GIC Care- New Claim Form VN
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Transcript of GIC Care- New Claim Form VN
GIC CareGIY NGH BI THNGn bo him s :___GM1914/09CK01PH_______________________________ Tn Ngi c bo him : Ngy sinh : 15/6/1988 o Mnh Qun Nam M s th bo him GIC Care : 86172/0
M nhn vin / s CMND : 633/012625778 L : chng /v /con ca :_________________________________________________________________________________ ang lm vic ti : T chc Tm Nhn Th Gii ti Vit Nam Chc danh : Tr L Hnh Chnh NBH : 29/8/2011 in thoi : 0936780660 1. M t tai nn / M t bnh tt Email : [email protected] Ngy bt u bo him ca
M t tai nnTai nn c lin quan n cng vic hay khng ? Thi gian v a im xy ra tai nn : ________________________________________________ _ ________________________________________________ _ ________________________________________________ _ Din bin ca tai nn : ________________________________________________ _ ________________________________________________ _ ________________________________________________ _ ________________________________________________ _ ________________________________________________ _ ________________________________________________ _ Mc thng tt ________________________________________________ _ ________________________________________________ _ Thi gian iu tr __________________________________________
M t bnh ttChn on v triu chng bnh : + n soi vo ht trc trng. Trc trng c 2 polyp ~ 0.5-0.6cm khng cung + Hu mn c tr ni II Thi gian nm vin / phu thut (nu c) + Ct Polyp qua ni soi : Ngy 14 thng 2 nm 2012 a im Bnh Vin Bch Mai Khoa Thm D Chc Nng
2. Qu khch bao gi b nhng thng tt / bnh tng t cha ?Nu c, xin vui lng cho bit chi tit (khi no, nguyn nhn, mc , v.v)
Khng
______________________________________________________________________________________________ ______________________________________________________________________________________________
3.
Xin hy gi km bng gc cc chng t y t, toa thuc v ha n thuc tng ng
a) b) c) d) e)
Khm Bnh Soi trc trng Ct Polyp ng tiu ha Xt nghim sinh khit n thuc Tng cng ton b chi ph
VND 30.000 VND 70.000 VND 800.000 VND 110.000 VND 576.000 VND 1.686.000
4.Xin hy gi bn photo bng li xe v Giy ng k xe gng my / xe hi v bin bn Cng An (nu c) trong trnghp b tai nn giao thng.
5.Xin hy gi bn tng trnh tai nn c xc nhn ca lnh o ni mnh lm vic (trong trng hp tai nn lao ng)6. Xin hy gi giy chng t (trong trng hp cht)
7.Xin hy gi giy xc nhn quyn tha k hp php (trong trng hp cht) nu ngi c bo him khng ch nhngi tha k trong giy yu cu bo him.
8.Xin cho bit qu khch mun nhn tin bi thng di hnh thc no : (tin mt / chuyn khon) Trong trng hp nhn tin mt xin cho bit : H tn ngi th hng :____________________________________________________________________________ a ch :______________________________________________________ in thoi lin lc :___________________ S CMND hoc Passport :___________________________ngy cp:________________________________________ Ni cp:_________________________________________ngy ht hn (nu c):______________________________ Nhn tin mt ti Gras Savoye Willis Vietnam __________________________________________________________ Trong trng hp chuyn khon xin cho bit : H tn ngi th hng : o Mnh Qun a ch : Gii Phng, ng a , H Ni S TK : 020704070005685 a ch Ngn Hng : 32 Trn Hng o, Hon Kim, H Ni Ti tn l, o Mnh Qun cho php bt c bc s iu tr ti bnh vin hoc trung tm y t, phng khm a khoa nhng ni m ti iu tr cung cp ton b chi tit v sc khe ca ti cho GIC v Gras Savoye Vietnam, l i din c y quyn ca GIC . Bn photo ca vn bn ny cng s c hiu lc nh bn chnh. Ti cng cam oan rng nhng li khai trn y ca ti l hon ton ng s tht v y nh nhng g ti c bit. Ngn Hng : HD Bank Hon Kim
Xc nhn ca Cng ty (K tn ng du)
Ngi khai k tn
H tn :__________________________________ Ngy : ________________________ Ngy :___________________________________
