Aviva Life Insurance Company Limited

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1 Aviva Life Insurance Company Limited Room 1701, Cityplaza One, 1111 King s Road, Taikoo Shing, Hong Kong Tel: Fax: Website: DEATH CLAIM CLAIMANT S STATEMENT CLAIMS PROCEDURE 1. Please refer to the instruction in page 5 before completing this form. 2. The Claimant will be responsible for the accuracy and integrity of the information provided. Failure to provide details or disclose all relevant information may delay the claim assessment. 3. The medical reports fees (if any) will be borne by the Claimant. 4. Aviva Life Insurance Company Limited does not admit liability by the mere issue of this or any other form. POLICY NUMBER: 1) Name of Policyholder ID/Passport No. Occupation Martial Status Date of Birth Sex 2) Name of Deceased (if different from Policyholder) ID/Passport/Birth Cert. No. Occupation Martial Status Date of Birth Sex 3) Relationship of Deceased to Policyholder 4) Sum Assured in respect of Deceased 5) Place of Birth 6) Date of Death 7) Residence at Time of Death 8) Place of Death (specify Hospital if death occurred in Hospital) 9) Cause of Death 10) Was the Cause of Death Work-Related? Yes No If Yes, please provide detail. 11) If Cause of Death is a result of Illness or Suicide, please state a) Date of First Complaint of Illness: b) Details of Symptoms suffered: c) Date First consulted a Doctor: 12) If Cause of Death is a result of Accident, please state a) Date and Time of Accident: b) Description of Accident: 13) Name and Address of All Doctors who attended (i) during His/Her LAST Illness/Accident, and (ii) His/Her Medical Conditions for the Last 3 Years. a) Name of Doctor and Name & Address of Clinic/Hospital b) Date First and Last Attendance c) Detail of Illness Death Claim Form / Page 1 of 6

2 14) If Death Occurred OUTSIDE of Hong Kong, please state: a) Was the Deceased Buried or Cremated outside of Hong Kong? Yes No If Yes, what Documentation was obtained to allow the Burial or Cremation to take place? Please enclose a copy of the Burial / Cremation Permit. b) Give Names and Addresses of two people, not related to the Deceased / Assignee, who were present at the Burial or Cremation where Death occurred c) Name of Doctor and Address of Hospital certifying the Death. 15) Was a Post-Mortem or Autopsy carried out? Yes No If Yes, please submit a copy of the report. 16) Did the Deceased leave A Will? Yes No If Yes, please provide a certified copy of the Last Will. 17) Who are the Surviving Family Members of the Deceased? 18) In what Capacity or by what Title do you claim the Assurance? Please indicate your relationship. Next of Kin. Assignee.. Others. 19) Is the Deceased insured with other Insurer(s)? Yes No If Yes, please provide Name of Insurer/ other source Type of Plan Date of Issue Sum Assured Death Claim Form / Page 2 of 6

3 Personal Information Collection Statement 1. This Personal Information Collection Statement ( PICS ) is made in accordance with the (i) guidelines issued by the Privacy Commissioner for personal data; and (ii) Personal Data (Privacy) Ordinance (Cap. 486) ( PDPO ) together with amendments thereto. Personal Data means personal data as defined in the PDPO. The PICS sets out the purposes for which your Personal Data will be used following collection, what you are agreeing to with respect to Aviva s use of your Personal Data and your rights under the PDPO. 2. For the purposes of this PICS, Aviva, we, us and our mean Aviva Life Insurance Company Limited and Aviva Group means Aviva Life Insurance Company Limited and its holding companies, branches, subsidiaries, representative offices and affiliates, wherever situated. Affiliates include branches, subsidiaries, representative offices and affiliates of Aviva Life Insurance Company Limited's holding companies, wherever situated. 3. It is voluntary for you to provide the Personal Data requested in the application form and in the ordinary course of our business relationship. However, if you fail to do so, we may not be able to assess / process your application and provide you with the insurance and related services and products and facilities due to lack of information. Purpose of Collection 4. The information collected from you will be used for the following purposes (all purposes particularized in this paragraph 4 shall collectively be referred to as the Purposes ): a. processing your application and verifying your eligibility for insurance, financial or wealth management products or services; b. managing your account with us (including account collection); c. assignment processing; d. designing, providing and arranging of insurance / financial products or related services; e. processing of any credit, medical, security and underwriting checks and insurance claims; f. processing payment instructions; g. statistics and research; h. providing you with promotional materials relating to our insurance or financial services or related wealth management products, and those of other companies within the Aviva Group; i. marketing the following services / products: i) reward, loyalty or privileges programmes and related services and products; ii) donations and contributions for charitable and / or non-profit making purposes; j. performing policy review and needs analysis; k. information intelligence including customer due diligence and anti-money laundering screening; l. meeting any disclosure requirements pursuant to any local or foreign law, legislation or regulations or any guidelines or guidance given or issued by any local or foreign legal, regulatory, governmental, tax, law enforcement or other authorities, or any present or future contractual or other commitment with a local or foreign legal, regulatory, governmental, tax, law enforcement or other authorities, or financial intermediary, or self-regulatory or industry bodies or associations of financial services providers assumed by or imposed on Aviva and / or companies within the Aviva Group; m. communication with you; and n. fulfilling any other purposes directly related to (a) to (m) above. Transfer of Personal Data 5. The data that you have supplied in this insurance application for the Purposes may be transferred within or outside of Hong Kong to: a. other companies within the Aviva Group; b. any companies carrying on insurance and / or reinsurance related business; c. any insurance intermediaries who have an agency or brokerage agreement with Aviva; d. any insurance claim investigators; e. loss adjusters; f. partnering financial institutions; g. third party administrators; h. professional advisors; i. any associations and federations of the insurance industry that exist from time to time; j. any other service providers providing insurance and / or reinsurance related business; k. any agents, affiliates, contractors or third party service providers who provides administrative, telecommunications, computer, payment, printing, redemption or other services to Aviva in relation to the operation of the business of Aviva; l. any credit reference agencies; m. any debt collection agencies; n. researchers; o. any person and corporate entities to whom Aviva is obliged to disclose under the requirement of any law relating to Aviva or any of its affiliates or business partners; p. any local or foreign governmental and judicial bodies, legal, regulatory, governmental, tax, law enforcement or other authorities, or financial intermediary, or self-regulatory or industry bodies or associations of financial services providers arising out of or in connection with the disclosure requirements of Aviva and / or companies within the Aviva Group as mentioned in paragraph 4(l) above; q. medical bill review companies; and r. information intelligence provider(s). 6. Aviva may transfer your Personal Data in connection with a transaction with another company which affects the control, governance, structure and / or management of all or a substantial part of its business, or if required to satisfy applicable legal or regulatory requirements. Death Claim Form / Page 3 of 6

