AIA

Network Surgery / Medical Claim Form

網絡手術 / 醫療賠償申請表
If claim application can be done through AIA+ mobile app, there is no need to complete the PART I of this claim form. Please contact
your attending doctor to complete PART II of this claim form.
若透過AIA+手機程式遞交申請索償，無需填寫此賠償申請表的第一部分。閣下可進一步安排主診醫生填寫賠償申請表第二部分。

PART I (TO BE COMPLETED BY INSURED / CLAIMANT) 第一部分（由受保人或申請人填寫）

Policy Number Name of Insured ID Card Number / Passport Number
保單號碼 受保人姓名 身份證號碼 / 護照號碼

XXXX
Please indicate who to follow up this claim 請指示由以下哪位人士跟進此索償申請
By Servicing Agent as policy record 保單記錄中的營業員
By other agent / broker of below details 其他營業員 / 經紀業務代表資料如下
Area Code Agency / Broker Name Agent / Broker Code O1002179
區域編號 營業員組別 / 經紀名稱 營業員號碼 / 經紀號碼

Agency Code Agent / TR’s Name Agent / TR’s Tel. No.

營業員組別編號 營業員 / 業務代表姓名 營業員 / 業務代表聯絡電話

TR Membership Number 業務代表會員號碼 IA ANG

By own self of policyowner 保單持有人親自跟進

For proper follow up on your claims progress, your AIA financial planner / broker / IFA of your latest inforce policy can view this claim’s
information if no specific agent / broker / IFA / TR information is provided at above. 為了妥善地跟進您的賠償進度，若於以上沒有提供指定
營業員 / 保險或理財顧問 / 業務代表資料，您最新生效保單的友邦財務策劃顧問 / 保險或理財顧問將能夠查閱是次申請資料。
If you do not agree on the above arrangement, please mark a “X” in the box. 如果您不同意上述安排，請於空格內劃上「X」號。
Benefits to Claim 索償類別
Accident Medical Reimbursement 意外醫療費用賠償 Medical Reimbursement 醫療費用賠償 Health Wallet 健康賞
Accident / Weekly Indemnity 意外 / 每週賠償 Hospital Income / Benefit 住院入息 / 惠益
Broken Bone 骨折惠益 Voluntary Group Assurance 自選團體保障
Remarks: Please select the appropriate box; otherwise we will apply this claim to all of your eligible benefits.
註: 請選擇適用者，否則我們將會把申請應用於您的所有同類保障。

CLAIMS SEQUENCE 理賠次序

Please use 1, 2, and 3 to indicate the order of claim 請以1, 2, 3 表示你所選擇的理賠順序
AIA Individual Life AIA Group Insurance Other Insurance Company
友邦個人壽險 友邦團體醫療保險 其他保險公司
Please further provide the below information and relevant settlement advice, if applicable:
請提供以下資料及遞交有關的賠償金額通知書（如適用）：
(I) AIA Group insurance policy: 1) group policy no. & employer name, 2) member/certificate no., 3) employee name & 4) relationship with
employee)
友邦團體醫療保險保單：1）團體保單號碼 & 僱主名稱、2）會員 / 證書編號、3）員工姓名 & 4）與員工的關係

(II) Other insurance company: 1) name of other insurance company, 2) policy no., 3) name of insured & 4) name of policyowner
其他保險公司：1）其他保險公司名稱、2）保單號碼、3）受保人姓名 & 4）人保單持有人名稱

If the insured or the policyholder is holding both AIA International Limited and AIA Everest Life Company Limited policies, the claims (including
registration of FPS / e-BankIn services) will be processed together. In addition, the “Declaration and Authorization” and “Personal Information
Collection and Use” in the claim form will be also applicable to AIA International Limited and AIA Everest Life Company Limited.
若受保人或保單持有人同時持有友邦保險(國際)有限公司及友邦雋峰人壽有限公司之保單，相關賠償（包括登記「轉數快」或「電子入賬服務」）
將會一併處理。此外，賠償表格內之「聲明及授權」及「個人資料收集及使用」亦同時適用於友邦保險(國際)有限公司及友邦雋峰人壽有限公司。
If you do not agree on the above arrangement, please mark a “X” in the box. 如果您不同意上述安排，請於空格內劃上「X」號。

