8/12/2019 BORANG CH

1/8

BORANG TUNTUTAN HOSPITAL

SILA PASTIKAN @ DAPATKAN

** SALINAN KP AHLI DAN PESAKIT ( WAJIB )

** BORANG SECTION A & LETTER OF AUTHORISATION / CONSENT

( WAJIB DIISI OLEH PESAKIT )

** SIJIL PERAKUAN PENYERTAAN (JIKA ADA):

1. JIKA KEMASUKAN KE DLM WAD KURANG DARI 1 HARI BERTURUT!TURUT

** LAMPIRKAN DISCHARGE NOTE @ SUMMARY @ SEBARANG DOKUMENYG MEMPUNYAI

PENGESAHAN DARI DOKTOR BERKENAAN DIAGNOSIS @ NAMA PENYAKIT YG

DIHIDAPI ( DOKTOR PERLU T/TGN & COP HOSP.) RUJUK CONTOH

----------------------------------------------------------------------------------------------------------------

2. JIKA KEMASUKAN KE DLM WAD LEBIH DARI 1 HARI BERTURUT!TURUT SILA ISI

** BORANG SEKSYEN B "STATEMENT MEDICAL E#AMINER"

--------------------------------------------------------------------------------------------------------------

SEBELUM HANTAR $ SILA PASTIKAN DOKUMEN LENGKAPDGN LAMPIRAN YG

DIPERLUKANJIKA TIDAK TUNTUTAN ANDA AKAN DITOLAK%Kembalia! &'()(*+ ,-. ()* / 0*+' BUKAN 2)0.&+(+ / EMAIL DAN HANTAR SEGERA

KE KOPERASI CUEPACS BUKAN KEPADA ETI3A:

8/12/2019 BORANG CH

2/8

8/12/2019 BORANG CH

3/8

HOSPITALISATION BENEFIT (HB) CLAIM FORM

SECTION A & LETTER OF AUTHORISATION / CONSENT ( WAJIB DIISI OLEH PESAKIT )

Every question must be fully answered and the Company reserves the right to require further information should it deem necessary. Submission of thisClaim Form does not guarantee admission of liability.

Instruct!n " Su##!rtn$ %!cu'nts r'ur'%

* JIKA KEMASUKAN KE DLM WAD KURANG DARI 1 HARI BERTURUT!TURUT PERLUKAN SALINAN

** DISCHARGE NOTE @ SUMMARY @ SEBARANG DOKUMENYG MEMPUNYAI PENGESAHAN

DARI DOKTOR BERKENAAN

1.1 DIAGNOSIS @ NAMA PENYAKIT YG DIHIDAPI ( DOKTOR PERLU T/TGN & COP HOSP.)

1%4 TARIKH MASUK DAN KELUAR WAD

+* JIKA KEMASUKAN KE DLM WAD LEBIH DARI 1 HARI BERTURUT!TURUT SILA ISI

** BORANG SEKSYEN B "STATEMENT MEDICAL E#AMINER"

P,rtc#,nt-s D't,.s " PESAKIT SALINAN KAD PENGENALAN DIPERLUKAN JIKA TIDAK TUNTUTAN ANDA AKANDITOLAK

Name of Participant : CHE NURAISAH BINTI CHE MOHD HAFI0UL

N!C No. : 12+344135 "C # $ld !C No. : %%%%%%%% &ge : 6 EARS

Se' : (ale Female )ate of "irth : 3 DISEMBER +112 (arital Status : SIN7LECorrespondence &ddress : NO* +18 JLN BUN7A ROS8 OFF JLN TELUK PULAI8 911 KLAN78 SELAN7OR

(obile Phone No. : 1+:2211:5 $ffice Phone No. : ................. ................ .............. *ouse Phone No. : 13335+233

Fa' No. : %%%%%%%%%%%%%%% E+mail &ddress : n!r,s.n,,;%u.$,.*c!!f wor,ing- please state :

i Present $ccupation : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

ii E'act nature of occupation and duties : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

iii Name / address of employer : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

iv $ffice 0elephone No. : ................ ................ ............... ........... v )ate 1oin company : .................. ............... ............... ................ ......

C.,,nt-s D't,.s (I? !t='r t=,n P,rtc#,nt) " PEMBAAR INSURAN SALINAN KAD PENGENALAN DIPERLUKAN JIKATIDAK TUNTUTAN ANDA AKAN DITOLAK

Name of Claimant : NORASLINA BINTI ABDUL WAHAB

N!C No.: 5@151+44@21+ $ld !C No. : %%%%%%%%%%%%%%%%%%%%%%%

Correspondence &ddress: NO* +18 JLN BUN7A ROS8 OFF JLN TELUK PULAI8 911 KLAN78 SELAN7OR

(obile Phone No. : 1+4:2211:5 $ffice Phone No. : 134336331 *ouse Phone No. : 134335+233

Fa' No. : %%%%%%%%%%%%%%% E+mail &ddress: n!r,s.n,,;%u.$,.*c!

