富勤住院及手术索偿表格（2页）.pdf-业务单证-保险资料库

富勤住院及手术索偿表格（2页）.pdf

PART 1 - TO BE COMPLETED BY CLAIMANT (PATIENT)
第一部份 – 由索偿人(病人)填写
1a. Policy No. 保单号码
1b. Policyholder Name 保单持有人名称
2. Employee 僱员
2a. Name in English 英文姓名
Surname 姓 Other Name 名
2b. 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
3. Claimant (Patient) (if other than Employee) 索偿人(病人) (如非僱员)
3a. Name in English 英文姓名
Surname 姓 Other Name 名
3b. Relationship
关係
3c. 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