Medical Insurance. Part 1: Claim Form (To be completed by Patient and Employer) Particulars Of Insured

Transcription

1 09/2015 Claim Form Medical Insurance Agent s Code: Policy.: Information collected in this claim form shall be used in connection with the Company s purposes and course of business only. Please write in block letters and tick ( ) in the appropriate boxes. Kindly attach separate sheet if space is insufficient. Part 1: Claim Form (To be completed by Patient and Employer) Particulars Of Insured i. Name of Insured: NRIC: ii. Occupation: Date of Birth: Plan: Age: Sex: iii. Name of Employer / Policy Holder: Date of Employment(For Group Policy): Particulars Of Patient (if patient is a Dependent) i. Name of Patient: NRIC: ii. Relationship: Plan: Date of Birth: Age: Sex: Statement By Patient (By Parent If Claimant is a Child below 18 years old) a. Accident i) Date and Time of Accident: ii) Place of Accident: iii) Brief Description of Accident: iv) Final Diagnosis: b. Illness i) Symptoms First Appeared on: ii) First Treatment Sought iii) Name of 1st Doctor Consulted: iv) Name & Address of Clinic / Hospital: v) Final Diagnosis: c. Others i) Is the Patient covered by any Medical / Health Insurance? ii) Will the whole or any part of the medical expenses incurred covered by any other form of indemnity or insurance? If Yes, Policy. Insurance Company d. Claim Payment in Favour of? (Please specify the name of payee) Policy Holder / Employer: Insured Person / Employee / Claimant: Subsidiary: Others (Please Specify): Tokio Marine Insurans (Malaysia) Berhad ( U) 29th Floor, Menara Dion, 27 Jalan Sultan Ismail, Kuala Lumpur, Malaysia. T : (03) , F : (03) tokiomarine.com

2 Declaration on GST (To be completed by Insured who is GST Registered) GST Registration : GST Registration Declaration and Authorisation To Physician, Clinic or Hospital By signing this Claim Form: Acknowledgement & Declaration i) I hereby declare that the answers provided above are true and complete to the best of my/our knowledge and belief. ii) I hereby irrevocably authorize any organization, institution or individual that has any record or knowledge of my health and medical history or treatment or advice that has been or may hereafter be consulted, other personal information or details of related disability, to fully disclose to TOKIO MARINE INSURANS (M) BHD or its authorized representative such information in relation to this claim. This authorization is irrevocable and a photocopy of it will have the same effect and validity as the original. Personal Data Protection Act 2010 (PDPA) tice i. I/We acknowledge and consent that the personal data, including any sensitive personal data, collected herein be used and processed for the purpose of this claim and be disclosed to reinsurers; individuals or organizations associated with Tokio Marine Group, or involve in any claim settlement; or PIAM/ISM; ii. I/We confirm that I/we have obtained the consent of the person(s) and/or nominee(s) named herein, where applicable, and that he/she/they has/have authorized me/us to disclose their personal data and to give consent on their behalf for the above collection, use, process and disclosure; iii. I/We acknowledge that I/we am/are obligated to provide the above personal data failing which my/our claim could not be processed and that I/we am/are entitled to obtain access to, request for correction of or limit the processing of my/our personal data; and iv. I/We acknowledge the detail Privacy Policy Statement, governing the above, posted at and that I/we could also make enquiry with regard to the PDPA through send to enquiry@tokiomarine.com.my. Declaration I/We understand that it is my/our duty to take reasonable care not to make a misrepresentation in answering the questions in this Claim Form and I/we hereby declare that I/we have fully and accurately answered the questions above. Signature of Patient Name: NRIC: Signature of Insured / Employer Name & Company Stamp: (Company Stamp is compulsory for Group Policy)

3 tice: To ensure payment is made via e-payment, kindly complete the e-payment registration form. Registration Form E-Payment Please complete the details herein this Form with capital letters and cross (X) the appropriate box. Policy Holder Agent Broker Reinsurer Adjuster Repairer Lawyer Financial Institution Service Provider Others (Please specify) Personal Details Beneficiary Name: Business Registration (non-individual): NRIC (individual): Address: Telephone : Contact Person 1: Contact Person 2: Banker (Please select from Appendix A) Handphone : Bank Code Bank Account Number (please ignore all dashes: - ) Documents To Be Attached Herewith This Form For verificaton purpose, kindly attach the following supporting document that confirm the said account belongs to you/your company Photocopy of top portion of the bank statement of Current Account, OR Front page of the Savings Account Passbook, OR Confirmation letter from bank Declaration I/We hereby authorize Tokio Marine Insurans (Malaysia) Berhad (TMIM) to credit all monies due to me/us to my/our bank account indicated above by way of Giro Fund Transfer/Rentas and confirm that: 1 I/We hereby declare that the above is my personal account/our company account, NOT joint account and the information given is true and accurate to the best of my knowledge and record. 2 I/We shall indemnify TMIM for any loss, damage or claims incurred as consequence of acting on such reliance. 3 I hereby give my consent to TMIM to disclose my Personal Data provided in this E Payment Registration Form to TMIM, TMIM s service providers and bankers and such service providers and bankers have my consent to process my Personal Data for the purpose of effecting and administrating the electronic payments to me (including without limitation, my name, personal identification number, contact details and any other personal data obtained hereafter collectively known as Personal Data ). 4 I understand that I have the right, upon payment of a prescribed fee, to request access to my Personal Data that is being processed by TMIM and to request correction of my Personal Data. Such request shall be submitted to the Head of Finance, TMIM; and 5 I understand that the supply of my Personal Data herein is voluntary and it is necessary for TMIM to process my Personal Data for effecting and administrating the electronic payments to me. Authorized Signature Name: Position: Signature of Insured / Employer Name & Company Stamp: (Company Stamp is compulsory for Group Policy)

