Giy ngh bi thng

Thng tin ca Ngi c bo him

Tn Ngi c bo him: M s th bo him: L ngi thn ca: S in thoi: Ngy sinh: S CMND/S h chiu/M nhn vin: Tn Cng ty: a ch email: Gii tnh: Nam N

M t tai nn / bnh tt
1Tai nn Tai nn c lin quan n cng vic hay khng? Thi gian v ia im xy ra tai nn: Bnh tt Chn on v triu chng bnh:

Din bin ca tai nn:

Mc thng tt:

Thi gian nm vin/phu thut (nu c):

Thi gian iu tr:

a im:

2-

Qu khch bao gi b bnh/thng tt tng t cha? No Khng Nu c, vui lng cho bit chi tit (khi no, nguyn nhn, mc v.v...)

Thng tin thanh ton

31 2 3 4 5 4- Vui lng chn hnh thc nhn tin bi thng: Nhn tin mt (di 1 500 000 VND): H tn ngi th hng: S CMND/passport: Ngy cp: Ni cp: Chuyn khon: H tn ngi th hng: S TK: Tn ngn hng: Chi nhnh ngn hng: a ch ngn hng: Vui lng lit k cc chng t gi km theo giy ngh bi thng: Chng t y t 1 2 3 4 5 Chng t k ton VND VND VND VND VND TNG CNG:

Cam kt
Ti, cam oan nhng li khai trn y ca ti l hon ton ng s tht v y nhng g ti c bit. Ti cho php GSW, Cng ty bo him hoc i din ca cng ty bo him thu thp ton b cc chng t cn thit t bt c bc s, bnh vin, trung tm y t, nh thuc, Cng ty v cc i l hoc t chc khc (bao gm c nhng Cng ty bo him khc) xem xt s tin bi thng cho hp ng bo him ca ti.

Xc nhn ca Cng ty (k tn, ng du)

Ngi khai (k tn)

H tn: Ngy:

H tn: Ngy:

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