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《groupinsuranceclaimform团险理赔申请表》由会员上传分享，免费在线阅读，更多相关内容在工程资料-天天文库。
1、GroupInsuranceClaimForm团险理赔申请表SectionAGeneralInformationA.基本信息PrimaryInsuredInformation主被保险人信息NameEmployerName姓名投保单位名称ID/Passport#Membership#证件号码客户号InsuredTelephone#EmailInformation电话号码电子邮箱*Ifthisistheclaimforprimaryinsured,dependentinformationcanbeskipped.被保险人信息*若理赔仅涉及主被保
2、险人，则无需填写附属被保险人信息。DependentInformation附属被保险人信息NameMembership#姓名客户号ID/Passport#Telephone#证件号码电话号码*IfclaimamountexceedsRMB10,000orothercurrenciesinequivalent,copyofbeneficiary'sidentification(i.e.IDorpassport...)isrequired.*若理赔金额超过人民币10,000元或等值外币，请提供被保险人的有效身份证件（如身份证、护照等）。Expe
3、nsesforWhichReimbursementisClaimed申请报销费用明细及金额DateDescriptionofInjury,IllnessorTreatmentsCurrencyAmount日期受伤、疾病或治疗描述货币种类金额PaymentInformation给付信息√I,thebeneficiary,authorizeGeneraliChinaLifeInsuranceCompanytotransferreimbursementintothebankaccountdesignated.本人授权中意人寿保险公司将赔付款项划入
4、本人或直付机构在贵公司指定的银行账户。1.Intheeventthatoriginalmedicalreceiptsarerequiredforreimbursementfromotherinsurers,wesuggestyoumaysubmitclaimtosuchinsurersfirst;若本次理赔的医疗费用收据原件需提交给其他保险机构进行赔付,请您先行向其它保险机构进行理赔;2.GeneraliChinaacceptsoriginalcopyofExplanationofBenefitsfromotherinsurersalong
5、withphotocopyofrelevantmedicalreceiptsandmedicalproofstoprocessclaim;中意人寿接受并可受理持其它保险机构出具的理赔明细说明书（理赔分割单）原件及ClaimFile相应的医疗费用收据和医疗证明复印件的理赔申请;Management3.IntheeventthatyoumayprefersubmitclaimtoGeneraliChinapriortootherinsurers,originalmedicalreceiptswon'tbereturnedhoweverExpla
6、nationofBenefitsisavailableasthesubstituteoftheoriginalmedicalreceipts;若您选择先行向中意人寿理理赔单据管理赔则医疗费用收据原件不予退还，但可出具理赔明细说明书（理赔分割单）以作为医疗费用收据原件替代文件以便被保险人后续向其他保险机构进行理赔;4.Incaseofincident3,pleaseclarifyifExplanationofBenefitsisrequired;若属上述第3项情况,请告知是否需要理赔明细说明书（理赔分割单）:□Yes是□No否Iherebyd
7、eclarethattheaboveinformationisprovidedbymyselfandnomaterialhasbeenwithheldandinformationgivenhereinistrue.Iauthorizethatanydoctors,hospitals,clinics,insurancecompanies,policeinstitutesandpublicorprivateorganizationsthatkeepanymedicalhistoryorrecordsorknowledgeofmewhoIhave
8、attendedormayhereafterattendtodisclosesuchinformationtoGeneraliChinaLifeInsuranceCo.Ltd.f
