CLAIM FORM (Giay yéu cau béi thuéng) in tt cd cdc chimg tir hod don ma 46 ghi r6 t6n bénh nhén, chén dosn bénh, nady khém bénh, ligt ké chi tiét cée Satan ver ike dco ond dba cin so'26'y 1) (Pease sub documents whch cary eae Tone o Patek eget, oe aroun, charges beekdonn mh the atending physician's chp and signa) Policyholder (Chi hop dng): LE BUC ANH Policy No (Hop dng bi hiém s6):00001571016-PCNICN 4.512022 ‘A. Personal information (Théng tin c& nhén) Name ofthe Pationt (Tn ngudi dupe bao hiém ~ Bénh nh Relevant employee (Té nha vin) LEDUC ANH LEDUC ANH DOB of insured (Ngay sinh) 2010111993. Employee No (Ma s6 nhan vign) 0125 Level (Me bio him) Job Tle (Chie dan): KY Sw Van Hanh Than TelNo (in hoa)’ _ 0338998465, Email_coe ducanhle@nsZpe.com 'B, Payment (Thanh toan) Total amount claimed Bank anster (Chuyén Khoa) =< Cash (Tidnmag: «OD (Chiphiy #6 oe yéu edu bd thyong) Account No(S6 talkhogny 1017488829 [Mgt Trigu_ Nam Tram Nohin 88ng Chin (1.600.000 | Bank name(Tén Ngan hang) vietcombank vd) te bp ngay nm ven Number of Days oft work Bank adoress(Bia chi Ngan hang): NGHI SON (88 ngay ngh you cdu b6) thug) Beneficiary(Nguos thy hung): LE BUC ANH 6. Treatment information (Thong tin vé aiéu tr): Date of visitor Date of accident (Nady Khem Bn hoc ngay xdy ra tal nan): 24/6/2023, Medical conditions or Diagnosis / Cause of accident (Chudn don bénn / Nguyén nha tal nan): Viem amydt Name of Hospital or clinica bh vin hay phng khde) Benh Vien Ba Khoa Qube Té Hop Lu. Date of admission (Ngdy nhdp wien) 24/6/2023 Date of discharge (Ngdy xudt vién: 29162023 Important! (Lou y kiém tra hutng din duc dy tcc Kh Kham va qi so bt thurong)) 1. Outpatient (RS ng08 0: 2 patent (nim vib) 3. Accent (Ta nan) Prescton (Ben thud): cb dy 6 chk & ho tn cla bef, | - Hospital discharge (iy r= én) = Incident report (ién bin sy i) (fu ca cosy tv gh rn Boh nbn = Surgery report (Pfu m8) Driving cense (Copy aly pp i esical book (56 knirPRGsKhém):Gh 5 chin doin bénh “Tiong eng hop phSu thustséu pbs | nu Ta ran gla thing {8 Boh on; chy & tn By ca BSF Docuerts and in iveces smfar ter epee torus AP + Chi din & Ket qud xd nghibm, chi6u chyp ln quan Serene aah {Chi anh cho nahi cia bie sf) CO He ce Rang due au tr & phvtcng php eu th, Prim cup = Rtendance card (Bing chm cng): ing (8 i Rng) (thers (Ching tire) + voces (od dn: Ho8 dan op ec HEH ch UE nt dung pi nod Kem Bg Ke ch |ctimant nerdy declare tat tre above ivormation is covet the best of my krowledge and belt, (er vauosen gut 4b hung x cam Goan nang Wha Wn yt ag svat | alo understand that hie dacaraton gives permision he insure: and the appointed representatives to proach ny thi part or fost requved to compete thor assessment othe claim nsudng, but net bmteo to. my crrert and proves Masel Praciiones (To eang cong y rang vo gy yeu cu nay. 1 cho pep Cy he le gnc hop scorch ben mab bt pagan Ok ee tel ng ra bm im. hg yar 8c bac avs ‘Sang au ot), “Tai cong a ne cong yo idm than ton ib Db ron co evo Kade nh dng tin tl Kod rb ly yu cu Bi rng Ti xin chi rh nig har {an vue pap ust ru co Bacar cp rao ve quem ty hung sd ny. ate ngay): 3.$-90L% Date gay): 3-4-WLS Date nga) Signature of insured Signature of emolayee Signature of Polcy holder & Stamp (Chik & ho ten cia Novo! duoc BH) © (Chirki & ho ten cia Nhan vgn) (ChiFki va ddu cbs don vi dug bso hiém) Dregne Plena