太平住院及手术赔偿申请表（3页）.pdf-保险单证-保险资料库

太平住院及手术赔偿申请表（3页）.pdf

This form is applicable to both inpatient
and outpatient surgical claim
本表格适用於住院或门诊手术赔偿
PART I – TO BE COMPLETED BY THE PATIENT
甲部 – 由病人填写
Policyholder
保单持有人名称
保单号码
Policy No.
Employee/Member Name
僱员/成员姓名(英文正楷)
电邮地址
E-mail Address
联络电话：
Contact Tel. No.
Patient’s Name
病人姓名(英文正楷)
H.K.I.D. No.
香港身份证号码
Plan
计划编号
Relationship to the Employee/Member
与僱员/成员之关係
Client Code(Member Ref)
客户编号(员工编号)
Correspondence Address
通讯地址
(1) a. Is condition congenital
此是否先天性缺陷？
No 否   Yes 是
b. If confinement is due to childbirth,
please indicate the commencement of Pregnancy.
如住院是因生育导致，请提供开始怀孕日期 :
c. Have you had any prior treatment
for this or related conditions
阁下是否曾经因同一病况而接受治疗？
No 没有  Yes 有