信用卡担保
Credit Card Guarantee Form
信用卡担保函
wish to access the “GBG China” Direct Billing Providers.
我 GBG中国”直付医疗供应商的服务。
1. I, and the dependents enrolled under the “GBG China” Plan if any, hereby agree that
should I/we receive medical treatment from a member of the GBG Direct Billing
Providers that later proves to be ineligible within the terms and conditions of the Policy Wording, that I/we, as the Policyholder, will be fully responsible for reimbursement to “GBG China” or the medical provider within 30 days notice of all treatment costs incurred in connection with any claim for such medical treatment.
本人,及共同购买由“GBG中国”提供服务的保险计划的附属被保险人,在此声明,如本人/我们在GBG医疗供应商接受治疗并享受直付服务,但根据保单条款不属于保险合同所涵盖的范围,本人/我们作为被保险人,将有责任在通知30天内向“GBG中国”或其医疗供应商偿付此次治疗有关的理赔费用。
2. I/we further agree that should reimbursement not be forthcoming with 30 days, “GBG
China” or the provider is authorized to collect any and all outstanding claim amounts from my credit card; the details of which follow this declaration.
本人/我们进一步声明,若在30天内未付款,“GBG中国”及其医疗供应商有权以我的信用卡代扣未付债务;有关详情遵循本声明。
3. I/We understand and confirm that in the event that reimbursement is not received by
“GBG China” or the medical provider for said ineligible medical treatment within 30 days, then insurance cover under my policy will be suspended immediately until the date of full settlement of all outstanding amounts due.
本人/我们理解并确认,若在30天内“GBG中国”或GBG医疗供应商未收到上述付款,本人所投保的保险将立即暂停服务,直到剩余债务全额清偿。
4. I/We further understand and accept that where the reimbursement is outstanding to
“GBG China” or the medical provider for a period in excess of 60 days, my/our Policy may be cancelled with immediate effect and there will be not any premium refund. Furthermore, “GBG China” and the provider reserve the right to collect the uncovered expenses.
本人/我们进一步理解并接受,无论赔付债权人是“GBG中国”或其医疗供应商,若在60天内本人未履行债务责任,本人所投保的保险将立即失效,并无法获得保险金的退还。并且,“GBG中国”及其医疗供应商保留收取不属于保险合同所涵盖医疗费用的权利。
”GBG China” is the short for “Shanghai GBG Enterprise Management Consulting Co., Ltd.”
“GBG 中国”为“上海吉倍吉企业管理咨询有限公司”简称。
Service Provider: Shanghai GBG Enterprise Management Consulting Co., Ltd.
Suite 3102, 707 Zhang Yang Road, Shanghai 200120,PRC. Tel:+86-21-3126-9300 Fax: +86-21-5835-3368
第三方服务提供商:上海吉倍吉企业管理咨询有限公司
中国上海浦东张杨路707号3102室,邮编200120,电话: Tel:+86-21-3126-9300 Fax: +86-21-5835-3368
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Credit Card Authorization
I understand the terms of this Credit Card Guarantee Form and authorize “GBG China” and/or the medical provider, to debit my credit card for any and all medical reimbursements not covered under my medical insurance policy.
我理解信用卡担保函及信用卡授权的条款,在发生不属于保险合同所涵盖医疗费用时,同意“GBG中国”和/或其医疗供应商从我的信用卡中支付该医疗费用。
A photocopy of the credit card should be attached to the form as a proof.
附上信用卡复印件,以资证明。
Your Signature Date
您的签名 日期
Service Provider: Shanghai GBG Enterprise Management Consulting Co., Ltd.
Suite 3102, 707 Zhang Yang Road, Shanghai 200120,PRC. Tel:+86-21-3126-9300 Fax: +86-21-5835-3368 第三方服务提供商:上海吉倍吉企业管理咨询有限公司
中国上海浦东张杨路707号3102室,邮编200120,电话: Tel:+86-21-3126-9300 Fax: +86-21-5835-3368
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