Accident Protect/ Hospital Income Protect Claims Procedure 意外保障 / 住院入息索償程序

Transcription

1 Accident Protect/ Hospital Income Protect Claims Procedure 意外保障 / 住院入息索償程序 1. Submit your claims within 30 days from the date of sickness/ accident 於疾病 / 意外後 30 天內提交索償申請 - Please complete the following Claim Form and submit your claim through / by post to our company together with the supporting documents. 請填妥以下索償表格, 連同有關證明文件之正本電郵 / 郵寄至本公司 電郵 Claims@allianz.com Postal Address Allianz Global Corporate & Specialty SE Hong Kong Branch Units , BEA Tower, Millennium City 5, 418 Kwun Tong Road, Kwun Tong, Kowloon 郵寄地址 安聯環球企業及專項保險香港分公司香港九龍觀塘道 418 號創紀之城五期東亞銀行中心 23 樓 室 2. Provide your Claims supporting document(s) 提交索償證明文件 - Completed and duly signed Claim Form. 已填妥之索償表格 - Original medical receipt(s)/ bill with diagnosis. 附有臨床診斷之正本醫療收費單據 - Discharge slip/ summary (for claims with hospitalization). 出院紙 / 出院撮要 ( 適用於住院索償 ) - Attending Physician Statement (Appendix B of the Claim Form) (for claims with hospitalization). 主診醫生報告 ( 索償表格之附錄 B) ( 適用於住院索償 ) - Medical report(s)/ certificate(s)/ note(s), if any. 醫療報告 / 證明 / 備忘, 如有 - Referral letters for any specialist consultation, if any. 專科治療轉介信, 如有 - Sick leave certificate(s), if any. 病假紙, 如有 - Employer s confirmation of sick leave (Appendix A of the Claim Form), if any. 僱主確認病假信 ( 索償表格之附錄 A), 如適用 3. General claims assistance and enquiries 一般索償協助及查詢 Should you have any claim enquiries, please contact us by our Hotline at or through at Claims@allianz.com. 如有任何索償查詢, 請致電熱線 或電郵至 Claims@allianz.com 與我們聯絡 Important Notes 重要事項 - For reimbursement claim of medical expenses, original receipts with full details must be provided. 有關醫療費用之索償, 必須提供正本醫療收費單據 - For any document(s) to substantiate your claim, you have to bear the charges on your own expense. 有關索償證明文件之費用須由申索人支付 - Depending on the nature of your claim, we may require you to provide additional document(s)/ information. 我們將根據索償情況要求閣下提供其他索償證明文件 - Please retain a copy of all your documents submitted to us for your own reference. 請於提交索償文件前保留一套參考副本

2 Allianz Global Corporate & Specialty SE (incorporated in the Federal Republic of Germany with limited liabilities) Hong Kong Branch 安聯環球企業及專項保險 ( 在德意志聯邦共和國註冊成立的有限公司 ) 香港分公司 Address Suites , 4/F, Cityplaza Four, 12 Taikoo Wan Road, Taikoo Shing, Island East, Hong Kong 地址 香港港島東太古城太古灣道 12 號太古城中心四座 4 樓 室 Tel 電話 電郵 Claims@allianz.com.hk Website 網址 http// N.B. The issue or acceptance of this form is not an admission of liability by the Company. 注意 發放或接收此索償申請表並不代表本公司承認任何賠償責任 ACCIDENT PROTECT/ HOSPITAL INCOME PROTECT CLAIM FORM 意外保障 / 住院入息入息保障保障索償表格 THE CLAIMAINT AND POLICYHOLDER ARE REQUESTED TO NOTE 申索人及保單持有人需知 (a) This form must be duly signed and completed by Claimant and Policyholder then delivered to the Company together with supporting document(s) within thirty (30) days for any circumstances that may give rise for a claim. 申索人及保單持有人必須在事件發生後的三十 (30) 日內填妥本表格並連同相關證明文件一同交往本公司 Please to 請電郵至 Claims@allianz.com.hk Or by Post Allianz Global Corporate & Specialty SE Hong Kong Branch Units , BEA Tower, Millennium City 5, 418 Kwun Tong Road, Kwun Tong, Kowloon 或郵寄至 安聯環球企業及專項保險香港分公司香港九龍觀塘道 418 號創紀之城五期東亞銀行中心 23 樓 室 (b) Particulars of the claim should be stated as fully as possible and any suspicions as to parties implicated should be communicated to the Company at or to Claims@allianz.com.hk. 申索人應盡量完整地填寫本申索的詳細情況, 如有任何疑問, 應致電 或電郵至 Claims@allianz.com.hk 與本公司聯絡 Policy No. 保單號碼 Name of Claimant 申索人姓名 Contact No. 聯絡電話 Correspondence address 通訊地址 Occupation of Claimant 申索人職業 Date of birth (dd/mm/yyyy) 出生日期 ( 日 / 月 / 年 ) address 電郵地址 Did you reside outside of Hong Kong for more than one hundred and eighty (180) consecutive days in the Policy Year? 閣下曾否在該保單年度內連續一百八十 (180) 日不在香港? No 沒有 Date of departure 離港日期 Yes, please provide the following details 有, 請提供以下詳情 Country 國家 Duration of stay 逗留時間 Type of Claim 索償類別 Personal Accident 人身意身意外 Date of accident 意外日期 Time 時間 Place 地點 Hospitalization Benefit 住院保障 Date of sickness 患病日期 Date of first consultation 首次看診日期 Page 1 of 5

