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  • FORM ID English Version 06/2020

    Page 1/6

    PART 1: TYPE OF CLAIM

    Please complete in DARK BLACK ink only and TICK (√) the boxes where appropriate.

    CLAIM FORM

    116010 Prudential Assurance Malaysia Berhad 198301012262 (107655-U)

    Level 20, Menara Prudential, Persiaran TRX Barat, 55188 Tun Razak Exchange, Kuala Lumpur, Malaysia P.O. Box 10025,50700 Kuala Lumpur. Customer Service Hotline: 603-2771 0228, E-mail: customer.mys@prudential.com.my

    Agent's Code/Bank/Prudential Assurance Malaysia Berhad Representative's Number

    Agent/Bank/Prudential Assurance Malaysia Berhad Representative's Contact Number

    Agent/Bank/Prudential Assurance Malaysia Berhad Representative's Name

    Policy Number

    1.

    4.

    2.

    Date Submitted (dd/mm/yy)

    3.

    6.5.

    Note: Correspondences in relation to this claim will be delivered to the agent / bank representative / Prudential representative stated above, unless claimant explicitly specifies his / her preferred method.

    Correspondence Delivery Method: Send directly to Claimant Collection at PAMB / Bank Branches:

    [68]

    Outpatient Treatment

    Allowance Benefits

    Well Being Benefit

    Deductible Accumulation

    Deductible Accumulation

    Hopitalization Benefit / Allowance

    Medical

    Hospitalisation / Day Care Surgery

    Partially Settled By Other Insurers

    Overseas Treatment

    Surgical & Nursing Loan

    Pre & Post Hospitalization

    Outpatient Cancer & Kidney Dialysis / Dengue Fever Treatment

    Personal Accident Kemalangan Peribadi

    Weekly Indemnity Accident Medical Reimbursement

    Accidental Disablement

    [67]

    Critical Illness

    [11] Crisis Cover

    Emergency Treatment of Accidental Injury

    Home Nursing Care

    Hospitalisation / Day Care Surgery

    Others Lain-lain

    Death Kematian

    Death

    Total and Permanent Disability

    Long Term Care Benefit

    Essential Child Benefit

    Neonatal Jaundice

    Incubation / Intensive Care Unit / High Dependency Unit

    Congenital Conditions

    Pregnancy / Maternity Complication

    [69] Crisis Cover Income

    Total and Permanent Disability

    [11]

    Total and Permanent Disability Instalment Benefit

    [09]

    [57]

    Life Stage / Life Change Benefit

    Snatch Theft Benefit

    Female Carcinoma-in-situ / Recovery Benefit

    Infectious Disease Benefit

    [12]

  • FORM ID 116010

    Other Insurance Coverage Name of Company / Insurer / Scheme Policy / Membership Number Sum Insured

    Page 2/6

    PART 3: CLAIMANT'S DETAILS (IF OTHER THAN LIFE ASSURED)

    Name

    NRIC/Old IC/Passport/Other

    Correspondence Address*

    Contact Number*

    Relationship to Life Assured

    CLAIMANT'S DETAILS Claimant A Claimant B Claimant C Claimant D

    PART 4: CLAIM INFORMATION

    4.1 For Medical, Critical Illness, Total Permanent Disability and Others Claim if due to illness

    PART 2: LIFE ASSURED'S GENERAL INFORMATION

    Name

    NRIC/Old IC/Passport/BC/Other

    Occupation

    Contact Number*

    Name and Address of Employer

    Month Year

    E-mail Address*

    E-mail Address*

    *For personal details update (applicable for Assured only), please log on to https://pruaccessplus.prudential.com.my and update Change of Contact Details.

    Date of consultation Name of doctor & Address

    4.1.1 Presented sign and symptom / diagnosis

    4.1.2 How long has Life Assured been aware of the condition

    4.1.3 First consultation with doctor to seek treatment Day

    4.1.4 Details of first and all doctors who have been consulted for the above condition.

    English Version 06/2020Prudential Assurance Malaysia Berhad 198301012262 (107655-U) Level 20, Menara Prudential, Persiaran TRX Barat, 55188 Tun Razak Exchange, Kuala Lumpur, Malaysia P.O. Box 10025,50700 Kuala Lumpur.

