理赔（垫付）申请&授权书.pdf

理赔申请&委托授权书 APPLICATION & POWER OF ATTORNEY 兹有：学校(School name)： 证件号码(ID number)： ，国籍(Nationality)： ，中文名（Chinese name）： 英文名（证件全名）English name（Full name on ID）： ， ， CSC号（公费生）CSC number (Chinese government scholarship students) ： 本人因病（意外伤害）在医院进行治疗，现提出理赔申请并授权。Due to illness / accidental injury go to the hospital for treatments. I hereby apply for reimbursement and authorization from your company. 本人申请并授权联华国际保险经纪（北京）有限公司通过如下形式办理本次理赔相关事宜： I applied and authorized Unichina International Insurance Brokers (Beijing) Co., LTD to apply claim this time in two ways as below: □住院垫付(Advance payment in hospitalization)； □通过联华国际保险经纪（北京）有限公司代理赔; (Advance payment from Unichina International Insurance Brokers (Beijing) Co., LTD) 请联华国际保险经纪（北京）有限公司将代理赔款汇至如下指定账户： Please Unichina International Insurance Brokers (Beijing) Co., LTD send claim advanced payment, which I authorized as below. 户名 Account name： 账号 Account number： 开户行 Bank branch name： 郑重声明Solemnly Declare： 1. 本人同意保险公司将理赔款汇至联华国际保险经纪（北京）有限公司指定账户。 I agree that the insurance company will remit the claim payment to the designated account of Unichina International Insurance Brokers (Beijing)Co.,Ltd. 2. 本人承诺所提供信息完全属实，如有虚假或隐瞒，本人愿意承担由此产生的一切法律后果。 I confirm that the information provided in this document is all true. In the event of false or concealed circumstances, I am willing to undertake all the legal consequences arising therefrom. 3. 本人自愿签署申请&委托授权书，即视为同意并遵守保险条款中的各项规定。 I voluntarily sign this application and power of attorney, and I shall be deemed to agree and comply with the provisions in the insurance clauses. 被保险人签字(Insured signature)： 学院盖章(College stamp)： 日 期 Date： ------------------------------------------------------------------------------------------------------------------------------------------以上内容准确无误 The above contents are accurate 单位：联华国际保险经纪（北京）有限公司（盖章） Unichina International Insurance Brokers (Beijing)Co,Ltd (seal) 日期 Date: