被保险人姓名
身分证号码
事故种类
□ 疾病
□ 意外
申请
项目
□医疗
□重大疾病/特定伤病
□身故/完全失能
□失能
□豁免保费
□其他:
意外
事故
说明
事故发生时间: 年 月 日
事故地点:
是否报案: □ 是 □ 否
处理单位: _____________警局/地检署
处理人员:
员警电话:
事故详情:
受益人给付方式与联络资料
* 为确保您的权益,填写汇款资料时,请务必确实填写户名、金融机构名称、分行名称及帐号。 户名、帐号
有误或不全,将改以禁止背书转让支票给付。
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