文档介绍：理赔申请表国寿康优全球团体医疗保险(B 型)
Claim Form China Life Goodhealth International Healthcare Plan (Type B)
(2009 年 10 月 10 日版)
(Version: Oct 10, 2009)
中国人寿保险股份有限公司
China Life pany Limited

All claims under ￥1, 600 (or corresponding rates) per condition, plete Section A, B and C and return this with the
original receipt(s) showing the diagnosis and a full breakdown of costs for each condition being claimed for. ALL sections MUST
pleted in full for hospitalization claims and all claims over ￥1, 600 (or corresponding rates). A referral letter from Your
Specialist should be attached when You are claiming for diagnostic tests or covered alternative treatments.
索赔金额低于 1,600 元人民币(或等值的其他货币),如原始发票已清楚写明病症并列明费用明细,请完整填写 A,B,C 栏。
住院治疗或索赔金额高于或等于 1,600 元人民币(或等值的其他货币) 的,请完整填写 A, B, C, D, E 栏。填写完毕后请和
医疗费用收据原件、医疗费用明细清单原件、诊断病历原件一起提交。如索赔诊断性检验或非常规治疗的费用,请同时
提供您的治疗医师的书面介绍证明。不同的病症请分别填写理赔申请表。

保险单持有人保险单号码
Policyholder Policy Number
栏目 A:出险人详细资料–由被保险人/附带被保险人填写
Section A: Patient’s Details - To pleted by the Insured/Supplementary Insured
姓: 住址及邮政编码:
Surname Address & Post Code
名及英文字母简写: 身份证号/护照号码:如索赔为人民币付款且大于 1 万元或外币
First Name & Initials 付款且大于等值美元 1 千元,请提供相关护照或身份证件复印件.
ID No. / Passport No. : Please attach with your ID card/Passport
copy if the claim amount is above RMB10,000 for RMB
payment or above USD1,000 for Non-RMB payment

出生日期(日/月/年): 电邮:
Date of Birth: D