4 Access to Data 7. You have a right under the PDPO to make a data access or correction request concerning your Personal Data held by us. You may make such request by writing to: Attn. Contact Centre Manager of the Customer Services Department Aviva Life Insurance Company Limited Suite 1701, CityPlaza One, 1111 King s Road, Taikoo Shing Hong Kong Application of the PDPO 8. Nothing in this PICS shall limit your rights under PDPO. Direct Marketing and Your Right to Opt In for Use of Personal Data in Direct Marketing We intend to use your name, telephone number, address and address for direct marketing insurance / financial products and directly related services but we cannot so use your Personal Data without your consent. Please indicate your agreement to such use by ticking the box below. Should you find such use of your Personal Data not acceptable, please indicate your objection by not ticking the box below. I / we agree to the proposed use of my / our Personal Data in direct marketing. Declaration and Authorisation I,..... (ID/PP No.....) declare that the answers given by me in this Form are in every respect true and correct and that no material information has been withheld nor any relevant circumstances omitted. I do solemnly and sincerely declare that the answers given to the above questions are true to the best of my knowledge. I further consent to Aviva Life Insurance Company Limited seeking information from any clinic, hospital, physician, person, organisation, employer that may be required in connection with this claim and I authorise the giving of such information to Aviva. A photocopy of this authorisation shall be considered as effective and valid as the original. I/We hereby acknowledge that it is voluntary for me/us to provide the Personal Data but if I/we fail to do so, Aviva may be unable to assess/process my claim, due to lack of information. I / we hereby agree and consent to the collection, use and transfer of my/our Personal Data for the Purposes as further set out above. Signature of Witness : Signature of Claimant : Name of Witness : Name of Claimant : ID / PP No. : ID / PP No. : Address : Address/Company s Stamp : Telephone no. : Telephone no. : Date : Date : Death Claim Form / Page 4 of 6

5 INSTRUCTIONS When submitting the claim, please furnish the following documents (where applicable): 1) Certified true copy of the Death Certificate 2) Certified true copy of the Birth Certificate of the Deceased 3) Original Insurance Policy or Certificate of Insurance 4) Original Assignment 5) Certified true copy of the Deceased s Marriage Certificate 6) Certified true copy of the Birth Certificate of the Claimants 7) Certified true copy of the Identification (ID, Passport, etc) of the Claimants Together with 1) Duly completed Claimant s Statement 2) Any other documents that support the claim, if applicable 3) Duly completed Physician s Statement If death is resulted from accidental or violent causes, the following additional documents are required: 1) Certified true copy of the Police Investigation Report 2) Post Mortem Report 3) Coroner s Inquest Report NOTES: 1. We reserve the right to pursue for any documents that are not mentioned above if they are deemed necessary. These said documents shall be in the forms as prescribed by Aviva Life Insurance Company Limited and shall be furnished at the expense of the claimant(s). 2. The cost of the Physician s Statement and/or medical evidence shall be borne by the claimant. Death Claim Form / Page 5 of 6

6 Aviva Life Insurance Company Limited Room 1701, Cityplaza One, 1111 King s Road, Taikoo Shing, Hong Kong Tel: Fax: Website: CLINICAL ABSTRACT APPLICATION (for Death claim) To whom it may concern: Dear Sir/Madam Please furnish Aviva Life Insurance Company Limited with a detailed medical report on: ID / BC No.: (Name of Patient) This report is required for insurance purposes. Upon receipt of this application from Aviva Life Insurance Company Limited, you may furnish a detailed medical report (together with histology report, laboratory results, etc.) whether for use in connection with litigation or for other legitimate purposes. I agree that a copy of this authorisation form shall be considered as effective and valid as the original. Signature of Next-Of Kin Name : Address : ID No Date : : Relationship to Patient / Deceased: Death Claim Form / Page 6 of 6

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