Prudential Assurance Co. - Hospital Claim Form Page 2
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43.
Consultation and Hospitalization
a) The Physician first consulted for this illness.
Contact Phone No.
Patient No.
Consultation Date
Physician
(DD/MM/YY)
/ /
b)
The Physician who referred to hospital.
Contact Phone No.
Hospital No./Patient No.
Referral Date
Referral Physician
(DD/MM/YY)
/ /
/
Date of confinement/consultation: From
_________________________
To
_______________________________
Physician / Hospital
c)
/
(DD/MM/YY)
/ /
(DD/MM/YY)
/ /
/
4.
Concurrent Claims
Did you apply for compensation from another insurers/organization for the same event?
Yes, please provide details:
No
Insurance Company/Organization
Policy No.
Benefit(s) to claim
Result/Status
Declaration & Authorization
I declare that the above information is true and complete to the best of my knowledge and belief.
I/We hereby declare and agree that any personal information collected or held by The Prudential Assurance Company Ltd. ( "the Company" ) (whether
contained in this application or otherwise obtained) is provided and may be held, used, disclosed and transferred by the Company to any related
companies/organizations or any selected parties (within or outside Hong Kong, including reinsurance and claims investigation companies and industry
associations/federations) for the purpose of processing this application or claims and providing subsequent services for this and other products and services,
direct marketing, and data matching, and to communicate with me/us for such purposes. I/We have the right to obtain access and to request correction of any
personal information held by the Company. Such request can be made to the Company's Principal Office.
I/We authorize that any doctors, hospitals, clinics, insurance companies, employer, organizations, or persons that have any medical history or records or
knowledge of me/us who I/we have attended or may hereafter attend to disclose such information to the Company for the purpose of assessing and processing
this application or claims or subsequent services. To avoid any uncertainty, this authorization shall bind all my/our successors, assignees, executors and
administrators and shall remain valid notwithstanding my/our death or incapacity (including but not limited to mental incapacity.) A photocopy of this
authorization shall be deemed to be valid as the original.
Name & I.D. No. of Life Assured/Claimant
Date (DD/MM/YY)
Signature of Life Assured/Claimant
/
(
/
/
)
/
Checklist for Documents Submission
Basic Required Documents
Additional Documents
Claim Form Part I
Discharge Summary
Claim Form Part II
Sick Leave Certificate with clear diagnosis
Laboratory / X-ray / CT scan / MRI / Pathological Report(s)
Original Receipt(s) and Total Medical Expenses HK$
/ X-
/
/
/
Referral Letter by General Practitioner/Hospital
/
(for medical reimbursement benefit
)
Copy of Follow-up Consultation
Photocopy of Receipt
(for income benefit
)
Photocopy of the Identification of the Life Assured and Policyowner
chpfrm0102
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