Hospital Claim Form

Name of Consultant

Consultant Mobile Phone No.

Consultant Code

Division Code & Branch Office

Part I - Claimants Certificate (to be completed by Life Assured / Policyowner / Claimant) - //

Policy Number

Name of Policyowner

Name of Life Assured

Policyowner Contact Phone No.

Residential Address

Name and Address of Life

Assureds Employer
()

ID / Birth Cert. No. of Life Assured

/

Life Assureds Present Occupation /

Job Nature /

Benefit(s) to Claim
Medical Expenses Benefit

Income Benefit

New Claim
Further Claim
Pending Claim

Important Note

Please submit claim application within 90 days from hospital discharge or surgical procedure. If you request any certified true copy(ies) of
medical receipt(s), please also attach with a completed "Request For Certified True Copy Of Medical Receipt(s)" Form. Otherwise, the Company
will not be able to comply with the request.
90

1. If Hospitalization was due to an ACCIDENT, please state:- a) Date, Time & Location of Accident
AM
/ PM
(DD / MM / YYYY) (//)
Time

Location

b) Where and how did it happen? (Describe activities engaged if applicable) ()

c) Part(s) of body injured and degree of injury

d) Did you report to the police?

No

Yes Police Station

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) Signs and symptoms

b) For this episode, since when have these symptoms first appeared?
(DD / MM / YYYY) (//)
c) Other than this episode, have you had any similar / related past history?
No
Yes, please provide details
Consultation Date
Physician / Hospital /
Diagnosis
Patient No.
(DD / MM / YYYY) (//)

d) Please provide details of usual Physician(s) / Hospital(s).

Since (MM / YYYY) (/)
Physician / Hospital /
Contact Phone No.

Prudential Hong Kong Limited

(A member of Prudential plc group) ()
LACL/HOSP (01/16)

Patient No.

3. Consultation and Hospitalization

a) The Physician first consulted for this illness.
Date of Consultation
Physician

Contact Phone No.

Patient No.

Contact Phone No.

Hospital No. / Patient No.

/

(DD / MM / YYYY) (//)

b) The Physician who referred to hospital.
Referral Date
Referral Physician

(DD / MM / YYYY) (//)

c) Details of confinement / consultation: From
/
(DD / MM / YYYY) (//)

4.

To
(DD / MM / YYYY) (//)

Hospital / Physician
/

Concurrent Claims

Did you apply for compensation from another insurers / organization for the same event? /?
No
Yes, please provide details: :
Insurance Company / Organization /
Policy No.
Benefit(s) to claim
Result/Status /

5. Claims Cheque and Documents

(a) Method of delivery of claims cheque to policyowner By Mail* * Via Consultant
- if no selection is made, claims cheque will be delivered via Consultant
* by surface mail to the Policyowners correspondence address in the Companys record

(b) Please tick below to indicate the documents submitted with this application form.
Document Type

Medical Expenses Benefit

Income Benefit

(Original) ()

(Copy) ()

Copy of Discharge Summary / Discharge Slip /

Copy of Laboratory / X-ray / CT scan / MRI / Pathological Report(s) /X-/

//

Copy of Identification of Life Assured & Policyowner

Copy of Admission Note, Discharge Summary, Discharge Certificate, Daily

Medical Record & Temperature Sheet of hospital in Mainland China (
)

Copy of Sick Leave Certificate with clear diagnosis

Copy of Referral Letter by Registered Doctor / Hospital /

Claim Form Part I & Part

Medical Receipt(s) and Statement(s) of Charges ()

Required Documents Optional Documents

Prudential Hong Kong Limited

(A member of Prudential plc group) ()
LACL/HOSP (01/16)

6.

