Copy of the Life Insured s/payor s (for Payor Benefit)/ Child (For Serious Illness of a Child Benefit)) Identity Card/Birth Certificate/ Passport

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1 Dear Claimant We are sorry to learn of your illness/ injury. In order for us to process the claim, we require the following: 1. Critical Illness Form 2. Attending Physician s Statement 3. Copy of the Life Insured s/payor s (for Payor Benefit)/ Child (For Serious Illness of a Child Benefit)) Identity Card/Birth Certificate/ Passport 4. Copy of the policyholder s Identity Card/Passport, if different from Life Insured 5. Proof of Relationship for Payor Benefit claims e.g. Certificate of Marriage, Certificate of Registration of Birth 6. All available Laboratory and Test Results (as specified on the Attending Physician s Statement) 7. Upon receipt of ALL the above required documents, we will process your claim and inform you of the outcome as soon as possible. However, in certain circumstances, we may require further information after the above documents are received. 8. If you need any assistance, please contact our Client Services Officers at Notes: I. Please note that the fee for completing the Attending Physician s Statement shall be borne by the life insured/ policyowner. II. If you are asking another party to handle the claim process on your behalf, an authorisation letter is required. III. Please continue to pay the premiums until the claim is approved. IV. If the policy has a nomination under section 73 of the Conveyancing and Law of Property Act, the proceeds will be payable to the trustee for the benefit of the beneficiary(ies). V. If the policy has a nomination under section 49L of the Insurance Act, the proceeds will be payable to the trustee of the policy for the benefit of the beneficiary(ies). If the sole trustee is the policyholder, we are unable to make payment to the policyholder. In this instance,, the policyholder can either appoint another trustee by using a prescribed form to receive the proceeds for the benefit of the beneficiary(ies) or give us instructions to make payment to each beneficiary for his/ her share. Page 1 of 7

2 PERSONAL DATA PROTECTION NOTICE We will collect, use or disclose the personal data in this form to: - confirm your identity and uniquely identify you; - confirm the accuracy of the information collected; - communicate with you, especially with respect to the claims submitted to us; - assess, process, investigate or settle claims; - detect and prevent fraud, unlawful or improper activities; - comply with all legal and regulatory requirements within and outside Singapore including disclosures to judicial, regulatory, government, statutory authorities and industry entities; - resolve complaints, and handle requests for data access or correction; and compliance monitoring and audit reviews. A detailed list of purposes for which your personal data may be used or disclosed can be found in our Statement of Personal Data Protection which is available at We will only collect and use personal data in a lawful way. We do not, without your consent, give your personal data to any person and/or entity for the purpose of that person and/or entity marketing its own products or services directly to you. We will use and disclose your personal data only with your consent or where such is permitted or required under any relevant law. Where personal data is provided to our service providers, we will require them to protect the personal data in a manner that is consistent with our personal data protection policies and practices If you have any questions or concerns about our personal data protection policies and practices or wish to request access to, update or correct your personal data, please contact: The Data Protection Officer Manulife (Singapore) Pte. Ltd. 51 Bras Basah Road #09-00 Manulife Centre Singapore Page 2 of 7

3 CRITICAL ILLNESS CLAIM FORM Notes: (1) The issue of this form or any other form(s) does not represent any admission of liability by Manulife (Singapore) Pte Ltd ("Company"). (2) This form has to be signed by the life insured and the policyholder. (3) For Payor Benefit claim, please fill up the details of the Payor at Sections 2 to 6. (4) For Serious Illness of a Child Benefit claim, please fill up the details of the Child at Sections 2 to 6. (5) If the life insured/payor/child (as the case may be) is less than 16 years old, only the signature of the policyholder is required. Policy No. Claim No. (For internal use) 1. PERSONAL PARTICULARS OF POLICYHOLDER Name: NRIC No/ Passport : Date of Birth: Age: Sex: Tel (O): Address: Tel (H): Mobile: Present Occupation: 2. PERSONAL PARTICULARS OF LIFE ASSURED (if different from above) Name: NRIC No/ Passport : Date of Birth: Age: Sex: Tel (O): Address: Tel (H): Mobile: Present Occupation: 3. DETAILS OF ILLNESS (a) Name of critical illness: (b) Describe in detail all symptoms and/or nature of Life Insured s illness. (c) Date when Life Insured first experienced these symptoms: / / day month year (d) How long had the Life Insured been having these symptoms before he/she consulted a doctor? (e) Date when Life Insured first consulted a doctor for these symptoms: / / day month year (f) What was the diagnosis? Page 3 of 7