O1002179----7
Page 1 of 7 OPCLMF03.0325
 Policy Number 保單號碼

NETWORK SURGERY / HOSPITALIZATION PARTICULARS 網絡手術 / 入院詳情

Please provide the below information 請提供以下資料：
(I) Symptoms, Symptoms onset date or Accident incurred date and cause, diagnosis, name of doctor 徵狀、徵狀開始或意外發生日期及
原因、診斷、醫生姓名

(II) Hospitalization / Surgery 手術 / 入院資料

For the illness mentioned above, please provide the name of the hospital where treatment was received, the dates of admission and
discharge, and the name of the surgery. 對於上述提到的疾病，請提供接受治療的醫院名稱，入院和出院的日期，以及手術的名稱。

(III) Besides service provider/patient, please elaborate if insured has other relationship with the attending doctor e.g. immediate family, employer /
employee, business partners or insurance agent/broker. 除醫生與病人關係外，請說明受保人與醫生的其他關係，例如: 直系親屬、僱主或
僱員、商業合夥人或本公司保險代理人 / 受保人的保險代表。

CLAIMS PAYMENT OPTION 支付賠償方法：

IMPORTANT NOTE 重要事項：
For customers who have registered FPS / e-BankIn, the payment will be remitted to the designated bank account.
如客戶已登記使用「轉數快」或「電子入賬服務」，賠償款項將會自動入賬至指定銀行戶口
To receive claims payment easily and conveniently, please register FPS / e-BankIn by completing the following:
為更方便快捷收到賠償款項，請填妥以下資料以即時登記「轉數快」或「電子入賬服務」：
Owner’s Mobile Number
持有人流動電話號碼：_______________________________________________
If the telephone number provided differs from our company records, we will update it to all or selected policies as indicated in the following section. You will receive
an SMS notification upon the completion of the registration.
如所提供的電話號碼與公司的紀錄不同，我們將根據您於以下部分提供的指示，將該號碼更新至您於公司持有的所有或指定的保單。完成登記後，您將收到短訊通知。
Identity proof must be provided for registration of FPS / e-BankIn if you have not submitted a valid Identity Card / Passport before.
如未曾提供有效的身份證 / 護照，需遞交身份證明文件作登記「轉數快」或「電子入賬服務」之用

Complete this section if applying for Hong Kong Policy(ies) 請填妥以下部分如申請涉及香港保單 ：

Apply to all your Hong Kong policies held with our Company. 是次申請應用於您於公司所持有之所有香港保單。
Remark: If the stated AIA financial planner / broker / IFA on this form is not my current servicing AIA financial planner / broker / IFA of other policies, I give
consent to him / her to follow up my request for all Hong Kong policies.
備註：倘若表格上填寫的財務策劃顧問 / 經紀 / 獨立理財顧問並不是本人其他保單的財務策劃顧問 / 經紀 / 獨立理財顧問，本人同意他 / 她一併跟進我就所有
香港保單的要求。
Apply to the following Hong Kong policy / policies. 是次申請只應用於下列之香港保單：

Please select the appropriate box; otherwise we will apply to all of your Hong Kong policies held with our Company. 請選擇適用者，否則我們將會把是次申請應用
於您於公司所持有之所有香港保單。
Use “FPS / e-BankIn” to transfer policy benefits paid under the above policy to the below designated bank account. The transferred amount will not exceed the
maximum limit set by the Company. 使用「轉數快」或「電子入賬服務」將以上保單號碼所支付的保單利益轉入下列指定之銀行戶口，轉入之金額將不超過公司所
定的上限。
Please select transferring policy benefits paid to either FPS or e-BankIn. 請選擇「轉數快」或「電子入賬服務」其中一項以轉入以上保單號碼所支付之保單利益。