3 Details of accident/ sickness 意外 / 疾病詳情 Nature of injury/ diagnosis 受傷 / 疾病診斷結果 History of similar accident/ injury/ sickness 類似意外 / 受傷 / 疾病之病歷 Claim amount 索償金額 Current status of your treatment 是次治療之現況 Still under treatment 尚在治療中 Fully recovered 已完全康復 Any hospitalization for you related to this accident/ sickness? 有否因為是次意外 / 疾病而住院? No 沒有 Yes, please complete the table below and submit the Attending Physician Statement (Appendix B) duly signed and completed by your attending Physician/ Doctor 有, 請填寫下列列表及提交由主診醫生填寫之主診醫生報告 ( 附件 B) Name of hospital 醫院名稱 Diagnosis 病症 Date of admission (dd/mm/yyyy) 入院日期 ( 日 / 月 / 年 ) Date of discharge (dd/mm/yyyy) 出院日期 ( 日 / 月 / 年 ) Total days of confinement 總住院日數 Name and address of doctor recommending admission to hospital 建議入院的醫生名稱及地址 Any operation/ surgery performed during hospital confinement? If yes, please provide date and name of operation/ surgery 是次住院是否有接受手術? 如有, 請提供手術名稱及日期 No 沒有 Yes, please provide date and name of operation/ surgery 有, 請提供手術名稱及日期 Name of surgical procedures 手術名稱 Date of operation 手術日期 Period of medical leave after discharged from hospital 出院後之病假期 From 由 / / To 至 / / dd 日 mm 月 yyyy 年 dd 日 mm 月 yyyy 年 Total number of sick leave days 病假總日數 day(s) 日 * *Remarks 備註 If the total number of sick leave days are more than seven days, please ask your employer to duly signed and completed the EMPLOYER S CONFIRMATION OF SICK LEAVE (Appendix A) 如果病假期總日數超過七天, 請提交由僱主填寫之僱主確認病假信 ( 附件 A) If you are claiming under a section of the policy not provided on this claim form, please provide details below (e.g. Total Permanent Disability) 如果您的索償事項不包括在本申請表的項目中, 請註明於下列空白處 ( 例如 完全永久傷殘 ) Page 2 of 5

