1. Write the title in the center, and write your name and ID card on the top of the second line.

2. Fill in the business of binding the family account of the medical insurance electronic voucher. I guarantee that I meet the conditions for this business. The information stated is true, accurate, complete and valid. The legal liability for the instrument arising therefrom shall be borne by me. .

3. Contact number, mailing address, promisee (signature) and date.