claim form - · pdf file copy of passport1. indicating evidence of travel (for overseas...

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: [email protected]

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: [email protected]

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: [email protected]

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: [email protected]

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