太平财产保险有限公司CLAIMFORM理赔申请表

太平财产保险有限公司TAIPINGGENERALINSURANCECO.,LTDCLAIMFORM理赔申请表ThisclaimformistobeusedonlyifyourproviderdidnotfileclaimsdirectlytoICSonyourbehalf.Returnthisformalongwithfullyitemizedbills,receiptsanddiagnosistotheaddressbelow.InternationalClaimsServicesmustreceiveclaimswithinonehundredeightydays(180)afterfirstdayoftreatment.仅当您的医疗服务机构未直接以您的名义向ICS（国际理赔服务中心）申请赔理时，您才需要填写此表。将本申请表填妥后，连同完整的收费清单及诊断证明寄往如下地址。ICS必须在开始治疗之日起的（180）天内收到理赔申请。GBGChinaClaimcontactinformationGBG中国理赔联系信息:ShanghaiClaimsCenter·Suite3007,SinoLifeTower,707ZhangyangRoad,Shanghai,200120P.R.China中国上海张杨路707号生命人寿大厦3007室邮编200120Tel:[phone]·Fax:[phone]·Email:[e-mail](PrimaryInsured)Information持保人(主投保人)资料Name:持保人姓名:Employer雇主名称:PolicyNumber保单号码:Telephone:联络电话:CurrentResidentAddressandCountry当前居留国家及居住地址:E-Mail:电子邮箱:Fax传真:Pleasecheckwhothisclaimisfor:请勾选保险理赔申请人:PrimaryInsured主投保人Name姓名:DateofBirth出生日期:Male男Female女Married已婚Single单身DependentInsured附属投保人Name姓名:DateofBirth出生日期:Male男Female女RelationshipwithPrimaryInsured与主被保险人关系:Spouse配偶Child子女CurrentCountryofResidence当前居住国家:Ifdependentisachild21yearsandolder,ischildafull-timestudent?如果附属投保人年龄大于21岁，那么他/她是否是全职在校生？Yes是No否Ifyespleaseprovide:若是，请填写NameofSchool学校名称:Location地址:Allfulltimestudentsmusthavealetterverifyingfull-timestudentstatusfromtheirschool’sregistrarofficeatthebeginningofeachschoolyear.所有全职在校生在每学期开学时，必须具有从学校的注册管理处开据的全职学生身份的证明书。SectionA第一部分Isthispatientalsocoveredby:申请人是否同时持有及合乎以下保险:Anyothergrouphealthplan其它集体健康保险MedicareorotherGovt.Agency联邦医疗健保或其他政府机构的保险No-Faultautocarrier无究肇事责任的汽车保险Ifyes,providenameandaddressofothersource:如果选择以上任何选项，请提供其名称及地址:PAYMENTINFORMATION付款资讯Pleasemakepaymentto:保险理赔受益人:Member持保人Provider(Paymentbycheck)医疗服务机构(支票付款)PaymentType:Pleasemakepaymentasmarkedbelow付款方式:请按照以下方式付款:SendcheckandEOBto:将支票和保险受益清单（EOB）寄至:MemberAddressonPart1寄至列于持保人资料第一部分的通讯地址OtherMailingAddress寄至其它通讯地址:SendbyElectronicDirectDeposit(BankmustbelocatedinUS),orWireTransfer(BankslocatedoutsideofUS)通过直接银行转账(只适用于美国地区的银行),或电汇(美国以外地区的银行)NameofBank:银行名称___________________________________________________________________________NameonAccount:账户持有人姓名:_________________________________________________________________Account#/IBAN账号:_____________________________________________________________________________RoutingNumber(ABA)forelectronictransfer,and/orSWIFTcodeforWireTransfers银行转帐代码(Routing/ABANumber)或银行汇款代码(SWIFTCode):_________________________________________________________________AddressofbankforWireTransfers电汇收款银行地址:___________________________________________________DescribeIllnessorInjury简述疾病或伤情:DateIllness/Injuryoccurred患病/受伤日期:DianosisordescriptionofillnessorInjury疾病或伤情的医生诊断或说明:IsthisclaimforMaternitytreatment?此次申请理赔是否属于妇产科治疗?Yes是No否DeliveryDate预产期/分娩日期:Hasdiagnosisand/ortreatmentforsameconditionorrelatedconditionbeengivenpreviously?Ifso,statedates,results,kindoftreatment,prescribeddrugsandnameofdoctororfacility:以前是否有过相同或相关的诊断或治疗？如果有，请注明日期、结果、治疗措施、处方药物、以及医生姓名或医疗机构名称:Wasillnessorinjurydueinanywayto请填写疾病或受伤原因:Thepatientsoccupation职业伤害AnautomobileAccident汽车意外伤害Anytypeofaccident任何其他意外伤害Ifyes,providedetails,includingdateofaccident:如果选择以上任何选项，请提供细节，包括发生日期:Doctor/FacilityInformation:医生/医疗机构资讯:DoctorsName:医生姓名:Phone#联系电话:Address/Country通讯地址及国家:Facilityname:医疗机构名称:Thefollowingtreatmentsandorprescribeddrugswereprovidedtomeandthechargesforeacharelistedbelow.(ATTACHRECEIPTSinordertoreceivepayment)以下分列出所有接受的医疗服务和(或)处方药物及其费用(依照保险理赔条款,需附上所有费用收据及帐单)SectionB第二部分Theaboveanswersaretrueandcorrecttothebestofmyknowledge.Iauthorizeanyphysician,medicalinstitution,pharmacy,insurancecompany,employer,laborunion,orassociationtoreleaseinformationtoGBG/TiecareInternationalinc.asisrequiredtoproperlypayallbenefits,ifany,dueme,myspouse,orparentofthisclaim.Aphotocopyofthisauthorizationshallbeconsideredeffectiveandvalidastheoriginal.以上所填写的内容是在尽我所知的范围内正确并属实的。为了使我,我的配偶或父母得到应获的保险理赔,本人在此授权给任何医生、医疗机构、药店、保险公司、工会、雇主等相关单位,提供给GBG/Tiecare国际公司任何与此保险理赔要求的相关资料。本批准书的影印件应被视为与原件同样有效。_______________________________________________________________Signature签字Date日期DateofService治疗服务日期MM/DD/YY月/日/年Descriptionofeachserviceand/orprescribeddrug描述每项医疗服务和或处方药物Cost费用Currency货币TotalAmountPaidbyPatient患者支出金额合计Totalbalancestillduetoprovider未付医疗机构的差额合计