PDF《TRAVEL INSURANCE》

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邮箱: [email protected] Yes No If yes, please state the date on which you last received treatment 有无如有,请说明最后一次接受治疗的日期 Were you repatriated? 您是否被转运回国? Yes No If yes, when? 有无如是,在何时? Medical history 病史 Name of hospital last visited in China Name of treating doctor 在中国最后一次看病的医院名称 主治医生姓名 Address (including postal code/city and telephone No.) Date of hospital visit 地址(包括邮编/城市名/电话号码) 看病日期 Names and addresses of hospitals allowed by your public health insurance 社保医院名称及电话 1. 2. Compensation claimed (please attach original documentation) 赔偿申请 (请附上原始文件) Expenses incurred on the account of the illness/injury?与伤/病相关的费用 Foreign currency 外币 RMB 人民币 Is the compensation to be paid directly to creditors outside China? Enter x for yes 赔偿是否直接支付给中国境外的债权 人?如是,请划 X Physicians fees 医生费用 Number of treatments 治疗次数 Outpatient Medical expenses 门诊费用 Hospitalisation expenses 住院费用 Burial Abroad or Body Repatriation 遗体安葬或遣返回国费用 Other expenses (extra hotel, transportation etc), Please specify 其他费用 (额外酒店、交通等),请详细说明 Death (Accident death acute illness death) 身故保险金 Has any amount been paid out in connection with the above claim? 是否被支付过与以上索赔相关的费用? Yes No If yes, RMB paid out on the date by 有无如有,人民币_元,支付日期_由_支付. Other insurance 其他保险 Company_Policy No.Has the claim been reported to this company? Yes No 保险公司 保单号 是否在此公司申请过理赔? 有无Company_Policy No.Has the claim been reported to this company? Yes No 保险公司 保单号 是否在此公司申请过理赔? 有Method of payment 付款方式 Which bank account do you want the claim balance transferred to? 您希望理赔金转账至哪家银行? Bank name and address Name of account holder Bank account No. 银行名称及地址 户名 账号 Signature etc. 签名 I hereby accept that the Insurance Company or the Assistance Provider appointed by the insurance company procures information about the state of my health with a view to obtaining the information necessary for the evaluation of the insurance event and for the assessment of the claim. My acceptance comprises medical reports from the date of which the policy came into force and until the final assessment date of the benefit, and any other supplementary medical records that may be deemed necessary by the Insurance Company or the Assistance Provider for the purpose of evaluating issuance event or assessing claims. The reports can be procured from the health care sector, hospitals and healthcare institutions, public authorities, insurance companies and pension funds. Other insurance companies, pension funds and other authorized persons within the health care sector, involved in the case, are allowed to become acquainted with the medical records procured. I hereby authorize the Insurance Company via its appointed Assistance Provider ERV (China) Travel Service and Consulting Ltd. to act on my behalf and settle payments directly with hospitals, clinics and other service providers. By this authorization I furthermore accept that the insurance payments for said services will be paid directly from the Insurance Company via the Assistance Company to the service providers. I declare that the above information is truthful and complete and has been entered in good faith. 本人在此同意, 保险公司 或其指定的 救援服务公司 为评估本人保险事宜及核定保险索赔之目的,有权获得有关本人健康状况的信息,包括自保单生 效之日起至........