hospitalclaimform住院理赔申请书

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1、HospitalClaimForm住院理賠申請書PolicyNumber保單號碼NameofPolicyownerNameofLifeAssured保單持有人姓名受保人姓名NameofFinancialConsultantFinancialConsultantContactNo.理財顧問姓名理財顧問聯絡電話號碼FinancialConsultantCodeDivisionCode&BranchOffice理財顧問編號分區編號及分行地點ImportantNotes重要提示：1.Pleasecomple

2、teinBLOCKLETTERS.請以正楷填寫。2.Pleasesubmitclaimapplicationwithin90daysfromhospitaldischargeorsurgicalprocedure.理賠申請需於出院或手術後90天內遞交。3.Pleasedonotsignonblankorincompleteform.請勿在空白表格或尚未填妥的表格上簽署。4.AnychangesoramendmentsinthisformmustbecountersignedbytheClaimant

3、infullsignature.索償人必須在此表格內任何更改或修改的地方簽署作實。5.PrudentialshallhavetherighttorejectthisformifyoufailtofulfillPrudential’srequirement.若閣下未能符合保誠的有關規定，保誠有權拒絕此表格。6.ReceiptofthisformbyyourFinancialConsultantsoryourBrokerdoesnotconstitutereceiptbyPrudential.閣下的理財

4、顧問或經紀收到此表格並不代表保誠亦已收到。7.Ifnecessary,pleasecompleteandsubmitthe“RequestforCertifiedTrueCopyofMedicalReceipt(s)”formtorequestforreturnofthecertifiedtruecopy(“CTC”)ofthemedicalreceipt(s)whicharesubmittedtogetherwiththisform.如需要退回隨附之醫療費用收據之核實副本，請填妥及交回「醫療費用收

5、據核實副本申請書」。PartI–Claimant’sCertificate(tobecompletedbyLifeAssured/Policyowner/Claimant)第一部分–索償人報告（由受保人/保單持有人/索償人填寫）A.ClaimDetails理賠資料Benefit(s)toclaimsMedicalExpensesBenefit醫療費用保障TypeofClaimsNewClaim首次理賠理賠類別IncomeBenefit入息保障理賠種類FurtherClaim再度理賠Pend

6、ingClaim待決理賠Did/Willyouapplyforcompensationfromanotherinsurer(s)/organization(s)forthesameevent?No沒有Yes,pleaseprovidebelowinformation有，請提供下列所需的資料閣下有否就此事曾/將會向其他保險公司/機構申請理賠?InsuranceCompany/OrganizationPolicyNumberBenefit(s)toclaimResult/Status保險公司/機構保

7、單號碼理賠類別結果/狀況B.LifeAssuredDetails受保人資料IdentityDocumentNumber身份證明文件號碼ResidentialAddress居住地址NameofEmployer僱主（公司）名稱AddressofEmployer僱主（公司）地址PresentOccupation現職PrudentialHongKongLimited保誠保險有限公司AmemberofPrudentialplcgroup英國保誠集團成員1LACL/HOSP(06/17)CHPFRM0301C.

8、IfHospitalizationwascausedbyILLNESS,pleasestate:如因疾病導致住院，請詳述如下：Signandsymptoms徵狀Forthisepisode,sincewhenhavethesesymptomsfirstappeared?//就是次病況而言，何時出現首次徵狀？Day日Month月Year年Otherthanthisepisode,haveyouhadanysimilar/relatedpasthistory?No沒有