Please complete clearly in block capitals. 敬请用楷体皓晰堵写以下情节。
Please remember these important points about filling in yo ur claim form: 堵写时剩意以下要紧事项：
Assessment of your claims may be delayed if you and your medical or dental
practitioner do not fill in all the necessary sections of this form.
Return this form to us within six (6) mo nths of the first treatment date.
Always send us the original invoice s with this form. Photocopies, receipts and
credit card statements will not be accepted.
Make sure that you fill i n sections A to F and that all doctors who have treated
you fill in section G (or section H for dental treatment).
C -- Further information 其他信息
Symptoms/condition needing treatment 症状/就症情景:
A -- Patient details 病人信息
B -- Main member details 首要成员信息
Does the patient have another insurance policy that covers medical costs您能否还拥有其他保单保障该项医疗费 Yes 是 No 否
If yes, please give details on a separate sheet. 若拥有，请供皓细。
D -- Payment details 给付信息
Have you personally had to pay costs for the treatment that you are claiming