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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