理赔申请书（2页）.pdf

For a claim to be valid, the following two 

pages (Part A and B) must be completed and 

submitted to MSH CHINA ENTERPRISE SERVICES CO.,

LTD. (hereinafter "Service Center") which is 

the appointed Service Provider appointed by 

your insurance company within 180 days after the date

of service.

为确保有效理赔， A与B两部分内容必须填写完整，并在从治疗之日后的180天之内向为您承保的保险公司指定的医疗保险服务机构万欣和（上海）企业服务有限公司（以下简称“服务中心”）提出理赔申请。

Pre-authorization is required for certain 

treatments. Failure to obtain pre-authorization will 

result in certain co-payment.

某些治疗需事先授权。未经事先授权将导致一定比例的自付额。

Chinese Name 中文姓名:

English Name 英文姓名:

□ Male 男

1. Who is this Claim for? 理赔申请人: □ Primary Insured 主被保险人 □ Dependent 附属被保险人

NOTE: If claim is for the Primary Insured, 

please do not fill out Dependent Information.

注：如果理赔申请人是主被保险人，则无需填写附属被保险人信息。