交。

5. 这保险索偿申请书之理赔程序将通过我们的授权声明的第三者管理员进行处理。

In-Patient Pre-Authorization Claim

住院预先授权申请

In-Patient Claim

住院索偿

Out-Patient Claim

门诊索偿

Dental Claim

牙科索偿