Personal Information Collection Statement

Prudential Hong Kong Limited (referred to as the Company, our, we, or us in this section entitled Personal Information Collection Statement) may
collect certain personal information, including without limitation your name, identity card number (and copy of identity card), passport number, contact
information, family history, health and medical information and financial information ("Personal Information") from you when you apply for insurance or
financial products and services from us, or when you apply to make changes to your policy, or when you make a claim against a policy. We may also
collect Personal Information about you from third parties such as other insurance companies or agents, government agencies, medical personnel, credit
reporting agencies, courts or public records.
1. Purpose of Collection
We may use your Personal Information for the following purposes: (a) to process your application; (b) to administer and process insurance policies,
insurance claims and medical, security and underwriting checks; (c) to process payment instructions; (d) to verify your eligibility for insurance, financial or
wealth management products and services; (e) to design and provide you with insurance, financial and related services and products; (f) to communicate
with you; (g) to provide you with promotional materials relating to insurance or financial services or related wealth management products of the Company,
and those of other entities whose ultimate parent company is Prudential plc ("companies within the Prudential Group") or partnering financial
institutions; (h) to perform a policy review or needs analysis; (i) to conduct research and statistical analysis; and (j) to meet disclosure requirements
imposed by law or regulatory authorities.
2. Classes of Transferees
We may disclose your Personal Information to third parties (within or outside Hong Kong) for the purposes outlined at Section 1 above, including without
limitation the following third parties: (a) insurance agents; (b) re-insurance companies; (c) other companies within the Prudential Group; (d) claims
investigation companies; (e) third party administrators; (f) third party service providers (including without limitation insurers, bankers, lawyers,
accountants, and other third party service providers who provide administrative, telecommunications, computer, payment, printing, redemption or other
services to us to enable us to operate our business); (g) industry associations and federations; (h) medical bill review companies; (i) professional advisors;
(j) researchers; (k) credit reference agencies; (l) debt collection agencies; (m) partnering financial institutions; (n) regulators and government agencies;
(o) law enforcement agencies; (p) the Courts.
We may transfer your name, contact information and information about the products you have purchased (including the sales channel from which such
products were purchased) to other companies within the Prudential Group, and other partnering financial institutions, for the purpose of providing you with
promotional materials relating to those entities' insurance or financial services or related wealth management products. However, we will not disclose your
Personal Information to any other third parties for direct marketing purposes without your consent.
We may transfer your Personal Information in connection with a transaction with another company which affects the control, governance, structure and/or
management of all or a substantial part of our business, or if required to satisfy applicable legal or regulatory requirements.
3. Consequence of failing to provide Personal Information
Unless otherwise specified by us, it is mandatory for you to provide the Personal Information requested by us. In the event that any such Personal
Information is not provided, we may be unable to provide you with the services or carry out the activities outlined at Section 1 above.
4. Access and Correction Rights
Under the Personal Data (Privacy) Ordinance (the "Ordinance"), you have the right to request access to and correction of any Personal Information that
you provide to us. You may make such a request by writing to our Data Protection Officer at P.O. Box No. 28058, Gloucester Road Post Office, Hong Kong.
In accordance with the Ordinance, we have the right to charge a reasonable fee for the processing of any Personal Information access request.

1.
(a) (b) (c)
(d) (e) (f)
(g)
(h) (i) (j)
2.
(a)
(b) (c) (d) (e) (f)
(g)
(h) (i) (j) (k) (l) (m) (n)
(o) (p)

3.

4.

28058

Opting-out Marketing Communications or Materials

We intend to send you marketing communications or materials (as set out in the above Personal Information Collection Statement), but we
cannot do so without your consent. In the event that you do not wish to receive such marketing communications or materials, please let us know
by ticking the Opt-out box below, and returning the form to us in person at our Customer Service Center or by post at P.O. Box No. 28058,
Gloucester Road Post Office, Hong Kong.

28058
Opt-out box
Prudential Hong Kong Limited
(A member of Prudential plc group) ()
LACL/HOSP (01/16)

7.

Declaration & Authorization

I / We, the Life Assured / Policyowner / Claimant, declare that the above information is true and complete to the best of my / our knowledge
and belief.
I / We, the Life Assured / Policyowner / Claimant, hereby confirm my / our understanding of and agreement to the above Personal Information
Collection Statement.
I / We, the Life Assured / Policyowner / Claimant, authorize on behalf of myself / ourselves and the minor Life Assured (if any) that (1) any
doctors, hospitals, clinics, insurance companies, employers, organizations and persons that have any medical history or records or knowledge
of me / us / the minor Life Assured, whom I / we / the minor Life Assured have attended or may hereafter attend may disclose such information
to Prudential Hong Kong Limited (the Company) for the purpose of assessing and processing the proposal for assurance and claims and
providing subsequent services. To avoid any uncertainty, this authorization shall binding on 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; (2) the Company or any of its appointed medical examiners or laboratories
may perform the necessary medical assessment and tests to underwrite and evaluate the health status of myself / ourselves / the minor Life
Assured in relation to the proposal for assurance and any claims arising therefrom.
////
////
////(1)
//
/
/
(2)/
/

Signature of Policyowner / Claimant

/

Name & I.D. No. of Policyowner / Claimant

/

Date (DD / MM / YYYY)

//

Signature of Life Assured

Name & I.D. No. of Life Assured

Date (DD / MM / YYYY)

//

Prudential Hong Kong Limited

(A member of Prudential plc group) ()
LACL/HOSP (01/16)

Part II - Medical Certificate (to be completed by the Attending Physician, duly qualified and registered, at the claimants own expense)
-
Name of Patient

Age & Sex

ID / Birth Cert. No.

