MSIG Insurance (Malaysia) Bhd (46983-W)

Head Office: Customer Service Centre, Level 15, Menara Hap Seng 2, Plaza Hap Seng, No. 1, Jalan P. Ramlee, 50250 Kuala Lumpur

MSIG Tel +603 2050 8228, Fax +603 2026 8086, Customer Service Hotline 1 800 88 MSIG (6744) www.msig.com.my

A member of H�fimj INSURANCE GROUP

PRE-AUTHORISATION FORM / BORANG PRA-KEBENARAN

Private and Confidential / Sulit don Persendirian

PART 1 (To be completed by Patient / Claimant) SAHAGIAN 1 (Untuk diisi oleh Pesakit I Penuntut)

1. Patient Name: 2. NRIC (Old & New):Noma Pesakit: K.P. (Lama & Boru):

3. a. Date of Birth: b. Age: C. Sex: D Male Tarikh /ahir: Umur: Jantina: Loki-Joki

4. Policy No. I Member ID/ Certificate No/ Plan/ Company Name : 5. Admission / Planned Admission Date:No. Palisi I No. Ahli I No. Siji/ I Pelan I Noma Syarikat: Tarikh kemasukan hospital:

6. Hospital Name: 7. Name of Attending Doctor/ Speciality:Namo Hospital: Noma Doktor yang merawatl Kepakaran:

ADMISSION REASON (.I) and answer accordingly Silo tanda (.I) don jawab soa/on yang berkenoon

D 8.

a. Occurred on: Date __ ! __ ! __ Time D am Accident: Berloku pado: Tarikh Maso pogi Kemolongan: b. Details of Accident:

Butir-butir kemalongon:

D 9.

a. Symptoms first appeared on: Date __ !__) __

10.

Illness: Torikh simptom tersebut bermulo: Torikh Penyokit: b. Doctor(s) consulted for this condition:

Doktor-doktor yang dilowoti bogi penyokit ini:

C. Doctor's or Clinic Contact (Address & Telephone):Alomot & Telefon Doktor

DECL8HATIQ� 8�D 8Uil::lQHIZATIQ� I declare that the answers given above are true and complete to the best of my knowledge and belief.

D

D

Female Perempuan

pm petong

I understand the delivery of this form is in no way an admission of MSIG Insurance (Malaysia) Bhd's liabilit(i and payment to the hospital by MSIG Insurance (Malaysia) Bhd or itsrepresentative shall not be construed as final admission of MSIG Insurance (Malaysia) Bhd's liability and or this and any further claims arising, MSIG Insurance (Malaysia) Bhd reserves all rights for evaluation as appropriate. I am fully aware of the limits as to my/Assured medical insurance under the above-mentioned policy. I hereby undertake to settle/reimburse any medical expenses exceeding my entitlement under the said policy contract, or that is not covered by the same. I hereby irrevocably authorize any organisation, 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 gersonal information or details of related accident/injury, to disclose to MSIG Insurance (Malaysia) Bhd or its representative such information. I agree thatMSIG Insurance (Malaysia) B d or its representative may use or disclose any of the information collected or held to third parties (within or outside Malaysia, including MSIG Insurance (Malaysia) Bhd's parent company, subsidiaries or any other associated comganies within MSIG Insurance (Mala�sia) Bhd's Group, reinsurers, medical examiners, claims investigatorsand industry associations/federations etc.) in relation to this claim. This aut orization shall bind my/the Assured s/lnsured's successors and assigns and remain valid notwithstanding my/Assured's/lnsured's incapacity in so far as legally possible. A photocopy of this authorization shall be valid as the ori�inal. I agree that in the event I make, or have in the pastmade, any false or untrue statement and/or sugpressed and/or concealed any material facts in respect of my/t e insured's condition, MSIG Insurance (Malaysia) Bhd shallabsolutely forfeit my/the lnsured's/ Assured's rig t to compensation and further reserves the right to recover any amounts paid earlier as a result thereof. ff.NGIS.'il.lti.dBdlY. (M(y_ PEMl]_ERIK1J.d5,g Soya mengisytiharkan bahawa jowapan yang diberikan di atas ado/ah benar don lengkap setokat pengetahuan don kepercayaan soya. Soya memahami bahawa penyerahan borang ini, tidak soma sekali bo/eh dianggap sebagai pengakuan liabiliti MSIG Insurance (Malaysia) Bhd ini ke atos tuntutan sf!lsa/Asured don soya bersetuju bahawa bar,aran kepada hospital oleh MSIG Insurance (Malaysia) Bhd atau wakiln