a. FPS* 轉數快* (Applicable to HKD payment only 只適用於港幣付款) b. e-BankIn 電子入賬服務

Please select either ONE of the “Proxy ID”# below by marking a “X” on appropriate box Please provide bank account information below and submit together with the following
and provide relevant information. More than one selection will be treated as invalid documents 請提供以下銀行戶口資料及提交下列之文件：
application. Your FPS account must also be registered under the policy owner. 請以 1) Copy of any recent bank passbook / bank correspondence / bank statement
(including e-statement) / valid bank card showing the account holder’s name and
「X」號選擇下列其中一種「識別代號」#及提供以下相關資料。 若多過一個選項將被 account number. 任何列有戶口持有人及銀行賬戶號碼最近期的銀行存摺 / 信件 /
視為申請無效。「轉數快」的用戶註冊名稱必須同樣為保單持有人。 月結單（包括電子結單）/ 有效銀行卡副本。
Email 電郵地址： 2) Joint account is not allowed. 不接受聯名戶口。
3) e-BankIn account must also be registered under the policy owner. 電子入賬服務
______________________________________________________________________________________________ 的戶口必須同樣為保單持有人。
4) Please ensure the bank account holder name is the same as the policyowner
FPS Identifier 「轉數快」識別號碼： name, otherwise the payment will be rejected by banks. 請確保銀行戶口持有人
姓名與保單持有人姓名一致，否則入賬指示將不被銀行接納。
_______________________________________________________________________________________________
Bank Name and Branch in Hong Kong 香港銀行及分行之名稱
Mobile Number 手機號碼：
( )
Country Code Telephone No
Bank No. Branch No. My Account No.
國際電話區號 手機號碼
銀行編號 分行編號 本人之賬戶號碼
* “FPS Service” means the services provided by us to you from time to time
to facilitate payments and funds transfer using the Faster Payment System and
related systems and services from time to time provided by Hong Kong Interbank
Clearing Limited, together with its successors and assigns. Name as recorded on Bank Passbook / Correspondence / Statement / Bank card
「快速支付系統服務（轉數快）」指我們不時向您提供的服務，以讓我們使用由香 (must be same as the Owner of the above Policy)
港銀行同業結算有限公司及其繼承人及受讓人不時提供的快速支付系統及相關系統 銀行存摺 / 信件 / 月結單 / 銀行卡上所記錄之戶口持有人姓名（必須與上述保單
及服務。 持有人相同）
#
“Proxy ID” means an identifier which may be accepted by HKICL for the
registration of an account in the HKICL Addressing Service, including your mobile
phone number, email address or FPS Identifier.
「識別代號」指結算公司接納用作結算公司賬戶綁定服務賬戶登記的識別
資料，包括您的手機號碼，電郵地址或「轉數快」識別號碼。

O1002179----7 Page 2 of 7 OPCLMF03.0325

 Policy Number 保單號碼

Complete this section if applying for Macau Policy(ies) 請填妥以下部分如申請涉及澳門保單 ：

Apply to all your Macau policies held with our Company. 是次申請應用於您於公司所持有之所有澳門保單。
Remark: If the stated AIA financial planner / broker / IFA on this form is not my current servicing AIA financial planner / broker / IFA of other policies, I give
consent to him / her to follow up my request for all Macau policies.
備註：倘若表格上填寫的財務策劃顧問 / 經紀 / 獨立理財顧問並不是本人其他保單的財務策劃顧問 / 經紀 / 獨立理財顧問，本人同意他 / 她一併跟進我就所有
澳門保單的要求。
Apply to the following Macau policy / policies. 是次申請只應用於下列之澳門保單：

Please select the appropriate box; otherwise we will apply to all of your Macau policies held with our Company. 請選擇適用者，否則我們將會把是次申請應用於
您於公司所持有之所有澳門保單。
e-BankIn 電子入賬服務
Please provide bank account information below and submit together with the following documents 請提供以下銀行戶口資料及提交下列之文件：
1) Copy of any recent bank passbook / bank correspondence / bank statement (including e-statement) / valid bank card showing the account holder’s name and
account number. 任何列有戶口持有人及銀行賬戶號碼最近期的銀行存摺 / 信件 / 月結單（包括電子結單）/ 有效銀行卡副本。
2) Joint account is not allowed. 不接受聯名戶口。
3) e-BankIn account must also be registered under the policy owner. 電子入賬服務的戶口必須同樣為保單持有人。
4) Please ensure the bank account holder name is the same as the policyowner name , otherwise the payment will be rejected by banks. 請確保銀行戶口持有人姓名與保單
持有人姓名一致，否則入賬指示將不被銀行接納。