4 (PLEASE RETURN ORIGINAL SIGNED FORM TO TMIM) FOR OFFICE USE ONLY: To be completed by relevant department: Department/branch: MO Code: Agent Name: Client Code: Verified by: Agent Code: Signature/ To be completed by Finance department: Date received: Data Entry by Finance: Signature/ Signature/ Verified by Finance: Appendix A LIST OF BANKERS - for E-Payment Registration Form Banker Bank Code Banker Bank Code 1 AFFIN BANK BERHAD PHBM 2 AGRO Bank ( Bank Pertanian M sia Bhd ) AGOB 3 ALLIANCE BANK MALAYSIA BERHAD MFBB 4 AL-RAJHI BANKING & INVESTMENT CORPORATION (MSIA) BHD RJHI 5 AMBANK BERHAD ARBK 6 BANK ISLAM MALAYSIA BERHAD BIMB 7 BANK KERJASAMA RAKYAT BERHAD BKRM 8 BANK MUALAMAT BERHAD BMMB 9 BANK OF AMERICA BOFA 10 BANK OF TOKYO-MITSUBISHI UFG (MALAYSIA) BERHAD BOTK 11 BANK SIMPANAN NASIONAL BSNA 12 CIMB BANK BERHAD CIBB 13 CITIBANK BERHAD CITI 14 DEUSTCHE BANK DEUT 15 HONG LEONG BANK BERHAD HLBB 16 HSBC BANK MALAYSIA BERHAD HBMB 17 J.P. MORGAN CHASE BANK BERHAD CHAS 18 KUWAIT FINANCE HOUSE (M) BERHAD KFHO 19 MALAYAN BANKING BERHAD MBBE 20 OCBC BANK (M) BERHAD OCBC 21 PUBLIC BANK BERHAD PBBE 22 RHB BANK BERHAD RHBB 23 ROYAL BANK OF SCOTLAND BHD ABNA 24 STANDARD CHARTERED BANK MSIA BHD SCBL 25 SUMIMOTO MITSUI BANKING CORPORATION MALAYSIA BERHAD SMBC 26 UNITED OVERSEAS BANK UOVB

5 Part 2: Medical Report (To be completed by Attending Physician / Surgeon) 1. a. Patient Name: c. NRIC: b. Age: d. Sex: Male Female 2. Admission Date and Time: (Time) 3. Discharge Date and Time: (Time) 4. a. Symptoms / Conditions requiring admission: b. Patient s BP / Temp. / Pulse: c. How long is patient aware of the condition: am am pm pm d. Date symptoms first appeared: e. Date first consulted: 5. a. Any previous consultation / treatment / hospitalisation for this symptom / illness or related conditions, or other disorders Whether in this hospital or any other facilities? Yes Name and Address of doctors previously consulted by the patient for the condition: b. Was this patient referred to you? If yes, please provide details below: c. If this condition existed before symptoms became apparent to the patient, please indicate in your professional opinion how long has the condition existed: d. Can the condition be managed under the Outpatient basis: If no, please provide reasons of admission: Yes 6. a. Final Diagnosis: b. Cause and pathology underlying the present diagnosis: c. Any possibility of relapse: Yes Is follow up required? Yes 7. Admission requires: Hospitalisation Day Care Surgery On Patient s Request 8. Is the illness / condition related to ( please tick ( ) if YES ): Pregnancy / Childbirth / Infertility / Caesarean Section / Miscarriage or any complications arising therefrom Congenital / Hereditary Diseases Influence of Drugs / Alcohol Nervous / Mental / Emotional / Sleeping Disorder Cosmetic Reason / Dental Care / Refractive Errors Correction AIDS / STD / VD / HIV Self-inflicted Injuries / Violation of Laws / Strike / Riots ne of the above Please provide details: 9. a. Treatment given / investigation done (please supply copy of all investigation results): b. Surgical procedures performed:

6 c. MMA code / PHFSR code: d. Date of surgery / procedure: 10. Any other medical / surgical conditions present: a. b. Yes, details below: 11. a. Was the patient pregnant at the time of hospitalisation? (For Female only) b. Was the illness caused directly or indirectly by pregnancy/child birth/ caesarian section/abortion miscarriage and all complications arising therefrom? Yes, months Yes, details below 12. a. If hospitalisation was due to injury, please describe circumstances and cause of injury: Yes, details below b. Please indicate date/time of accident: (Time) am pm 13. In the case of DEATH, please advise Date/Time and Cause of death: 14. I hereby certify that I have personally examined and treated the Patient for his/her injury/illness described above and that the facts as stated above represent my medical opinion of his/her condition. Date Name & Signature of Attending Doctor Doctor / Hospital Stamp