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1、 Claim Amount for Medical Expense 醫療費用索償金額 Amount of Chinese medical treatment receipt(s) Pieces 中醫門診金額 HK$ X 張 = HK$Amount of out-patient Western medical treatment receipt(s) Pieces 西醫門診金額 HK$ X 張 = HK$Amount of hospital receipt(s) Pieces 住院金額 HK$ X 張 = HK$HK$ Total receipts amount 收據總額Name of Poli
2、cyholder (English) 保單持有人姓名(英文) :Policy/certificate no. 保單號碼 :Name of Policyholder (Chinese) 保單持有人姓名(中文) :Name of Insured (Chinese) 受保人姓名(中文) :Name of Insured (English) 受保人姓名(英文) :Name of Claimant (English)(Only applicable for fatal case)Name of Claimant (Chinese)(Only applicable for fatal case)Ackno
3、wledgement will be sent to this mobile phone number via SMS upon receipt of this form.Insureds HKID No/Passport No 受保人香港身份証/護照號碼 :Name of Parent/Legal Guardian (Chinese) Only applicable if the Insured is below the age of 18 父母/合法監護人姓名(中文) 只適用於受保人未滿18歲的情況Name of Parent/Legal Guardian (English) Only a
4、pplicable if the Insured is below the age of 18 父母/合法監護人姓名(英文) 只適用於受保人未滿18歲的情況Are you a citizen of the United States? 閣下是否美國公民？ Yes 是 No 否New Claim 新的索償 Further Claim, with Claim Number 再度索償，索償檔案編號 :Claim Type (please tick) 索償類別(請選擇)Claim Item (please tick) 索償項目(請選擇)Amount 索償金額 HK$If yes, please pro
5、vide your social security number 如是，請提供社會保障編號 :If yes, please provide the details below 如是，請提供以下資料 Name of Insurer 保險公司之名稱_ Policy No. Policy Type Sum Insured 保單編號_ 保單類別_ 保額_Do you have any other insurance policies covering this loss or expenses incurred? 是項索償項目是否受保於其他保險合約？Yes 是 No 否Parent/Legal Gua
6、rdians HKID No/Passport No 父母/合法監護人香港身份証/護照號碼 :索償申請人姓名(中文)(只適用於死亡個案)索償申請人姓名(英文) (只適用於死亡個案)E-mail Address 電郵地址 :Mailing Address 通訊地址 :Claimants HKID No/Passport NoRelationship between Claimant 2) otherwise for the purpose of administering the insured(s) insurance policy (including pursuing recovery f
7、rom reinsurers) and 3) for other purposes stated elsewhere in this form.(c) AIG HK may transfer the personal data to the following classes of persons (whether based in Hong Kong or overseas) for the purposes identified in (b) above: i) third parties providing services related to the administration o
8、f the Insureds policy (including reinsurers); ii) financial institutions for the purpose of processing this application and obtaining policy payments; iii) loss adjustors, assessors, third party administrators, emergency providers, legal services providers, retailers, medical providers and travel ca
9、rriers; iv) another member of the AIG group (for all of the purposes stated in (b) ) in any country; or v) other parties referred to in AIG HKs Data Privacy Policy for the purposes stated therein. (d) The Insured(s)/Claimant(s) may gain access to, or request correction of their personal data (in bot
10、h cases, subject to a reasonable fee)at any time, by writing to the Privacy Compliance Officer of AIG Insurance Hong Kong Limited at GPO Box 456 or . The same addresses may be used to contact us with any comments on our service. The full version of AIG HKs Data Privacy Policy can be found at .hk. C.
11、 The Insured(s) / Claimant(s) hereby irrevocably authorize:(a) any organization, institution, or individual that has any information, record or knowledge of the Insured(s) health and medical history or any treatment or advice rendered thereto to disclose to AIG HK such information, record and knowle
12、dge;(b) AIG HK or any of its approved medical examiners or laboratories to perform the necessary medical assessment and tests to underwrite and evaluate the Insured(s) health status in relation to the Claims therein and any matter arising therefrom. These tests may include, but are not limited to, t
13、ests for cholesterol and related blood lipids, diabetes, liver or kidney disorders, acquired immunodeficiency syndrome (AIDS), infection by any human immunodeficiency virus (HIV), immune disorder or the presence of medica- tions, drugs, nicotine or their metabolites;(c) the police that has any of th
14、e Insured(s) information to provide AIG HK with the information including but not limited to the police reports, witness statements, investigation and/or prosecution results;(d) airline(s) that has/have any of the Insured (s) information to provide AIG HK with the information including but not limit
15、ed to flight details, booking details, irregularities reports and all information related to the Insured (s) bookings; and(e) any organization institution or individual that has any information, record or knowledge of the Insured(s) travel record to disclose to AIG HK such information, record and knowledge. This authorization shall bind the Insured(s) / Claimant(s) successors and assigns and remain valid notwithstanding the Insured(s) / Claimant(s) death or incapacity in so far as lega
