Individual Life Outpatient & Dental Benefits Claim Form (Hong Kong) Mobile App

Included Fields

Customize to add, remove, or edit any of the fields below.

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  Policy Number

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  Name of Proposed Insured/Insured

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  I.

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  Area Code

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  Agency/Broker Name

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  Agent/Broker Code

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  Operations Team:

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  Agent/Broker’s Name

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  Agent/Broker’s Tel.

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  New Claim

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  Further Claim

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  Pending Claim

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  Review/Appeal

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  Are you making any other insurance or compensation claim as a result of this treatment?

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  If yes, please provide the below information.

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  Name of insurance company/organization:

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  Policy No.

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  Any relationship between the Registered Medical Practitioner/ Medical Services Provider and Insur...

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  If so, please state the relationship.

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  Please complete questions 1 to 5 if consultation was due to accident

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  1. Date of accident

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  2. Where and how did it happen

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  3. Part of body injured and type of injury

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  4. Present occupation (if more than one, state all) and exact nature of occupational duties

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  5. Name and address of business or employer

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  Please complete questions 6 to 9 if consultation was due to illness

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  6. Give a brief description of symptoms

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  How long have these symptoms existed prior to the first consultation?

• ...and More!