Bank Name in Macau 澳門銀行之名稱_________________________________________________________________________________________________

Account Currency 賬戶貨幣
My Account No. 本人之賬戶號碼
HKD 港幣 MOP 澳門幣

Name as recorded on Bank Passbook / Statement (must be same as the Owner of the above Policy)
銀行存摺 / 月結單上所紀錄之戶口持有人姓名（必須與上述保單持有人相同 ）

DECLARATION & AUTHORIZATION 聲明及授權

By using the FPS / e-BankIn, I / we confirm I / we have read and agreed to be bound by the terms and conditions as set out on AIA Corporate
Website (www.aia.com.hk). 藉使用「轉數快」或「電子入賬服務」，本人 / 我們確認本人 / 我們已經閱讀AIA公司網頁內(www.aia.com.hk)列明
之條款及條件，並同意受此約束。
Only if FPS / e-BankIn has not been registered or requested, we will follow payment option selected at below by marking a “X” in one
of the boxes.唯有未登記使用「轉數快」或「電子入賬服務」，我們將根據以下於空格內劃上「X」號的支付賠償方法。
Deposited the claims payment (in the same Policy Currency) in the ancillary Future Premium Deposit Account(s) (“FPDA”). Terms of Use
of the FPDA shall govern and apply. (Applicable to Mainland Chinese Visitors policy only) 以相應的保單貨幣將賠償款項存入該保單附屬的
「現金儲備金户口」。「現金儲備金户口」的使用受其使用條款規範。（僅適用於抵港抵澳內地人士業務保單）
Paid by Cheque in policy currency (not applicable for FPS / e-BankIn customers) 以保單貨幣支票支付 (不適用於「轉數快」或「電子入賬
服務」之客戶)
Paid by Cheque in Hong Kong Dollar (not applicable for FPS / e-BankIn customers) 以港幣支票支付(不適用於「轉數快」或「電子入賬
服務」之客戶)
(a) I / We understand that any benefits payable under the Policy will be paid in the latest policy currency as shown on the Policy Information
Page of the Policy or, if applicable, the appropriate subsequent endorsement. Accordingly, the provision of the option to receive any such
benefits in a currency other than the latest policy currency (the “Opted Currency”) is solely a service offered by AIA at its discretion. 本人 /
我們明白所有保單利益之款項將根據保單資料頁或隨後所發出之批註（如適用）所載之最近期保單貨幣為準。因此，提供選擇以最近期的
保單貨幣以外的貨幣（「選擇貨幣」）作為收取任何此等利益的貨幣只屬友邦保險酌情所提供之服務。
(b) I / We understand and agree that should I / we opt for payment of any benefits payable under the Policy in the Opted Currency, I / we
will bear the necessary exchange difference, such difference being determined by AIA on the basis of AIA’s internal exchange rates as at
the time of the relevant currency conversion. 本人 / 我們明白及同意如本人 / 我們選擇任何保單下所作出的利益款項以「選擇貨幣」支付，
本人 / 我們同意承擔所需的兌換差額，而該差額是有關貨幣兌換時依據友邦保險內部貨幣兌換率而釐定。