4 (g) Has the Life Insured previously suffered from or received treatment for a similar or related illness? If Yes, please provide the details. Yes No 4. RECORD OF MEDICAL CONSULTATIONS Please provide the names of the doctors Life Insured had consulted in relation to the illness at paragraph 3(a) and the addresses of the respective hospitals / clinics. Name of Doctor Name/ Address of Hospital/ Clinic Dates of First Consultation Details of the name(s) and address(es) of the doctor(s) Life Insured saw most of the time when Life Insured is sick. Name of Doctor Address Telephone No. / Fax No. 5. GENERAL Have any of the Life Insured s blood relatives suffered from a similar or related illness? Yes No If Yes, please provide us the following details. Relationship of Relative Nature of Illness Date Illness First Diagnosed Does the Life Insured smoke? Yes No If Yes, please provide us the following information. (i) How many cigarettes does the Life Insured smoke per day? (ii) For how long has the Life Insured been smoking? Page 4 of 7

5 Does the Life Insured consume alcohol? Yes No If Yes, please provide us the following information. (i) Type of alcohol: (ii) Quantity consumed per day: 6. OTHER INSURANCE(S) Are there any claims submitted or to be submitted to any other insurance company in respect of this critical illness? If Yes, please provide the following information: Yes No Claim Name of Insurer Policy No. Policy Effective Type of Plan Sum Claim Notified Date Assured Amount (Yes/No) Page 5 of 7

6 CONSENT, DECLARATION AND AUTHORISATION I / We agree on my / our behalf, Manulife (Singapore) Pte. Ltd. ( Manulife ) is authorised to collect, retain, use and / or disclose as it reasonably deems fit, any information in respect of me / us, that is received by Manulife to its Representatives and relevant third parties (including but not limited to companies within the Manulife Group, reinsurers, medical organisations, my / our financial advisers, financial institutions, CPF agent banks, credit agencies, investigators, service providers, judicial, regulatory, government, statutory authorities, dispute resolution parties and industry entities) whether within or outside Singapore that is necessary to evaluate and process my / our claim in any way permitted or required by law. As far as reasonably possible, Manulife will release such information to such parties on the understanding that the information will be kept strictly confidential and be used, disclosed and retained in accordance with the relevant law. A copy of this authorisation shall be as valid as the original. I / We understand the information obtained by the use of this Authorization will be used by Manulife to determine eligibility for benefits under the policy. I / We hereby authorize any physician, medical practitioner, hospital, clinic, other medical or medically related facility, insurance or reinsurance company, consumer reporting agency, or employer having information available as to diagnosis, treatment, or prognosis with respect to any physical or mental condition and / or treatment of me or my / our minor child to give to Manulife. I/We jointly declare that all information / answers given by me / us in this form are, to the best of my / our knowledge and belief, accurate and complete. I / We consent to Manulife seeking / providing information about me / us from / to any medical source, insurance office, organisation or person, governmental organisation and / or regulatory body. A copy of this authorisation shall be as valid as the original. I / We agree to bear the fees (if any) payable for any reports obtained for the purpose of processing of this claim. I / We understand that these reports may not be made available to me / us and that Manulife reserves the right not to release these report(s) or a copy of these report(s) to me / us. I give my / our consent for the fees to be deducted from the claim amount that is payable to me / us, if it is admitted. Page 6 of 7

7 CONSENT TO WITHHOLDING, TERMINATION AND PROVISION OF INFORMATION I / We understand that Manulife is a member of the Manulife Group and it has obligations to meet the requirements of both local and foreign regulatory authorities (including local and foreign tax authorities) as well as other legal obligations from time to time relating to, but not limited to, information sharing and tax reporting and withholding of any payments due to me / us from Manulife from time to time ( regulatory and legal requirements ). I / We consent to the use of information provided to Manulife and I / we will provide Manulife with information that Manulife request from time to time and allow Manulife to share such information with the local and foreign authorities (including local and foreign tax authorities) to meet these regulatory and legal requirements. I / We will notify Manulife as soon as possible of any change in the information that I / we have provided to Manulife, including any circumstances that would result in a change in my / our taxpayer status such as a change in my / our residence, address, telephone number and citizenship. I / We hereby waive any rights I / we may have that would prevent Manulife from meeting any regulatory and legal requirements. I / We understand and agree that Manulife can: withhold on payments to me / us (or any successor owner or payee); or Manulife can suspend or terminate the Policy if I / we (or any successor owner or payee under the terms and conditions of the Policy) fail to provide the information which Manulife requests from time to time to comply with any legal and regulatory requirements (within and outside Singapore) (the Information ) or if at any time I / we (or any successor owner or payee under the Policy) withdraw the consent to the provision of the information or contest the waiver provided above. Signature of Life Insured / Payor/ Child Signature of witness NRIC/PP No.: Contact No.: Signature of Policyholder (if different from Life Insured) Signature of Witness NRIC/PP No.: Contact No.: Page 7 of 7

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