4 For the claim payment (if applicable) direct credit to Policyholder s bank account, Please complete all of the following 請填寫以下所需資料以便本公司將賠償款項 ( 如適用 ) 直接存入保單持有人之戶口 Name of account holder 帳戶持有人姓名 Bank name 銀行名稱 Bank account No. 銀行帳戶號碼 - - Bank code 銀行編號 Branch code 分行編號 Account No. 帳戶號碼 Have you submitted a claim for employee compensation for this sickness/ accident? 閣下有否就是次疾病 / 意外索償勞工保險? No 沒有 Yes, please provide Name of Employer and complete the table below 有, 請提供僱主名稱及填寫下列列表 Name of Employer 僱主名稱 Have you applied any other insurance or compensation claim for this sickness/ accident? 閣下有否就是次疾病 / 意外向其他保險公司索償? No 沒有 Yes, please complete in the table below 有, 請填寫下列列表 Name of insurer 保險公司名稱 Policy No. 保單號碼 Type of benefit 保障類別 Date of file claim (if any) 申索日期 ( 如有 ) Claim amount (HKD) 索償金額 ( 港幣 ) DECLARATION AND AUTHORISATION 聲明及授權 1. I/We declare to the best of my/ our knowledge and belief that the above information and particulars to be true and complete. 本人 / 我們就此作出聲明, 以上所述事項均根據本人 / 我們所知及所信的情況下提供, 並且為正確及並無遺漏 I/We, the undersigned claimant, hereby authorize any parties, including but not limited to police, insurance companies, hospitals, or other persons and/ or authorities who are in possession of my/our insurance proposal information, claim information or any related information, to furnish to Allianz Global Corporate & Specialty SE Hong Kong Branch or its authorized representative, any and all information with respect to the subject or related incidents of injury, loss or damage. 本人 / 我們為下方簽署之申索人授權任何持有本人 / 我們之投保資料 索償紀錄或任何有關資料之一方, 包括但不限於警方 保險公司 醫院或有關人士及 / 或當局, 向安聯環球企業及專項保險香港分公司或其授權之代表提供所有有關是次或相關傷亡事件之資料 2. I/We, the undersigned claimant, hereby authorize any Hospital, Physician, or other person and / or Authority who has attended or examined me, to furnish to Allianz Global Corporate & Specialty SE Hong Kong Branch or its authorized representative, any and all information with respect to any illness or injury, medical history, consultation, prescription or treatment and copies of all hospital or medical records. 本人 / 我們為下方簽署之申索人授權任何曾照料及診察本人之醫院, 醫生或其他人士及或有關當局, 向安聯環球企業及專項保險香港分公司或其授權之代表提供所有有關任何疾病, 意外受傷, 健康背境, 醫療紀錄之資料及醫院或醫療紀錄之副本 3. I/We hereby declare the foregoing particulars to be true, accurate and complete in every respect and that no information has been suppressed and that the sum claimed as filled represents the amount I/we are entitled to claim in terms of the Policy and the Instructions contained herein. I/We understand that if I/we have in this or in any further declaration in respect of this claim, made any false or fraudulent statement or suppress conceal or falsely state any material fact whatsoever my/our claim may be refused. I/We undertake to advise the Company promptly of all developments in connection with the claim and to render every assistance in dealing with the matter. I/We further authorise the Company to treat the submission of this form as my/our making a claim under my/our Policy. 本人 / 我們謹此聲明上述詳細說明在各方面均為真實正確及完整, 本人沒有隱瞞任何資料, 在本文件列出的索償總額代表本人 / 我們在本保單及指引中包含的索賠金額 本人 / 我們明白若本人 / 我們就此索賠作出任何進一步的聲明, 作出錯誤或欺詐聲明或刻意隱瞞或錯誤地陳述任何事實, 本人 / 我們的索賠將可能被拒 索賠承諾會向貴公司即時提供所有與索賠有關的進展, 及全力協助貴公司處理索賠事宜 本人 / 我們進一步授權予貴公司提交此表格, 作為本人 / 我們在本人 / 我們保單下作出索賠 Page 3 of 5

5 4. I/We further declare that the information written in this claim form or held by the Company whether contained in my/our insurance application / proposal form or otherwise obtained may be used and disclosed to your authorised staff, associated individuals and/or companies or any independent third parties (within or outside Hong Kong) who will provide claims administrative, advice and/or information or claims services in relation to my/our claim. I/We understand my/our data that may also be used for audit, business analysis and reinsurance purposes. My/Our signature below will signify this consent. 本人 / 我們進一步聲明此申請書內填寫的資料及貴公司在本人 / 我們保險申請 / 計劃書內獲得的資料, 可向貴公司就本人 / 我們索賠提供索賠管理 建議及 / 或資料或索賠服務的獲授權員工 相關人士及 / 或公司或任何獨立的第三方人士 ( 在香港境內或外 ) 披露或被其使用的資料 本人 / 我們明白本人 / 我們的數據可用作核數 業務分析及再投保之用 本人 / 我們在以下部分的簽署可茲證明 5. I/We acknowledge and agree (in case of corporate policy, I represent that I have obtained the consent of the individuals in relation to this policy) that the Company may collect, use, disclose and/or process my personal data (in case of corporate policy, personal data of individuals in relation to this policy) in accordance with the Personal Data (Privacy) Ordinance (Cap 486),for the purposes and uses described in Allianz s Privacy Policy (including the provision of protection, services related to this insurance policy, screening activities in accordance with legal/regulatory obligations/risk management procedures). This may include disclosure to Allianz s business partners, intermediaries, third party service providers and industry associations. Allianz s Privacy Policy can be found at 本人 / 我們知悉及同意 ( 如是企業保單, 本人代表本人已獲得本保單相關人士的同意 ) 貴公司根據個人資料私隱條例 ( 香港法律第 486 章 ) 及其他法例 貴公司及 / 或其集團嚴格的內部政策收集 使用 披露及 / 或查閱本人的個人資料 ( 如是企業保單, 則指本保單相關人士的個人資料 ), 以作安聯私隱政策 ( 包括保障條例 本保單相關的服務 司法 / 監管義務 / 風險管理程序 ) 內提及的目的及用途 此可能包括向安聯的業務伙伴 中間人 第三方服務供應商及同行機構 安聯私隱政策請參閱 6. I/We have read and agreed to all of the Declarations and Authorisation, and the Personal Information Collection Statement. 本人 / 我們已閱讀 明白並同意所有聲明及授權及個人資料收集聲明 7. A photostat copy of this authorisation shall be as effective and valid as the original. 本授權書之影印本的法律效力等同正本 Signature of Claimant 申索人簽署 Signature of Policyholder 保單持有人簽署 (with company chop if applicable 如屬公司請蓋章 ) (with company chop if applicable 如屬公司請蓋章 ) HKID No. 香港身份證號碼 / Passport No. 護照號碼 HKID No. 香港身份證號碼 / Passport No. 護照號碼 Date 日期 Date 日期 Page 4 of 5

