Prudential Assurance Co. - Hospital Claim Form

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The Prudential Assurance Co., Ltd.
25th Floor, One Exchange Square, Central, Hong Kong
25
2977 3888
2977 4249
HOSPITAL CLAIM FORM
Insurance Consultant's Details
Insurance Consultant
Division
Contact Phone No.
Agent Code
Part I - Claimant's Certificate (to be completed by Life Assured/Claimant)
Policy No.
Life Assured
ID / Birth Cert. No.
New Claim
Further Claim
Pending Claim
Residential Address
Contact Phone No.
Benefit(s) to Claim
HC/JUHC/ SCP/MSA
MCP
HIP (for Direct Marketing only)
Present Occupation
Name & Address of employer
Employer Contact Phone No.
Return all original receipts /
(
)
sick leave certificates
Mail cheque to client
1.
If Hospitalization was due to an ACCIDENT, please state:-
a)
Date, Time & Location of Accident
DD/MM/YY
/ /
AM /PM
/
Time
Location
b)
Where and how did it happen ? (Describe activities engaged if applicable)
c)
Part(s) of body injured & degree of injury
d)
Did you report to the police?
?
Yes
Police Station
No
Case Ref. No.
Remarks: Please attach a photocopy of the Police Report/Traffic Accident Report/Police Statement/Alcohol Test Report
2.
If Hospitalization was due to an ILLNESS, please state:-
a)
Symptoms and complaints
b)
For this episode, since when have these symptoms first appeared ?
DD/MM/YY
/ /
c)
Other than this episode, have you had any similar/related past history ?
Yes, please provide details:
No
Consultation Date
Physician / Hospital
Diagnosis
Patient No.
(DD / MM / YY) / /
d)
Please provide details of usual Physician(s)/Hospital(s).
/
Since (MM/YY)
(
/
)
Physician/Hospital
Contact Phone No.
Patient No.
LACL/FR001 (10/06)
(P.T.O.)
chpfrm0101

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