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喪失工作能力/意外傷殘賠償申請書
B. Details of Employment 就業資料(If more than one occupation, please state all 倘若有其他職業,請詳細列出)
8. Position 職位 9. Industry 行業 10. Job Activities 工作範圍 11. Indoor 戶內 Outdoor 戶外
Indoor & Outdoor 戶內及戶外
12. Employer’s Name, Address & Telephone No. 僱主名稱、地址及電話
13 Did you provide a sick leave certificate to your employer? 曾否向僱主遞交病假證明書? Yes 有 No 沒有
14. Date you last worked 最後工作日期(DD 日/MM 月/YYYY 年) 15. Date you returned to work 何時恢復工作(DD 日/MM 月/YYYY年)
(If not, then give expected date of return)(如否,祈望何時可恢復工作)
(d) Was the accident reported to your employer or to the police? If so, please provide details. 曾否向僱主或警方申報是次意外?若有,請提供有
關資料。
(b) How long had you been having these symptoms prior to visiting physician? 受保人在首次就診前該等病徵已存在多久?
HSBC Life (International) Limited Incorporated in Bermuda with limited liability 於百慕達註冊成立之有限公司
Hong Kong SAR Office: 18/F, Tower 1, HSBC Centre, 1 Sham Mong Road, Kowloon, Hong Kong
F豐人壽保險(國際)有限公司 香港特別行政區地址:香港九龍深旺道 1號è豐中心 1座 18樓
C. Reason of Disability (Cont’d) 喪失工作能力原因(續)
18. Details of physician(s) consulted or hospital(s) to which admitted for current disability 曾就診之醫生姓名或醫院詳情:
19. Are you currently insured for disability benefit with any other insurance company? If the answer is “Yes”, please complete the following.
是否有其他喪失工作能力保障於其他保險公司?若答案為「是」,請填寫下列有關資料。 Yes 是 No 否
Name of Insurance Company Amount of Life Insurance Type of Disability Benefit Policy No.
保險公司名稱 人壽保險額數 喪失工作能力保障種類 保單號碼
Date 日期 Date 日期
To HSBC Life (International) Limited
致:#豐人壽保險(國際)有限公司
Date 日期:
1. Name of patient (Surname first) 2. Age 3. HKID No. / Passport No. 4. Occupation and job duties
(b) Date on which you first saw the patient for this illness or injury. (DD/MM/YYYY)
(c) Was the patient referred to you by another doctor? If so, please indicate his / her name and address.
(d) What symptoms did the patient complain of at this first consultation?
(e) Was the patient’s presentation consistent with the symptoms and level of disability complained of?
(b) How long do you think the symptoms had been in existence before the first consultation?
7. Please give details of all consultations and treatments given as far as your records go back. (Alternatively, a copy of the patient’s record can be provided.)
Date Complaints & Symptoms Diagnosis Type of Treatment Given Duration of Treatment
8. (a) Names and addresses of hospitals to which patient was admitted during this disability
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9. Please indicate the results of all investigation & test (such as neurological examination, laboratory tests, X-rays and Wassermann, etc.). We would
appreciate receiving copies of all such test results. If insufficient space, please attach a separate list.
10. Did the injury / illness result from or was the period of disability lengthened by? Yes No
(e) Smoking?
11. (a) Please give the date the patient was first absent from work.
(b) If the disability was interrupted, please give date(s) patient returned to work.
15. Please advise what duties of the patient’s pre-disablement occupation he / she is:
• Able to perform
• Unable to perform
16. On what date did the patient return to work? Was this on a full-time or part-time basis?
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17. To the best of your knowledge, has the patient ever been treated for the same / related conditions or for any other serious disorder? If so, please state when
and the names of any other hospital(s) and / or physician(s) attended.
18. Have any medical certificates been provided to any other persons, insurance companies or other companies? If so, please provide full details.
20. Has a treatment plan been put in place to return the patient to work? If so, please provide details.
Declaration
I hereby certify that I have personally examined and treated the patient in connection with the above disability and that the facts as given above present my
opinion of his / her condition.
I hereby certify that I have not withheld any information at the request of the patient.
Address
LI103a v03/0606 (0606) D
Date
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