PruFracture Care Claim Form

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1 Reg. No Z PruFracture Care Claim Form SECTION 1 This section is to be completed by the Life Assured who is at least 18 years old or the policyowner if the Life Assured is below 18 years old 1. The Company does not admit liability by the mere issue of this form. 2. Please complete and return this form together with the medical report, written prescription for purchase of mobility aid or house fitting, original tax invoices for mobility aid or house fitting, copy of inpatient hospital bill and radiological reports. 3. Please note that the X-ray report is a mandatory requirement for a claim on fracture benefit. Important Note: Please note that, under the policy terms and condition, the policy may be void if any information provided in this claim form are made knowingly by you that it is materially false or misleading. LIFE ASSURED S PARTICULARS Full Name NRIC No Address Date of Birth Contact No Occupation POLICY DETAILS Please indicate the policy number for the benefit type you would like to claim. Benefit Type PruFracture Care Policy Number(s) Fractures/ Burns/ Dislocations House Fitting Benefit Mobility Aid Benefit Recovery Benefit DECLARATION I hereby declare that all the information given by me in this form, is to the best of my knowledge and belief, true and complete. I authorise Prudential Assurance Company (Pte) Limited ( Prudential ) to: a) seek medical information from any doctor who, at any time, has attended to the life assured concerning anything that affects his/her physical or mental health; b) seek information from any insurance office to which an insurance proposal has been made; c) seek information from any other sources (including employer, government authorities) in connection with this claim; and d) disclose information including medical information about me to other insurers, reinsurers or other third parties assisting with my claim, for the assessment of my claim. I understand and agree that Prudential should have full access to the information stated above and a photographic copy of this authorisation shall be as valid as the original. Name & Signature of Life Assured or Policyowner if Life Assured is below 18 years old Date ID CMAHCLM Prudential Assurance Company Singapore (Pte) Limited 30 Cecil Street #30-01 Prudential Tower Singapore Postal Address: Robinson Road P.O. Box 492 Singapore Telephone: Fax: Website: Part of Prudential Corporation plc Reg. No Z 1

2 Details of Accident 1. Date and Time of Accident: 2. Describe in detail how the accident happened, stating the location and injuries sustained. 3. Was there a police report? If yes, please provide a copy. Yes No Other Information 4. Period of hospitalisation: From to 5. Date of surgical procedure: 6. Please provide details on any surgical procedure performed. 7. Are you claiming Medical Expenses from other sources? Yes No If Yes, please provide details of claim: Name of Company Nature of Claim Amount Claimed Policy Number (if applicable) 8. Details of all doctor(s) or hospital(s) consulted for this accident Name Address(s) Consultation/ Admission Date MEDICAL REPORT FOR PRUFRACTURE CARE (mandatory) SECTION 2 This section is to be completed by the life assured s attending medical specialist. 1 Date of Accident : 2 Please describe the injuries resulting from accident. Bone fracture. Dislocation Burns Head injury Internal injury required open abdominal or thoracic surgery. 3 Please describe how the accident happened. 2

3 4 When were you first consulted for the injuries? 5 Were the injuries caused solely by the accident described above? Yes ( ) No ( ) 6. Were there any underlying illnesses/ conditions that attributed to the accident/ injury? Yes ( ) No ( ) If yes, please provide full details of the condition (including the type of condition, date of diagnosis and how it attributed to the accident/ injury). 7. For bone fractures, excluding spine fracture, please provide details of the fracture in the table below: Name of bone fracture Position of fracture d. Others: Type of fracture d. Others: d. Other: 3

4 8. If a fracture is sustained to the spinal column, please provide the following details: a. Compress fracture b. Spinous, transverse process of pedicle fractures. c. Permanent spinal cord damage (kindly give detail on related symptoms): d. Other fracture: 9. For Head injury, please provide details of the injury in the table below: Lesion Purely Skull fracture Intracranial hemorrhage ( i.e. Epidural hemorrhage, Subdural (Not Applicable) hemorrhage, Subarachnoid hemorrhage, cerebral hemorrhage) Cerebral contusion (Not Applicable) 10. For Internal injury, please provide details of the injury in the table below: Injured Organ 11. For dislocation, please provide details of the dislocation in the table below: Dislocation Purely Slipped disc Spinal dislocation Hip dislocation Knee dislocation Wrist or elbow dislocation Ankle, shoulder Sternoclavicular Joint or Acrominoclavicular Joint Metacarpophalangeal Joint, Interphalangeal joint Metatarsophalangeal Joint, Interphalangeal joint Jaw dislocation 12. For burns, please provide details of the areas affected, the percentage of surface area and the degree of burns in each area? Areas affected Percentage of Surface Area Degree of Burns 13. What is the expected period of recovery for the patient s injuries? weeks 14. Please state the period of medical leave issued to the patient: to 15. Please indicate if the patient s condition is as a result of any of the following activities: winter sports, ice hockey Yes ( ) No ( ) horse riding, polo playing Yes ( ) No ( ) canoeing, sailing or windsurfing Yes ( ) No ( ) 4

5 mountaineering, rock climbing, caving, potholing, hunting Yes ( ) No ( ) hang gliding, sky diving, parachuting Yes ( ) No ( ) scuba diving Yes ( ) No ( ) boxing, wrestling, martial arts activities, whether in training or competition Yes ( ) No ( ) motocross Yes ( ) No ( ) military service Yes ( ) No ( ) 15. Has the patient been admitted to any hospital before, for the same or different cause? Yes ( ) No ( ) Period of Hospitalisation Diagnosis Hospital Name of Attending doctor Signature Practice Stamp Name (printed) Date SECTION 3 Attachment of Laboratory Reports Please enclose a copy of the x-ray report, ultrasound report or CT/ MRI reports taken on the patient s injury(ies). Prudential Assurance Company Singapore (Pte) Limited 30 Cecil Street #30-01 Prudential Tower Singapore Postal Address: Robinson Road P.O. Box 492 Singapore Telephone: Fax: Website: Part of Prudential Corporation plc Reg. No Z 5

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