富勤门诊医疗索偿表格（1页）.pdf-保险单证-保险资料库

富勤门诊医疗索偿表格（1页）.pdf

Policy No. 保单号码
Policyholder Name保单持有人名称
Employee 僱员
Name in English 英文姓名
Surname 姓 Other Name 名
Type of Personal Identification Document and Number 身份证明文件类别及号码
(Please tick the appropriate box 请於适当方格内画上号)
□ HKID Card No. 香港身份证号码
□ Passport No. 护照号码
□ Member Ref. No. 会员参考编号
□ Staff No. 职员编号
Claimant (Patient) (if other than Employee) 索偿人(病人) (如非僱员)
Name in English 英文姓名
Surname 姓 Other Name 名
Relationship关係
Type of Personal Identification Document and Number 身份证明文件类别及号码
(Please tick the appropriate box 请於适当方格内画上号)
□ HKID Card No. 香港身份证号码
□ Passport No. 护照号码
□ Member Ref. No. 会员参考编号
□ Staff No. 职员编号