IMPORTANT NOTE 注意事項

(a) In order to speed up your claim application, please attach the required claims documents together with this application form. You may check
the required documents on our website (http://www.aia.com.hk > Help & Support > Health Care and Claims > How to file a Claim). If you
want to get back the original medical receipt(s) / sick leave certificate(s) submitted, please also complete the “Request for Return of Original
Document(s)” Form. We will notify you or our AIA financial planner / your broker / IFA if we need to obtain extra information from you or
from outside parties to assess your claim. As the time required for obtaining the information is variable, the processing time of your claim
will likely be longer.
為使能儘速辦理您的索償申請，請將此表格連同有關索償文件一併遞交。有關申請索償所需遞交之文件，請參閱友邦的網頁
（http://www.aia.com.hk > 客戶支援 > 醫療保健和索償 > 如何索償）。如欲退回任何呈交之正本醫療收據 / 病假證明書，請一併遞交「退回
正本文件」申請表格。若我們有需要就審核閣下之賠償申請向您或其他人士索取額外資料，我們會通知您或友邦財務策劃顧問 / 您的保險
顧問 / 投資顧問。因索取有關資料需時，賠償申請的審核時間會較長。
(b) In case you want to claim for other benefits, you have to complete an appropriate claim form of that respective claim type and file it in
together with the necessary supporting evidence.
如您還需申請其他賠償類別，您須另行填寫及遞交相關的索償申請表格和所需證明。
(c) Please submit your claim application to our AIA financial planner / your broker / IFA or send it to us at the following address:
請將您的索償申請交予友邦財務策劃顧問 / 您的保險顧問 / 投資顧問，或郵寄至以下地址:
• HK : AIA Customer Service Centre, 12/F AIA Tower, 183 Electric Road, North Point, Hong Kong
香港：友邦客戶服務中心，香港北角電氣道183 號友邦廣場12樓
• Macau : AIA Customer Service Centre, Unit 201, 2F, AIA Tower, Nos. 251A-301, Avenida Comercial de Macau, Macau
澳門：友邦客戶服務中心，澳門商業大馬路251A-301號友邦廣場2樓201室

O1002179----7 Page 3 of 7 OPCLMF03.0325

 Policy Number 保單號碼

AIA E-ADVICE 「友邦電子通知書」

(Please mark a “X” in the box to apply for this service. 閣下如欲申請此服務請於空格內劃上「X」號。)
Apply for Internet Service “AIA e-Advice” to view / download the softcopies via AIA+ for the above policy and any other policy numbers
if specified as below, subject to the “Terms and Conditions for use of AIA+” which is available at https://www.aia.com.hk/aia-plus/en/tnc.
申請「友邦電子通知書」網上服務，就以上保單及其他下列保單號碼（如有）透過AIA+ 閱覽或下載副本，並受「AIA+ 使用條款及細則」
之約束，有關條款及細則可於https://www.aia.com.hk/aia-plus/zh-hk/tnc 。
* Email address Signature of Owner
電郵地址: 持有人簽署:
Other policy number(s)
其他保單號碼:
(Not applicable to Personal Lines policies with policy prefix C.
不適用於保單號碼字首為C之個人財物保險保單。）

No Claim Discount (NCD) (Only Applicable to product with NCD)

無索償折扣（只適用於享有無索償折扣的產品）

Important Note 重要通知

If a claim that arose in any previous Policy Year is eventually payable or paid by the company after the policy owner has earned the NCD and
thereby paid a discounted premium, the company will use the actual number of Claims Free Years and its corresponding NCD to recalculate
the actual eligible discounted premium.
若保單持有人獲得無索償折扣並已支付折扣後的保費，及後本公司若須就以往任何保單年度所出現的索償而作出應付或已付賠償，本公司將會
按照實際的無索償年度及其相應的無索償折扣重新計算實際之合資格的折扣後保費。
Declaration and Authorization 聲明及授權
I / We represent that I am / We are the Owner / Assignee / Trustee / Beneficiary (as the case may be) under the policy(ies) as given on
this form.
Unless marking a “X” in the above box, I / We hereby give my / our irrevocable consent to the company to deduct any balance in excess
of the actual eligible discounted premium recalculated in accordance with the eligible NCD and related levy (if any) from any insurance
proceeds.
本人/我們聲明，本人 / 我們為此索償申請表中列明的保單之持有人 / 受讓人 / 信託人 / 受益人（視情況而定）。除非於上列空格劃上「X」號，
否則本人 / 我們完全同意，公司會從保險賠償金中扣除超出根據實際合資格無索償折扣所重新計算的保費金額及有關保費徵費（如適用）。

