文档介绍：个人意外伤害保险索赔申请书
Personal Accident Insurance Claim Form
所有问题均须由被保险人/索赔申请人完全回答 保单号码
All questions must be answered ___________Postal code_________________________
联系电话(日间固定电话) 联系电话(手机)
Tel. no. (Daytime)_____________________________________________Mobile____________________________________________
与被保险人关系 身份证号码
Relationship to the insured________________________________________Identity Card
保险期间由(The insurance period is from)____________________________________至(to)________________________________
索赔类别 1. 医疗费用 2. 意外身故 3. 意外伤残
Claim Item Medical Expenses Accident Death Accidental Dismemberment
4. 意外住院津贴 (一般病房) 5. 意外住院津贴 (重症监护病房) 6. 其他______________
Accidental Hospital Cash (GW) Accidental Hospital Cash (ICU) Others
意外在何时何地发生When and where did the accident occur?
(a) Date 日期_______________________________________(b) Time 时间_____________________________________________
(c) Place 地点_______________________________