6 PERSONAL INFORMATION COLLECTION STATEMENT 個人資料收集聲明 Allianz Global Corporate & Specialty SE Hong Kong Branch ( we or us ) may use the personal data we collect about you for the following purposes 安聯環球企業及專項保險香港分公司 ( 我們 ) 可就我們收集有關您的個人資料作以下用途 (i) (ii) (iii) (iv) (v) (vi) (vii) (viii) (ix) processing and evaluating your insurance application and any future insurance application you may make; 處理及評估您的保險申請及您未來作出之任何保險申請 ; administering your insurance policy and providing services in relation to your insurance policy; 辦理保單文件及提供有關您保單之服務 ; investigating, processing and paying claims made under your insurance policy; 調查 處理及償付您保單之索償 ; invoicing and collecting premiums and outstanding amounts from you; 處理發票及向您收取保費及未付之費用 ; reinsurance purposes; 再保用途 ; statistical research, data matching and/or verification purposes; 統計研究 資料配對及 / 或調查之用 ; contacting you for any of the above purposes; 就以上任何用途與您聯絡 ; other ancillary purposes which are directly related to the above purposes; and 其他與以上用途直接有關之輔助用途 ; 及 complying with applicable laws, regulations or any industry codes or guidelines or requests. 符合適用之法例 規則或任何業內守則或指引或要求 Such personal data may be disclosed, shared, divulged, supplied or otherwise transferred, within or outside Hong Kong, to 這些個人資料可披露 分享 透露 提供或轉移至香港境內或境外的 a) any of our related or associated companies, third party service providers, intermediaries, professional advisers and/or vendors in relation to any of the aforesaid purposes; and 任何與上述目的有關的相關或相關聯公司 第三方服務供應商 代理, 專業顧問和 / 或供應商 ; 及 b) any association, federation or similar organization of insurance companies and/or other business participants in the insurance industry ( Federation ) that exists or is formed from time to time for the benefit and interest of the insurance industry or any members thereof or for regulating the insurance companies or other business participants or any other individual/organization/third party as we may consider necessary or desirable in our discretion; and 任何保險業協會 聯會 保險公司及 / 或業務參與者為業界利益不時成立的組織 ( 聯會 ), 任何為了規範保險公司或其他業務參與者的成員或任何我們認為必須的個人 / 組織 / 第三方 ; 及 c) any regulator or government body or authority. 任何監管機構, 政府或官方機構 If you do not agree to the provision of the personal data requested on the form or the use of such data for the above purposes, we may not be able to process your application. 如果您不同意為了上述目的而提供表格上要求的個人資料, 我們將無法處理您的申請 You may seek access to and request correction of any personal data we hold about you by contacting our Data Privacy Officer at Suites , 4/F, Cityplaza Four, 12 Taikoo, Wan Road, Taikoo Shing, Island East, Hong Kong 要查閱及更正我們所持有您的任何個人資料, 可投寄至香港港島東太古城太古灣道 12 號太古城中心四座 4 樓 室, 與我們的資料保護主任聯絡 Page 5 of 5

