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PERSONAL ACCIDENT AND HOSPITALIZATION INSURANCE CLAIM FORM

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PERSONAL ACCIDENT AND HOSPITALIZATION INSURANCE CLAIM FORM Powered By Docstoc
					                                                                                                         13/F., DCH Commercial Centre,
                                                                                                         25 Westlands Road, Quarry Bay, Hong Kong.
                                                                                                         Tel: (852) 2892 3888 Fax: (852) 2577 9578


                                                        書請申償賠險保療醫及外意身人
                      PERSONAL ACCIDENT AND HOSPITALIZATION INSURANCE CLAIM FORM

碼號單保                                                                           日期到單保
Policy No. :                                                                   Expire Date :

     名姓人 償賠請申
1.   Name of Claimant :

     係關之 人保被與
2.   Relationship to insured person :

     名 姓人保被                                                                                 碼 號證份身
3.   Name of insured person :                                                               Identity Card No.

     業職                                                                           別性                                          齡年
4.   Occupation :                                                               5. Sex                                     6. Age

     址地
7.   Address :

                                                                                                  話電
                                                                                               8. Tel.

     期日病 疾現發 期日 生發外意
                   /                                                                                     間時
9.   Date of Accident/Date of sickness first began :                                                     Time :

     間時 及點地 ,形情 事遇外 意該述詳
10. Describe when, how and where accident happened :



     話 電 及址地 ,名姓 其述詳 請,人 證見有如                                         是                                     否
11. Any Witness?                                                      Yes                                   No

     If yes, please provide us the name, address and tel. no. of the witness

     質 性病疾 傷受
         /
12. Nature of Injury / Sickness :

     期日 療治次初
13. Date of First Treatment :

     名姓 師醫治主
14. Name of attending physician :

     容 內險保 該明列 請,有若 險 保類同 保投司 公險保 他其向 否曾下閣   ?
15. Are you insured with any other insurance company for similar benefits? If so, please give particulars :



。的 有持地 誠實屬見 意 的達表 所中其 而,實 屬實事 述所書請 申 償賠險 保療醫 及外意 身人本 信相人本
I believe that the facts stated in this Personal Accident and Hospitalization Insurance Claim Form are true and the opinion expressed in it is honestly held.




期日                                                                 署 簽人償 賠請申 人保被
                                                                          /
Date :                                                             Insured Person / Signature of Claimant



                                                                            書權授
                                                                 AUTHORIZATION
利 與給供料 資等方藥及 告報斷診 療醫之害 傷人本關 有部全或份 部將,士 人之查檢 或,理護 ,治診人本 替曾他其 及師醫, 院醫有所 權授茲人本
                         。 力效之 等同俱本 原 與本印 影則, 本印影 成攝經 如,書權 授 此,人 表代其 或司公 限有險 保際國寶
I hereby authorize any hospital, physician or other person who has attended or examined me to furnish to Liberty International Insurance Ltd. or its
authorized representative any and all information with respect to any illness or injury, medical history, consultation, prescriptions or treatment and copies
of all hospital or medical records. A Photostat copy of this authorization shall be considered as effective and valid as the original.




                            期 日及區地                                                                       署 簽人償 賠請申 人保被
                                                                                                                /
                            Place and date                                                        Insured Person / Claimant Signature(s)
                                                                                                          13/F DCH Commercial Centre
                                                                                                          25 Westlands Road , Quarry Bay, Hong Kong
                                                                                                          Tel : (852) 2892 3888
                                                                                                          Fax: (852) 2577 9578
                                   ATTENDING PHYSICIAN’S STATEMENT                 告報生醫
                                                                                   告報生醫
                                                                                   告報生醫
                                                                                   告報生醫
                                     (to be completed by physician                    供提生醫診主由
                                                                                      供提生醫診主由
                                                                                      供提生醫診主由
                                                                                      供提生醫診主由     )

Patient’s Name   名姓人病     : _____________________________________________ Age      齡年                       :

1.   Diagnosis and concurrent conditions                  狀症人病及斷診:                                                                      ___

2.                                                 麼什是因原的狀症致引
     Is present condition due to injury or sickness?                                  ?



2.   Is present condition due to pregnancy?             否 是 狀症致引孕懷因否是人病            ? Yes   / No

3.                                                 外意上遇 徵病現發時何人病
     When did symptoms first appear or when did accident happen?                                      /            ?



4.   When did the patient first receive your consultation about his/her present condition?            期日診就次首而徵病述上因人病

5.   Nature of surgical or obstetrical procedure, if any:   序程娩分或質性術手述詳請,術手受接要需人病如


     Date Performed   期日行進術手           :

6.   If hospitalized, please provide name and address of hospital:        址地及稱名院醫供提請,院住需如


7.   Date of admission     期日院入    :

8.                       期日院出
     Date being discharged                 :

9.   Commencement date of total disability        期日殘傷性久永致引               :

     Date of partial disability       至        / 由 期日殘傷性暫短 部局致引 : From        __________________To              _____________________

10. Is patient still under your medical attention for this condition?
                                  生醫診主之人病述上為仍否是下閣                                                                         ? Yes   是   / No   否
                                    期日症診人病為後最供提請,否如
     If not, please advise us the cessation date of medical care                                                       ____________________


                                                      Signature of Physician        署簽生醫診主        :

                                                      Qualifications     歷資    :

                                                      Address   址地   :

                                                                         _________________________________________________

                                                                         _________________________________________________


Date: _______________________________