PERSONAL DATA COLLECTION AND USE 個人資料收集及使用

I / We confirm that I / we have read, understood and agreed to the Personal Information Collection Statement(s) of my / our
policy issuer(s) and / or pension scheme provider(s), i.e. AIA International Limited (Hong Kong Branch), AIA International
Limited (Macau Branch), AIA Company Limited and / or AIA Everest Life Company Limited, where applicable, (the “PICS”)
which is available for download: https://www.aia.com.hk/en/privacy-statement-main.
I / We declare and agree that any personal data and other information relating to me / us or my / our policy(ies), account(s) or
investments contained in this application or collected, obtained, compiled or held by my / our policy issuer(s) and / or pension
scheme provider(s) by any means from time to time may be collected and utilized in accordance with the PICS.
I / We acknowledge and consent to the transfer of my / our personal data to parties within or outside Hong Kong (for policy(ies) /
pension scheme(s) issued in Hong Kong) or Macau (for policy(ies) / pension scheme(s) issued in Macau), as the case may be,
for the purposes as set out in the PICS.
The latest version of the PICS which complies with the relevant rules and regulations is / are available for download from the
above website and upon request.
我 / 我們確認我 / 我們已閱讀、明白及同意我 / 我們的保單繕發人及 / 或退休金計劃服務提供者（即友邦 ( 國際 )
有限公司（香港分行）、友邦 ( 國際 ) 有限公司（澳門分行）、友邦保險有限公司及 / 或友邦雋峰人壽有限公司
（如適用））的個人資料收集聲明（「該聲明」），該聲明可在以下網址下載
https://www.aia.com.hk/zh-hk/privacy-statement-main 。
我 / 我們聲明及同意在本申請所載或我/我們的保單繕發人及 / 或退休金計劃服務提供者不時以任何方法收集、
獲得、編製或持有的任何個人資料及關於我 / 我們的保單、帳戶或投資的其他資料，可根據該聲明收集及使用。
我 / 我們知悉及同意就該聲明所述目的轉移我 / 我們的個人資料至香港境外 / 境內（如保單 / 退休金計劃在香港
繕發）或澳門境外 / 境內（如保單 / 退休金計劃在澳門繕發）（視乎情況而定）予該聲明所載的資料承讓人。
該聲明的符合相關守則及法規之最新版本可於以上網址下載及可供索取。