/

Date of admission

Date of discharge

Name of Hospital

(DD / MM / YYYY) (//) (Time )

(DD / MM / YYYY) (//) (Time )

Had the client confined in Intensive Care Unit? ?

No

Yes, from

to
(DD / MM / YYYY) (//) (Time ) (DD / MM / YYYY) (//) (Time )

Any home leave taken during the said hospitalization period?

No

Yes, please state the date, time and reason:

1. a) Date on which the patient first consulted you for this illness or injury?

(DD / MM / YYYY) (//)

b) What were the signs & symptoms the patient complained of at this first consultation?

c) Date of the accident occurred or signs &symptoms first appeared before the first consultation?

Since
(DD / MM / YYYY) (//) (Time )
d) Are you the patients usual physician? No

OR existed for

day(s)

month(s)

year(s)

Yes, medical records date back to

(DD / MM / YYYY) (//)

2.

For this episode, had the patient previously been seen other physician(s) for these symptoms?

By (name & address of doctor)

No
Yes,

(DD / MM / YYYY) (//)

3. a) Please state the recommended diagnostic tests and the reason for the tests during this hospitalization.

b) Please provide reasons(s) for this hospitalization if this type of treatment / test can be managed on daycare or outpatient basis?
/

4. a) Final diagnosis

b) What is / are the underlying cause(s) for final diagnosis

c) Surgery performed with dates and surgeons name.

d) Summary of medical treatment given and tests performed with results.

Remarks: please attach copies of histopathology / endoscopic / diagnostic / laboratory test report / operation summary etc.
////
5. a) The prognosis of the condition: Good / Fair / Poor

//
Prudential Hong Kong Limited
(A member of Prudential plc group) ()
LACL/HOSP (01/16)

b)

Any possibility of having a relapse? Yes / No

6. Was the patients injury / illness directly or indirectly due to or aggravated by the following:
/
No
(
(
(
(
(

Yes, please tick where it is appropriate and give details

) alcohol / narcotics / drug abuse

//
) self-inflicted injury

) pregnancy / childbirth
weeks
/

) mental disorders

) others, please specify details:

(
(
(
(

) hazardous sport / activity

/
) infertility / sterilization / termination of pregnancy
//
) AIDS / AIDS related complex disease
/
) body check / vaccination & immunization injections
/

(
(
(
(

) cosmetic or plastic surgery

) congenital / inherited condition

/
) corrective aids or treatment of
refractive errors
) rehabilitation / convalescence
/

7. Did you refer the patient to another physician or hospital?

No

Yes, please give the name and address of the physician / hospital and provide details for referral reason.

8. Other than this episode, has the patient ever been treated for the same / related conditions? /

No
Yes, please provide details
Consultation Date (DD / MM / YYYY)
(//)

Physician / Hospital
/

Diagnosis

Details of Treatment(s) / Hospitalization

/

9. a) Did the patient have the following PAST medical history / habit? /
No

Yes, please tick where it is appropriate and give details. (

( ) asthma
( ) hepatitis B
( ) previous operation

(
(
(

) cardiac problem
) hypertension
) drug addiction

(
(
(

) diabetes mellitus
) unfavorable family history
) others, please specify details:

(
(

) drinking habit
) smoking

b) By whom was the above PAST medical history first detected? Please give the name and address of the physician / hospital.
/

c) Please provide first diagnosis date and treatment details of the above PAST medical history

d) Current Prognosis of the above past medical history:

Fully recovered

On treatment

e) Present smoking / drinking status

/

Not quited

Quitted, since

Name of Attending Physician

Never

Qualification

Hospital Name (if applicable)

Contact Phone No.

Address

Signature & Hospital / Physician Chop

/

Prudential Hong Kong Limited

(A member of Prudential plc group) ()
LACL/HOSP (01/16)

(DD / MM / YYYY) (//)

Date (DD / MM / YYYY)

//