J4071_H1_4.eps
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23 To the Attending physician Please issue doctor's diagnosis and specification of medical treatment together with receipt for expeditious handling of claim payments by the insurance company. An den behandelnden Arzt : Wir bitten um Aufstellung einer Diagnose und der Behandlungen sowie Ihre Kostenrechnung zur Vorlage bei der Versicherungsgesellschaft. Au médecin Veuillez avoir l'obligeance de remettre au porteur du présent certificat, votre diagnostic ainsi que la description détaillée du traitement médical. Par la mè`me occasion, veuillez également lui remette le ruçu du montant de vos honoraires, afin de lui permettre un remboursement rapide par sa compagnie d'assurance, des frais engagés. Estimado Doctor : Sirvase expedirme un certificado medico con sus especificaciones junto con el recido de pago para presentarlo a la oficina de seguros para su correspondiente reclamo. Atentamente. 21
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37 NEW OVERSEAS TRAVEL ACCIDENT INSURANCEOVERSEAS TRAVEL ACCIDENT INSURANCE CLAIM FORM Sompo Japan Nipponkoa Insurance Inc. is a new company which was launched by a merger of Sompo Japan Insurance Inc. and NIPPONKOA Insurance Co.,Ltd. on September 1, I hereby make a claim for insurance benefits, by confirming the accuracy of the contents hereof and also by agreeing to the matters mentioned below. A photocopy of this form shall be considered as effective and valid as the original. Sompo Japan Nipponkoa Insurance Inc. (hereinafter Sompo Japan Nipponkoa ) uses personal information regarding this insurance claim in order to judge insurance underwriting or payment, to perform this contract, to provide relevant services, to introduce or provide products and services that our company offers such as non-life insurance or to conduct questionnaire, and acquires, uses, provides or registers such personal information in so far as the following items to are concerned and to the extent that our company needs it for the business purposes. Sompo Japan Nipponkoa may provide the information to, or accept provision of the information from, an outside service provider of Sompo Japan Nipponkoa s business (including insurance agencies), insurance brokers, medical institutions, parties related to claim or payment of insurance money, or other related parties. Sompo Japan Nipponkoa may provide or register the information to or with, or accept provision of the information. from, The General Insurance Association of Japan, Non-Life Insurance Rating Organization of Japan, other non-life insurance companies or other related parties for the purpose of sound management of the Insurance system. Sompo Japan Nipponkoa may provide the information to a reinsurance company, etc. (including provision from the reinsurance company, etc. to another reinsurance company, etc.) in order to enter into a reinsurance contract or receive payment of a reinsurance claim, etc. Sompo Japan Nipponkoa may provide the information to its group company or partner company, and may introduce or provide products, etc. that such a company offers. Sompo Japan Nipponkoa does not use healthcare or other special non-public information (sensitive information) for any purpose, except as conditionally permitted under the Enforcement Regulations of the Insurance Business Law in Japan. For Sompo Japan Nipponkoa s declaration of personal information protection, group companies, partner companies, etc., please visit Sompo Japan Nipponkoa s official website ( or contact the following contact. Contact for inquiries: Sompo Japan Nipponkoa Customer Center Tel: Reception hours: Weekdays: 09:00 a.m. to 08:00 p.m. Weekends/holidays: 09:00 a.m. to 05:00 p.m. (closed from December 31 to January 3) I hereby authorize any hospital, physician, or other person who has attended or examined me, or any government authority or other person who is related to the accident, to furnish Sompo Japan Nipponkoa or its authorized representative with any and all information or document with respect to any sickness/injury or accident. I accept that a photocopy of this authorization shall also be considered as effective and valid as the original. When "CASHLESS MEDICAL SERVICE" is provided for me by the hospital or medical provider, I authorize the hospital or medical provider to make an insurance claim for the medical expenses for my treatment. In case the medical expenses turn out not to be payable under insurance policy, I pledge myself to pay such medical expenses as not covered under the insurance policy to the hospital or medical provider (or to Sompo Japan Nipponkoa) without delay. I agree that if I receive payments such as insurance payouts that exceed the amount of insurance money, etc., stated in the policy under which this claim is made or in any other policies, etc., (insurance contractsmutual aid contracts or any other contracts under whatever name they are known and under which payoutsetc., are made to cover the same damage or cost; and the same applies in this contract) for the same damage or cost, I shall repay, without delay, the amount exceeding the insurance money, etc., to Sompo Japan Nipponkoa or to the other non-life insurance companies, mutual aid associations, etc., with which the relevant insurance contracts, etc., are concluded. [lf Sompo Japan Nipponkoa, other non-life insurance companies, mutual aid associations, etc., with which the relevant insurance contracts, etc., are concluded, specify procedures for such repaymenti shall follow the procedures.] In the case of the existence of other insurance contracts, etc., I agree that Sompo Japan Nipponkoa may claim any excess of the amount it is obliged to payout from the non-life insurance companies, mutual aid associations, etc., with which the relevant insurance contracts, etc., are concluded. (DATE) (YEAR) (MONTH) (DAY) (ADDRESS) (NAME- SIGNATURE) (Male)(Female) (INSURANCE PERIOD) (TEL) (Home) (Office) (Mobile) (CLAIMANT)
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40 (DATE) (YEAR) (MONTH) (DAY) (INSURANCE PERIOD) (ADDRESS) (NAME- SIGNATURE) (Male)(Female) (TEL) US $ US $ , JJ (Home) (Office) (Mobile) (CLAIMANT) ,800
J4073_00_H1-4.eps
平成 26 年７月 ９月 OVERSEAS TRAVEL ACCIDENT INSURANCE ポケットガイド 海外旅行総合保険ご契約のしおり 約款集 2014年7月1日以降保険始 損保ジャパンと日本興亜損保は 関係当局の認可等を前提として 2014年 9月1日に合併し 損害保険ジャパン日本興亜株式会社 になります Emergency Assistance
CASHLESSMEDICAL SERVICE I, the undersigned, hereby irrevocably authorize the Medical Service Providers to file a claim for and on behalf of me and/or
1 CASHLESSMEDICAL SERVICE I, the undersigned, hereby irrevocably authorize the Medical Service Providers to file a claim for and on behalf of me and/or the Insured Patient, for the costs of medical services
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(CLAIMANT) NEW OVERSEAS TRAVEL ACCIDENT INSURANCE OVERSEAS TRAVEL ACCIDENT INSURANCE CLAIM FORM Sompo Japan Nipponkoa Insurance Inc. is a new company
(CLAIMANT) NEW OVERSEAS TRAVEL ACCIDENT INSURANCEOVERSEAS TRAVEL ACCIDENT INSURANCE CLAIM FORM Sompo Japan Nipponkoa Insurance Inc. is a new company which was launched by a merger of Sompo Japan Insurance
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西川町広報誌NETWORKにしかわ2011年1月号
NETWORK 2011 1 No.657 平 成 四 年 四 の 開 校 に 向 け て 家 庭 教 育 を 考 え よ う! Every year around the winter holiday the Japanese custom of cleaning out your office space is performed. Everyone gets together and cleans
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Copyright - Zac Poonen (1999) This book has been copyrighted to prevent misuse. It should not be reprinted or translated without written permission from the author. Permission is however given for any