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 Policy Number 保單號碼

DECLARATION AND AUTHORIZATION 聲明及授權

I / We DECLARE that the answers given above are true and complete and I / we have already paid in full to the attending physicians for the
medical expenses specified on the receipts which I / We am / are now submitting to AIA International Limited (hereinafter called “Company”).
本人 / 我們現聲明以上每一項答案為完全和真確及確認是次向友邦保險(國際)有限公司（以下簡稱「公司」）遞交之單據乃由本人 / 我們之醫生
發出，單據所載之醫療費用經已全數繳付。
I / We hereby irrevocably authorize:
本人 / 我們茲授權 :
(a) any organization, institution including but not limited to any hospitals / clinics under The Hospital Authority, or individual that has any
record or knowledge of my / our / the Insured‘s employment, sick leave records, accident or loss details (of any sorts), health, medical history
or any treatment or advice, that when requested by an authorized representative of the Company may disclose any such information. This
authorization shall bind my / our / the Insured’s successors and assigns and remain valid notwithstanding my / our / the Insured’s death or
incapacity in so far as legally possible. A photocopy of this authorization shall be as valid as the original.
任何知悉或擁有本人 / 我們 / 被保人之工作、病假紀錄、意外或損失（任何類別）之詳情、健康狀況、病歷或任何治療或諮詢紀錄及曾為或
將為本人 / 我們 / 被保人診治之任何機構、組織包括但不限於任何醫院管理局轄下醫院 / 診所或人士、向貴公司透露有關資料，不得撤回，
即使本人 / 我們 / 被保人死亡或喪失能力，此授權書仍然存有法律效力，而本人 / 我們 / 被保人之繼承人及轉讓人亦會受此授權書約束。
此授權書之正本與副本同屬有效。
(b) The company or any of its approved medical examiners or laboratories to perform the necessary medical assessment and tests to
underwrite and evaluate my / our / the Insured’s health status in relation to this application and any claim arising therefrom. These tests may
include, but are not limited to, tests 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 medications, drugs, nicotine
or their metabolites.
貴公司或任何其認可之驗身醫生或化驗所，替本人 / 我們 / 被保人進行所需之醫療評估及測試，並對本人 / 我們 / 被保人之健康狀況進行
審核及評估，作為處理本申請及其後與之有關的賠償事宜，不得撤回。此等化驗會包括，但並不限於，膽固醇及有關之血脂肪、糖尿病、
腎或肝功能失常、愛滋病或感染人體免疫力缺乏病毒、免疫系統失常或體內藥物、毒品、尼古丁及其代產品之含量等化驗。
(c) All personal information obtained herein is collected for the purpose of, (i) assessing, processing, evaluating and determining your
requests of application for medical claims or services referral and (ii) analysing, investigating, approving and / or determining your claims
submitted and will be transferred to AIA’s authorized medical panels or its relevant associates / nominees / subsidiaries (“third party
administrators”). You authorize us to transfer your personal information to the third party administrators and further give your consent to
all third party administrators who / which are in receipt of your personal information that they may process your personal information and
transfer all your processed personal information to us for the administration of your insurance policy and provide insurance services to you.
Without your voluntary consent, personal information collected will not be transferred to the third party administrators. You can choose not
to provide the personal information required, but that will result in not qualifying for receiving any of the services above.
所收集的個人資料會被用作 (i) 評估、處理、審核及釐定您的索償申請或服務轉介及 (ii) 分析、調查、批核及 / 或釐定您的索償申請之用及
轉移至友邦保險授權之醫療網絡或其相關之附屬成員 / 代名人 / 附屬公司（「第三方管理人」）。您授權我們轉移您的個人資料給予第三方
管理人，並進一步授權所有第三方管理人在收到您的個人資料後，他們可以處理您的個人資料並將您的個人資料轉移至友邦保險作處理保
單行政事宜，並為您提供保險服務。然而所收集的個人資料未經您授權將不會轉移至該第三方管理人。您可選擇不向我們提供所需的個人
資料，惟這樣可能導致未能獲得任何上述的服務。

Signature of Owner / Trustee 持有人 / 信託人簽署 Signature of Insured, if other than Owner / Trustee 受保人簽署，倘非
(Please do not sign on blank form and use the signature on our file. 持有人 / 信託人(Please do not sign on blank form and use the
請勿在空白表格上簽署，並確保簽名與保單申請表一致） signature on our file. 請勿在空白表格上簽署，並確保簽名與保單申請表
一致）(Whose age is 18 or above 年齡十八歲或以上必須簽署）
Name Name
姓名 姓名

ID Card / Passport Number 身份證 / 護照號碼 Date 日期 ID Card / Passport Number 身份證 / 護照號碼 Date 日期

Relationship with the Insured Signature of Witness

與受保人關係 見證人簽署

Name Date
姓名 日期

“AIA” shall refer to AIA International Limited (Incorporated in Bermuda with limited liability), AIA Company Limited (Incorporated in Hong Kong
with limited liability), as the case may be, depending on the issuing company of the relevant insurance policies this form is subject to.
「 AIA 」或「友邦」指友邦保險 ( 國際 ) 有限公司（於百慕達註冊成立之有限公司），友邦保險有限公司（於香港註冊成立之有限公司）（視情況而定），
具 體 取 決 於 此 信 件 相 關 表 格的簽發公司。
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O1002179----7
 Policy Number 保單號碼

PART II TO BE COMPLETED BY THE ATTENDING PHYSICIAN / SURGEON AT THE CLAIMANT’S OWN EXPENSES
第二部分申請人自費由主診醫生 / 手術醫生填寫
1. (a) Name of patient (c) Age
病人姓名 年齡

