危疾–首次心脏病次级严重心脏疾病

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1、AIAInternationalLimited(IncorporatedinBermudawithlimitedliability)CONFIDENTIALMEDICALCERTIFICATE-醫生報告PARTII-TobecompletedbydoctoratInsured’s/Claimant’sexpense第二部份（受保人或申請人自費由主診醫生填寫）PolicyNo.保單號碼NameofInsured受保人姓名IDCard/PassportNo.身分證/護照號碼CRITICALILLNESS–FIRSTHEARTATTACK/LESSSEVEREHEAR

2、TDISEASE危疾–首次心臟病/次級嚴重心臟疾病GENERALINFORMATION一般資料1.AreyoutheInsured’susualmedicalphysician?閣下是否受保人慣常求診之醫生？Detailsof“Yes”answers.(Includediagnosis,dates,durationandYes是No否namesandaddressesofallattendingphysiciansandmedicalfacilities).If“yes”,whendidtheInsuredfirstconsultyou?如“是”，請問受保人

3、首次向閣下求診之日期？如答“是”，請提供診斷結果、日期、病徵持續時期及主診醫生姓名、醫療機(//)MM/DD/YYYY月/日/年構名稱及地址等資料。2.Whenwereyoufirstconsultedforthisillness?受保人首次就有關疾病向閣下求診之日期。(//)MM/DD/YYYY月/日/年Whatwerethesymptoms?受保人之病徵。…….....................................................................................................

4、.............................................Howlonghadthesymptomsbeenpresent?該病徵約存在了多久?..........................................................................................................................................................3.HastheInsuredpreviouslysufferedfromthisi

5、llnessoranyrelatedconditions?受保人是否有同類之病史？Yes是No否If“yes”,pleasegivedatesofconsultationsandtheresultingdiagnosis.如“有”，請提供求診日期及診斷詳細結果。.......................................................................................................................................................

6、..4.Onwhichdatewasthediagnosismade?有關疾病之診斷是何時首次確認?(//)MM/DD/YYYY月/日/年OnwhichdatewastheInsuredfirstmadeawareofit?受保人何時首次知悉有關疾病之診斷？(//)MM/DD/YYYY月/日/年5.IsthereanythingintheInsured’sfamilyhistorywhichwouldhaveincreasedtheriskofthisillness?受保人之家族病史是否增加受保人患上此病之機會？Yes是No否6.IstheInsuredas

7、moker?受保人是否吸煙人仕???Yes是No否If“Yes”,whatishis/hersmokinghabit?若為吸煙人仕，他/她的吸煙習慣為何?Dailysmokingamount每日吸煙數量:______________forhowmanyyears?吸食年數:__________OTHER/ADDITIONALINFORMATION其他/附加資料1.Pleaseprovidenames,addressesanddatesofdoctorsandhospitalswhichtheInsuredwasreferredand/oradmittedto.

8、請提供受保人曾經就診之所