61a tidak akan ditafsirkan sebaga, pengakuan muktamad liabiliti SIG Insurance

(Malaysia) Bhd don MSIG nsurance (Malaysia) Bhd berhak menjalankan peni/aian sewajarnya ber ubung tuntutan ini otau apa-apa tuntutan yang timbul selanjutnya. Soya memahami sepenuhnya had-had insurans perubatan soya di bawah Polisi yang tersebut di atas. Soya dengan ini berjanji akan menyelesaikan sebarang amaun yang me/ebihi had ke/ayakan soya, yang tIdak dilindungi oleh insurans berkenaan. Soya yang bertandatongon di bawah, dengan ini membenarkan pada setiap mosa, mana-mana organisasi, institusi atau individu yon!} mempunyai apa-apa rekod atau pengetahuan tentang kesihatan don lotar belokong atou rowoton otau nasihat perubatan soya/Asuredllnsured, yang teloh atou mungkin kemud1on dari ini diru1uk untuk mendedahkan kepada MSIG Insurance (Malaysia) Bhd otau wakilnya sega/o maklumot tersebut. Soya bersetuju membenorkan MSIG Insurance (Malaysia) Bhd otau wokilnya untuk mengguno don mendedahkon apa-apa maklumat biang dikumpul otau dipegong kepada pihok ketigo (di dalam atou di /uar Mator,�/o, termosuk syorikat induk, anak MSIG Insurance (Malaysia) Bhd otou MSJG Insurance (Malaysia) hd berkait dalom MSIG nsurance (Malaysia) Bhd, reinsurer, pemerikso peru tan, penyiosot tuntuton don pertubuhonlpersekutuon industri di/.) berkaiton dengon tuntuton ini. Pe71aesohon ini hendoklah mengikat waris-wans don penamo soyo/Asuredllnsured don kekol soh meskipun seteloh kemation soyo/Asuredllnsured setokat yang dibenarkan di sisi un ang-undong. Solinon pengesohon ini ado/oh sah. Soya bersetuju sekironyo soya membuat pengokuan palsu otou tidok mendedahkon moklumat yang berkaiton, MSIG Insurance (Malaysia) Bhd berhak membatolkan tuntuton soya don menorik batik sebarang tuntuton owo/ yang teloh dibayor.

Signature of Patient/ Tondatongan Pesokit Signature of Assured/ Claimant Pemi/ik Palisi /Penuntut

I Tondatangan Signature of Witness / Tandotangan Saksi

Full Name/ Noma Penuh: Full Name / Noma Penuh:IC No. I No. K.P: IC No. I No. K.P:Date / Tarikh: Date I Tarikh:

Full Name / Noma Penuh:

IC No./ No. K.P:Date I Tarikh:Contact No. I No. untuk dihubungi:

Contact No. I No. untuk dihubungi: Contact No. I No. untuk dihubungi:

Relationship to Patient/ Hubungan dengan pesakit

NOTE: COMPLETION OF THIS PRE AU THORISATION FORM DOES NOT GUARANTEE THE ISSUANCE OF GUARANTEE LE T TER. NOTA: MELENGKAPKAN BORANG PERMINTAAN IN/ T/DAK SEMEST/NYA MENJAMIN BAHAWA SURAT JAM/NAN AKAN O/KELUARKAN. F-AO-Cl3-V2

Leandra Sagah840712-13-5272

082 - 260773

Aniziatun Basar811226-13-5098

082-260805

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