(b) ID Card / Passport Number (d) Sex

身份證 / 護照號碼 性別

2. Hospitalization 住院
Name of hospital 醫院名稱 :

Date of Admission Date of Discharge

入院日期 出院日期
MM月 DD日 YYYY年 MM月 DD日 YYYY年

Period in Intensive Care Unit From 由 To 至

入住深切治療部日期 MM月 DD日 YYYY年 MM月 DD日 YYYY年
3. Chief complaints of the patient relating to this hospitalization / surgery / investigation 此次住院 / 手術 / 檢驗的主要原因

4. Date when symptoms first appeared or date when the accident occurred
首次出現病徵日期或意外發生日期
MM月 DD日 YYYY年
5. Date of first consultation for this condition or related illness
病人就此病症或相關疾病的首次求診日期
MM月 DD日 YYYY年
6. Final diagnosis / Pathological diagnosis 最終診斷 / 病理診斷 ICD-10 code 國際疾病分類代碼(ICD-10)

7. Medical / Surgical Procedure 醫療 / 手術程序 Date of Operation

手術日期
MM月 DD日 YYYY年

Name of Procedure 手術名稱 (please supplement with CPT code 請提供目前使用醫療服務術語代碼)

8. Please answer the following questions if the insured requires hospitalization 若受保人需要住院，請回答以下問題
Can the medical test(s) and the procedure be done on an outpatient basis in hospital? Can 可以 Cannot 不可以
該檢查及手術可否在醫院的日間手術中心進行？
If cannot, please give details 若不可以請詳述
Please indicate the clinical risk(s) and medical reason(s) for hospitalization 請註明臨床風險及須留院的醫療原因：
Current Health Status (Co-morbidity), please specify 現時健康狀況（合併症），請明確說明：

Expected higher risk at operation, please specify 預期較高手術風險，請明確說明：

Expected higher post-operative risk, please specify 預期較高手術後風險，請明確說明：

Others, please specify the reason for admission and hospitalization: 其他，請註明必須入院及留院的原因：

Is it a case of emergency? 這是否緊急個案？ Yes 是 No 不是

If Yes, please specify 如是，請明確說明。

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 Policy Number 保單號碼

9. Brief discharge summary (including treatments, investigation procedures, results and / or any complications and follow up plan)
出院撮要：（治療及以後治療計劃，包括診查辦法、結果，併發症及跟進計劃）

10. To the best of your knowledge, has the patient ever had the same or similar conditions or symptoms relating thereto?
據閣下所知，病人以前有沒有患有同類病況？ Yes 有 No 不是
If Yes, please state dates and details 如有，請說明何時及當時情況：

Dates Treatment for the condition(s) 治療詳情

日期
MM月 DD日 YYYY年

11. Was the patient referred by another doctor? Yes 是 No 不是

病人是不是經其他醫生轉介？
Name and address of the referral doctor 轉介醫生的姓名和地址：

12. If the patient is suffering from cancer, please complete the below information. Yes 有 No 沒有
病人患上癌症，請填寫以下資料：

a) Please provide treatment regimen details of the patient including name of drugs, dosage, treatment delivery/ duration, frequency etc.
請提供病人的癌症治療方案包括藥物名稱、劑量、治療方式、次數等資料
Radiotherapy 放射性治療：

Chemotherapy 化學治療：

Others (e.g. Hormone therapy, Targeted Therapies 其他治療（例如荷爾蒙治療，標靶治療）：

b) Any Cancer Genomics test done by the patient? 病人有否接受癌症基因檢測?

ACT Genomics 行動基因
FoundationOne 全方位癌症基因檢測
Others 其他 ____________________________________________________________________________________________

I / We hereby declare that the information given on this form is true to the best of my / our knowledge and belief.
本人 / 我們現聲明此申請表上所填資料皆為本人 / 我們所知及所信之事實。

Name of Attending Physician / Specialist (with qualifications) Signature (with chop) 簽名（蓋印）
主診 / 專科醫生的姓名（資歷）

Address and Telephone No. 地址及電話 Date 日期

O1002179----7 Page 7 of 7 OPCLMF03.0325