1. CLAIM FORM
Gi畉y y棚u c畉u b畛i th動畛ng
(Xin vui l嘆ng g畛i t畉t c畉 c叩c ch畛ng t畛 ho叩 董n m trong 坦 ghir探 t棚n b畛nh nh但n, ch畉n o叩n b畛nh, ngy kh叩m b畛nh, li畛t
k棚 chi ti畉t c叩c chiph鱈 v畛ich畛 k箪 v c坦 坦ng d畉u cua c董 s董 y t畉) (Please submit documents which clearly indicate name of patient,
diagnosis, date of consultation, charges breakdown with the attending physicians chop and signature).
Main Insured:
(T棚n Ng動畛i 動畛c b畉o hi畛m) Policy No.
Policy No:
(H畛p 畛ng b畉o hi畛m s畛)
A. Personal information (Th担ng tin c叩 nh但n)
Name of the Policyholder (T棚n B棚n mua b畉o hi畛m): Level (M動c b畉o hi畛m):
Home address (畛a ch畛 nh): Date of Birth (Ngy sinh):
Email: Tel No (i畛n tho畉i):
B. Payment (Thanh to叩n)
Total amount claimed:
(Chi ph鱈 y t畉 動畛c y棚u c但u b畛i th動畛ng)
Bank transfer (Chuy畛n Kho畉n) Cash (Ti棚n m味t):
Account No(S畛 ti kho畉n):
Bank name(T棚n Ng但n hng):
Number of Days off-work:
(S畛 ngy ngh畛 tai n畉n th畛c t畉)
Bank address(畛a ch畛 Ng但n hng):
Beneficiary(Ng動畛i th畛 h動畛ng):
C. Treatment information (Th担ng tin v畛 i畛u tr畛):
Date of visit or Date of accident (Ngy kham b畛nh ho味c ngy x畉y ra tai n畉n):
Medical conditions or Diagnosis / Cause of accident (Chu但n oan b畛nh / Nguy棚n nh但n tai n畉n):
Name of Hospital or clinic(畛a ch畛 b畛nh vi畛n hay phong kham):
Date of admission (Ngy nh畉p vi畛n): Date of discharge (Ngy xu畉t vi畛n):
Important!(L動u 箪 ki棚m tra h動畛ng d但n d動畛i 但y tr動畛ckhi i kh叩m v g畛i h畛 s董 b畛i th動畛ng!)
1. Out-patient (Kh叩m ngoa味i tru):
- Prescriptions(董n thu畛c): L動u y l畉y d畉u cua c董 s畛 y t畉
v ghi ro t棚n b畛nh nh但n
- Medical book(S畛 kham b畛nh):Ghi ro chu但n oan b畛nh
V t棚n b畛nh nh但n
- Invoices(Hoa 董n): Hoa 董n h畛p l畛 co li畛t k棚 chi ph鱈 y
t畉 v chi ti畉t s畛 l動畛ng&董n gia thu畛c
2. In-patient (Nm vi畛n)
- Hospital discharge(Gi畉y ra vi畛n)
- Surgery report(Phi畉u m畛):
Trong tr動畛ng h畛p phu但u thu畉t
3. Accident (Tai na味n):
- Doctor proposalfor Days off-work
(Ch畛 畛nh cho ngh畛 cua bac s挑)
- Attendance card(B畉n ch畉m c担ng):
Ho味c xac nh畉n cua c担ng ty
- Incident report(Bi棚n b畉n s畛 vi畛c)
- Driving license(Copy gi畉y phep lai xe)
- Others(Ch動ng t畛 khac)
I, claimant, hereby declare that the above information is correct to the best of my knowledge and belief.
(T担i, v畛i t動 cach l ng動畛i oi b畛i th動畛ng, xin cam oan nh畛ng l畛i khai tr棚n 但y l 炭ng s畛 th畉t)
I also understand that this declaration gives permission the insurer and their appointed representatives to approach any third party for information
required to complete their assessment of this claim including, but not limited to, my current and previous Medical Practitioners.
(T担i c滴ng 畛ng y r畉ng v畛i gi畉y y棚u c但u ny, t担i cho phep Cty b畉o hi畛m v 畉i di畛n cua h畛 ti畉p x炭c v畛i cac b棚n th動 ba 畛 thu th畉p th担ng tin c但n
thi畉t cho vi畛c xet b畛i th動畛ng ny bao g畛m, nh動ng kh担ng gi畛i h畉n 畛 cac bac s挑 達 v ang i棚u tr畛 cho t担i)
Date (ngy):
Signature of the Claimant
(Ch畛 k鱈 cua ng動畛i y棚u c但u b畛i th動畛ng)
2. SPECIFICATION OF MEDICAL EXPENSES
(B畉ng k棚 chi ph鱈 ph叩t sinh)
Name of the Claimant:
Ng動畛i y棚u c但u b畛i th動畛ng:............................................................................................................................
No.
STT
Invoices/receipt date
Ngy c畉p h坦a 董n
Amount
S畛 ti畛n
Total
T畛ng c畛ng
In Number:
In word:
ia ch畛 g畛i h畛 s董 y棚u c但u gi畉i quy畉t quy棚n l畛i b畉o hi畛m
C担ng ty TNHH Insmart
T畉i H N畛i: T畉ng9, T嘆a nh HEID, K3B, Ng探 6A, Ph畛 Thnh C担ng, qu畉n Ba 狸nh. Tel : 04 3 7728106 - Fax: 04 3
7728110