SALINAN KAD PENGENALAN PENUNTUT DAN PESAKIT DIPERLUKAN

JIKA TIDAK TUNTUTAN ANDA AKAN DITOLAK

HANTAR SEMULA KE :

KOPERASI CUEPACS BHD

UNIT 244 BOULEVARD SENTUL RAYA

JALAN 15/48 A,

51000 SENTUL KUALA LUMPUR

C!ntr,ct N! TKM 1@65TEL : 03 404 40817

8/12/2019 BORANG CH

4/8

SECTION A HB MS 4 +

* H!s#t,.s,t!n-s D't,.s

i. Name of illness # diagnosis : ACUTE TONSILITIS & IRAL FEER

ii. )ate of diagnosis : 2/1@/+192dd#mm#yyyy

iii. Symptoms of illness : DEMAM8 SAKIT TEKAK8 MUNTAH

iv. *ow long the symptoms e'isted prior to ?rsthospitalisation 3 + DAS

v. )ate of ?rstconsultation : 2/1@/+19 2dd#mm#yyyy

vi. Name of ?rstclinic # hospital consulted for this illness # in1ury : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%

vii. &ddress of the clinic # hospital : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%..%%%%%%%%%.

viii. Contact no. of the clinic # hospital : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%..

i'. )ate of &dmission: 2/1@/+192dd#mm#yyyy

'. )ate of )ischarge: :/1@/+192dd#mm#yyyy

4. Name2s of all medical practitioner2s and clinic2s # hospital2s which 2!#Participant5 have #has- sought or received medical treatment- advice-consultation and#or chec,+up within the #,st t=r'' (3) ',rs.

)ate of Consultation or 0reatment etc. Name of )octor 2s Name- &ddress and 0elephone No of Clinic # *ospital

67#89#68

9#87#68;

). )&!S0 (E)!C&> CEN0E- ?>N ($*E0-4888 =>&N@- SE>&N@$ 20E>: 8;+;;7;;A;A

Name- address and contact no. of the ParticipantBs regular doctor other than above :

..

.

9. &re there other policies in force on the ParticipantBs life ta,en with other companies3 es No !f yes- please furnish the following details :

Name of Company Policy No. 0ype of Coverage &mount of )ate which the policies Compensation 2( were effected

CRESCENT SOLUTION (M) SDN* BHD* 7T111191111+11 %%%%%%%. RM +@@:*+@ %%%..%%%..

2* P.',s' st,t' !ur (t=' C.,,nt) ;,n ,cc!unt %'t,.s n !r%'r ?!r us t! cr'%t t=' #,'nt %r'ct. nt! !ur ;,n ,cc!unt*

B,n MABANK (MBB) Acc!unt N! @5155 66+: ( NO AKAUN PEMBAYAR INSURAN )

DECLARATION

!#De hereby declare that the information given in this claim form are true and that !#the Participant did not suffer from any of the pre+e'isting conditionsat the time of this contract was ta,en up. ! agree that in the event that ! ma,e- or have in the past made- any false or untrue statement and#orsuppressed and #or concealed any materials facts in respect of my#the ParticipantBs health condition- the Company shall absolutely forfeit my#theParticipantBs right to compensation and further reserves the right to recover any amounts paid earlier as a result thereof.

Signature # 0humb print of Participant Signature # 0humb print of Claimant Signature of Ditness

Name : NORASLINA BT ABDUL WAHAB Name : Name : CHE MOHD HAFI0UL BIN CHE HUSIN)ate : +3 MEI +19 )ate : )ate : +3 MEI +19

N!C No : 5915+44@52:

8/12/2019 BORANG CH

5/8

SECTION A HB MS 4 3

LETTER OF AUTHORISATION / CONSENT

T! O;t,n Furt='r M'%c,. n?!r,t!n

0$ D*$( !0 (& C$NCEN

Name of Participant CHE NURAISAH BINTI CHE MOHD HAFI0UL

N!C No. 12+344135 2New %%%%%%%%%%%%%%%%%..2$ld

Contract No. %%%%%%%%%%%%%%%%%%%%%%%...

!- NORASLINA BT ABDUL WAHAB N!C No. 5@151+44@21+ hereby authorie and give my consent to any medicalpractitioner- physician- surgeon- nurse- medical staff- clinic- hospital- medical centre- insurance company or organiationor individual concerned 2Gthe information providerH that may have any record or ,nowledge of health or medical history ofthe above stated 2GParticipantH and to provide such information to Etiqa 0a,aful "erhad and its authoried serviceprovider and#or its employees in order to process my ta,aful claim.

! e'pressly waived all provisions of law or professional ethics forbidding the !nformation Provider2s from disclosing anysuch information acquired on myself in a professional and#or client capacity and ! further release the !nformationProvider2s and its agent#staff from any liability whatsoever that may arise- in supplying such information requested by theCompany.

0his authoriation#consent is irrevocable and a copy of it will have the same effect and validity as the original.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%Signature of Participant # Claimant 2!f Participant is a minor

Name: NORASLINA BT ABDUL WAHAB

elationship with Participant: MOTHER

)ate: +3 MEI +19

TKM 0578

8/12/2019 BORANG CH

6/8

8/12/2019 BORANG CH

7/8SECTION B HB MS 4 +

TKM 0578

8/12/2019 BORANG CH

8/8