    Customer Service Hotline: 603-2771 0228, E-mail: customer.mys@prudential.com.my

  • FORM ID 116010

    4.3.3 Please describe in detail the exact duties performed

    4.3.4 Are you medically boarded out?

    4.3.5 Are you currently confined to: Bed-Ridden Wheel Chair Bound Home Able to walk with Aid

    4.3.2 Name and Address of Employer

    4.3 Further information for Total Permanent Disability Claim

    4.3.1 Occupation

    Prior to suffering from disability Current employment status

    4.4 For Death Claim

    Illness SuicideAccident Others, please specify:

    4.4.5 Had the deceased suffered any illness previously? YES NO

    Date of consultation Name of doctor Address Telephone Number

    4.4.1 Date & Time of death

    4.4.2 Place of death

    4.4.3 Cause of death

    4.4.4 If due to accident, please provide date and time of accident

    If YES, please provide details in below

    Single DivorcedMarried

    Spouse Mother

    Widow/Widower

    Child(ren)_____person(s)Father

    4.4.6 Marital Status at point of death

    4.4.7 Deceased's surviving family member(s)

    4.4.8 Has the deceased left a Will or Testament? YES NO

    4.2.3 Detailed description of accident

    4.2.4 First consultation with doctor to seek treatment

    4.2.5 Last working date prior to Disability

    4.2.6 Date returned to work

    4.2.2 Place of accident

    Day Month Year

    Day Month Year

    Day Month Year

    Day Month Year am/pm

    Day Month Year am/pm

    4.2.1 Date & Time of accident Day Month Year am/pm

    4.2 For Medical, Personal Accident and Total Permanent Disability Claim if due to accident

    Page 3/6 English Version 06/2020Prudential Assurance Malaysia Berhad 198301012262 (107655-U)

    Level 20, Menara Prudential, Persiaran TRX Barat, 55188 Tun Razak Exchange, Kuala Lumpur, Malaysia P.O. Box 10025,50700 Kuala Lumpur. Customer Service Hotline: 603-2771 0228, E-mail: customer.mys@prudential.com.my

  • FORM ID 116010

    PART 5: CLAIM REQUIREMENT CHECKLIST

    NOTE: The following list serves as a guide for basic requirements. PAMB reserves the right to request or to view other relevant supporting document and information or the original of copied document whenever necessary.

    Hospitalisation / Day Care Surgery

    Overseas Treatment

    Partially Settled by Other Insurers

    Surgical & Nursing Loan

    Hospitalisation / Day Care Surgery

    Outpatient Treatment Benefit

    Pre & Post Hospitalisation

    Outpatient Cancer & Kidney Dialysis / Dengue Fever Treatment

    Emergency Treatment of Accidental Injury

    Home Nursing Care

    Allowance Benefit

    Hopitalization Benefit / Allowance

    Well Being Benefit

    Deductible Accumulation

    Deductible Accumulation

    Personal Accident

    Accident Medical Reimbursement (AMR)

    Weekly Indemnity (WI)

    Accidental Disablement

    Critical Illness

    Crisis Cover

    Payor / Waiver

    Total and Permanent Disability

    Total and Permanent Disability / Long Term Care Benefit

    Death / Kematian

    Others

    Neonatal Jaundice

    Incubation / Intensive Care Unit / High Dependency Unit

    Congenital Conditions

    Pregnancy / Maternity Complication

    Life Stage / Life Change Benefit

    Female Carcinoma-in-situ / Recovery Benefit

    Snatch Theft Benefit

    Infectious Disease Benefit

    Essential Child Benefit

    CLAIM TYPE Requirement List No. (Refer to Page 5)

    (a) For Infant Care

    (b) For PRUlady

    (a) For Infant Care

    (b) For PRUlady

    (b) For Accident or Suicide

    (a) For Natural Death

    Payor / Waiver

    Death

    Spouse / Parent Payor / Waiver

    (c) For Medical Rider

    1a

    3

    1a

    1a

    1a

    1a

    1a

    1a

    2

    2

    3

    43

    10

    12

    11

    13

    9

    6

    43 6

    43 6

    4 10 11

    43 10 11

    43 6

    43 10 11 12 13

    2524 26

    5

    4 10 11

    5 6

    5

    32 4 6 1210 13

    61b 7 10 1312

    61b 8 10 1312 17

    61c 17

    171c 20

    61d 13 17 2322

    6

    1e

    1f 1917 20 27

    1d 13 17 22206 23

    51g

    1g

    6

    5

    1i

    21

    13

    1c 6

    1j 5 6

    1h 6

    1i 186 21

    15 16 1917 2014

    2118

    271f

    1h 6

    1i 6

    43

    186 2143

    1k 6 17

    Total and Permanent Disability Instalment Benefit

    Crisis Cover Inccome Not Applicable

    Page 4/6 English Version 06/2020Prudential Assurance Malaysia Berhad 198301012262 (107655-U)

    Level 20, Menara Prudential, Persiaran TRX Barat, 55188 Tun Razak Exchange, Kuala Lumpur, Malaysia P.O. Box 10025,50700 Kuala Lumpur. Customer Service Hotline: 603-2771 0228, E-mail: customer.mys@prudential.com.my

  • FORM ID 116010

    Requirement List

    List of ORIGINAL RECEIPT(s) submitted (including Deposit/Refund/Final Receipt(s)). Please paste on A4 paper according to receipt date.

    Receipt Date Receipt No. Receipt Amount

    TotalNote: If space provided is insufficient, please continue on separate sheet of paper and