7 Employer s Confirmation of Sick Leave 僱主確認病假信 (This letter must be completed by claimant s employer 此確認信必須由申索人僱主填寫 ) (*Not applicable to self-employed individual* 不適用於自僱人士 ) Date of Sickness/ Accident 疾病 / 意外日期 Sickness/ Accident Description 疾病 / 意外描述 This Letter is to clarify that (Claimant Name) (HKID. No ) being the 茲證明 ( 申索人姓名 ) ( 香港身份證號碼 ) 為 employee of our company 本公司 (Current Position) with basis of employment of ( 現職位 ) 受聘形式為 Permanent / Part-time / Casual / Contract / Seasonal / Others (please specified ). 全職 / 兼職 / 散工 / 合約 / 季工 / 其他 ( 請註明 ) The above sickness/accident caused him/ her to have sick leave period from (dd/mm/yyyy) 上述疾病 / 意外引致他 / 她由 ( 日 / 月 / 年 ) to 至 (dd/mm/yyyy). ( 日 / 月 / 年 ) 休假 Signed & Stamped by Authorised Person 受權人簽署及公司蓋印 Name of Authorised Person 受權人姓名 Signature of Claimant 申索人簽署 (I CERTIFY that to the best of my knowledge the foregoing statements are correct. 茲證明就本人所知, 以上陳述均屬正確 ) Position of Authorised Person 受權人職銜 Company Name 公司名稱 Date 日期 Company Address 公司地址 Appendix A

8 Attending Physician Statement 主診醫生報告 1. To be completed by the Insured person s attending doctor at the Insured Person s own Expenses 由受保人之主診醫生填寫而費用由受保人負責 2. Please attach copies of any specialist or hospital reports, together with any tests, or similar evidences to support the validity of your patient s claim. 請附上任何有關專科診治有關專科診治 住院報告住院報告 測試檢查或其他證明文件, 以協助病人的索償申請申請 Full name of Patient 病人全名 HKID / Passport Number 香港身份證 / 護照號碼 Gender 性別 Part I General Information 第一部份 一般資料 Date of first consultation related to this sickness/ accident 有關是次疾病 / 意外之首次看診日期 Name of first consultation doctor and clinic address 首次診治的醫生名稱及診所地址 Symptom(s)/ complaint(s) of the patient relating to the first consultation/ hospitalisation 病人就有關首次看診 / 住院之徵狀 / 疾病 How long had the patient been experiencing these symptoms before the first consultation? 在首次看診前該病徵已經出現於病人身上多久? Diagnosis 診斷 Was the patient referred to you by another doctor for further management? 病人是否由另一位醫生轉介予您作進一步治療? No 否 Yes, please specify the name and address of referral doctor 是, 請提供該醫生之姓名及地址 Was there any hospitalization for the patient? 病人有否住院? No, please complete the Part III & Part IV of this form 否, 請填寫本表格之第三及第四部份 Yes, please complete Part II to Part IV of this form 是, 請填寫本表格之第二至第四部份 Part II Details of Hospitalisation 第二部份 住院詳情 Name of Hospital 醫院名稱 Date of admission (dd/mm/yyyy) 入院日期 ( 日 / 月 / 年 ) Date of discharge (dd/mm/yyyy) 出院日期 ( 日 / 月 / 年 ) Did the patient take any home leave during the hospital confinement? 病人曾否於住院期間請假離院? No 沒有 Yes, please specify the reason and the period of home leave 有, 請填寫離院時段及原因 Final diagnosis 最終診斷 Please give a brief discharge summary (including investigation tests and results, procedures, treatments, operations, result of such treatments and/or any complications and follow up plans) 請提供出院摘要 ( 包括診斷測試及結果 診斷經過 治療 手術 併發症及 / 或任何跟進計劃 ) If the patient has consulted other physician during this hospitalisation, please provide the following 如病人於是次住院期間曾向其他醫生求診, 請提供以下資料 No 沒有 Yes, please specify the following 有, 請填寫詳情 Name of doctor and clinic address 醫生名稱及診所地址 Treatment performed 提供治療 Reason 原因 Please provide reason(s) for hospitalisation if this type of cases can be managed on day care/out-patient basis. 假若這類個案可於日間 / 門診護理, 請提供入住醫院原因 Part III Profession Comment 第三部份 專業意見 Please tick the box if the medical condition and its subsequent treatment are associated with the followings. 如上述病況及其後的治療與下列情況有關, 請於下列方格加上剔號 Congenital condition, infertility or sterilization 先天性疾病, 不良或絕育情況 Pregnancy conditions or any related complications 懷孕或由此引發之病況 Cosmetic / Plastic surgery 整形外科手術 Mental psychiatric problems 心理精神科 Patient s occupational activities 病人之職業活動 Aerial/ Mountaineering/ Professional sports 空中 / 爬山 / 職業運動 Part IV Declaration 第四部份 聲明 I hereby declare that all the above information are to the best of my knowledge, is true and complete. 本人證明上述的資料根據本人所知皆為正確無訛 Signature and chop of attending physician 主診醫生簽署及蓋章 Date (dd/mm/yyyy) 日期 ( 日 / 月 / 年 ) Address and telephone no. 地址及聯絡電話 Appendix B