PDF《保单号码》

FWD Life Insurance Company (Bermuda) Limited Incorporated in Bermuda with limited liability 富卫人寿保险(百慕达)有限公司 (於百慕达注册成立有限责任公司) Page

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1 L-CL06-AUG17 Authorization for Living Claims 在生权益授权书 Policy No.

保单号码 : Name of Insured 被保人姓名 : Authorization I HEREBY AUTHORIZE AND AUTHORIZE ON BEHALF OF THE INSURED (if different): 1. any registered practitioners, hospitals, clinics, insurance companies, government institution, organizations or persons that possess any medical history or records or employment and salary information or other information of me/the insured or whom I have attended or may hereafter attend, to disclose any of my or the insured's medical information or other information to FWD Life Insurance Company (Bermuda) Limited in relation to this claim. 2. the Company or any of its approved medical examiners or laboratories to perform necessary medical assessment and tests to evaluate my or the Insured's health status in relation to this claim. 本人在此授权或代表被保人(如有不同)授权: 1. 任何持有本人/ 被保人的医疗病历、记录或职业及薪酬记录或其他资料或本人曾求诊或其后将会求诊的医生、医院、诊所、保险公司、政府机构、机构或人士向富卫人寿保险(百慕达)有限公司披露本人/ 被保人的任何医疗资料或其他资 料,作为评估或处理此索偿之用. 2. 公司或公司许可的医疗人员或化验所,就本赔偿申请,进行必要的医学评估及测试,以评估本人或被保人的健康状况. [Note : This authorization shall bind my and the Insured's successors and assigns and remain valid notwithstanding my or the Insured's death or incapacity in so far as legally possible. A photocopy of this Authorization shall be as valid as the original]. (注意:本授权对本人或被保人的承继人及转让人均有约束力,并且如法律上可行时,不论本人或被保人死亡及失去行为能 力,本授权仍然有效.本授权的影印本与正本同样有效.) Date (DD / MM / YY) Signature of Claimant 索偿人签署 日期 (日/月/年) Name of Claimant 索偿人姓名 ID Card No. 身份证号码 Relationship with Insured 与被保人之关系