CLAIMS REQUIREMENT CHECKLIST

CLAIM TYPE
MEDICAL
Hospitalization due to Illness
Hospitalization due to Accident
Pre / Post Hospitalization
Outpatient Cancer & Kidney
Emergency outpatient accident <RM500
Daycare surgery <RM500
Hospitalization benefit / allowance
Overseas treatment
Partially settled by other insurers
PRULADY
Life stage benefits
Female illness CIS
Infant congenital
Ectopic pregnancy
Late miscarriage
DIC after 7 months pregnancy
Death of foetus
Death of child
PRU MYCHILD
Neonatal jaundice
Incubation
Infant congenital condition
ICU / HDU
ACCIDENT
Accidental Medical Reimbursement (AMR)
Weekly indemnity & AMR
Accidental disablement
DEATH
Accidental / non-natural death
Natural death
CRISIS COVER
All crisis cover conditions
TOTAL & PERMANENT DISABILITY
All TPD conditions

DOCUMENT NO. (AS PER LIST BELOW)

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LIST OF DOCUMENTS

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* To be certified by PAMB branch PIC/ Business Development Executive

1 ) Claim Form by claim type

11) Photo: Full length and close up of injury (where applicable)

2 ) Medical Report Form by claim type:

- Attending Physicians Statement Medical / PA
- Attending Paediatrician Statement Pru MyChild
- Medical Examiner Certificate Pru Lady
- Confidential Medical Certificate Crisis Cover & TPD
- Medical Attendants Certificate Death

12) Evidence of Life Stage Benefit such as copy of:

Birth Cert, Marriage Cert, S&P, Spouse Death Cert etc.

3 ) Copy of bill with diagnosis certified by treating doctor

4 ) Original bills, itemized invoice and statement
5 ) Original receipts including deposit receipt
6 ) Copy of driving license (where applicable)
7 ) Copy of police report (where applicable)
8 ) Copy of test results: histopathology, X-ray, MRI, CT scan,
ultrasound, blood test, all other lab test report (to submit all)
9 ) Copy of admission bill / medical certificate

13) Copy of detailed post mortem report and toxicology report

(for Accidental Death Benefit)
14) Copy of Life Assureds NRIC
15) Certified copy of Death Certificate*
16) Copy of claimants NRIC if other than assured
17) Copy of proof of relationship : Marriage Cert, Birth Cert etc.
18) 5 copies of Consent (for policies <3 years)
19) Copy of Passport indicating evidence of travel
20) Copy of Birth Cert
21) Copy of settlement letter from other insurers
22) Newspaper cutting (for Accidental Death Benefit)

10) Medical report and medical bill translated in English (where

applicable)
TEST RESULTS FOR CRITICAL ILLNESS
Cancer
Heart Attack
Other Serious Coronary Artery Disease
Coronary Artery Disease Requiring Surgery
Angioplasty
Stroke
Brain Surgery
Benign Brain Tumour

- Histopathology Report (Biopsy Result), Imaging Report (CT Scan, Ultrasound, Mammogram etc)
- ECG, CKMB / Troponin T
- Coronary Angiogram Report
- Coronary Artery Bypass Graft Surgery Report
- ECG, Coronary Angiogram Report, Coronary Angioplasty Operation Report
- Brain CT Scan, MRI Report
- Brain Surgery Report
- Brain CT Scan, MRI Report

Note: The above serves only as a guide to the basic requirement. The company reserves the right to request for other relevant supporting
document and information or to view the original of copied document whenever necessary.
Nov 2014 v2

CONSENT TO RELEASE INFORMATION

SURAT KEBENARAN MENGELUARKAN MAKLUMAT
Dear Sirs/Tuan/Puan
POLICY NO :
Polisi No
NAME OF ASSURED & NRIC No (new and old) :
Nama Pemegang Polisi & No KP (baru dan lama)
NAME OF LIFE ASSURED & NRIC No (new and old) :
Nama Hayat Yang Diinsurankan & No KP (baru dan lama)
________________________________________________________________________________________________
I/We, the above-named Assured/Life Assured *..***********************. confirm as
follows./Saya/Kami, Pemegang Polisi/Hayat Yang Diinsuranskan seperti yang dinamakan di atas mengesahkan seperti
berikut :
1.

I/We, consent

to *************************************...(Medical

Service Provider) to disclose and provide to PRUDENTIAL ASSURANCE MALAYSIA BERHAD (PAMB), LEVEL
17, MENARA PRUDENTIAL, 10 JALAN SULTAN ISMAIL, 50250 KUALA LUMPUR and/or its representatives any
and all health (physical and/or mental) and medical information about me/us and my/our health (physical and/or
mental) and medical history./Saya/Kami memberi kebenaran kepada ********..***********..
(Pemberi Perkhidmatan Perubatan) untuk mendedahkan dan memberi kepada PRUDENTIAL ASSURANCE
MALAYSIA BERHAD, LEVEL 17, MENARA PRUDENTIAL, 10 JALAN SULTAN ISMAIL, 50250 KUALA LUMPUR
dan/atau wakil-wakilnya apa-apa dan segala maklumat kesihatan (fizikal dan/atau mental) dan perubatan mengenai
diri saya/kami dan rekod kesihatan (fizikal dan/atau mental) dan perubatan saya/kami yang lampau.
2.

I/We, release PAMB and the Medical Service Provider from all legal responsibilities and liabilities that may arise from
this consent and disclosure./ Saya/Kami melepaskan PAMB dan Pemberi Perkhidmatan Perubatan daripada segala
tanggungjawab dan liability di sisi undang-undang yang mungkin berbangkit daripada keizinan dan pendedahan ini.

Thank you / Terima kasih

___________________________________________

_____________________________________

Signature of Assured/Life Assured/Parent

Tandatangan Pemegang Polisi /Hayat Yang Diinsurankan/Ibubapa

Signature of Witness
Tandatangan Saksi

m Name
Nama

___________________________________

NRIC No ___________________________________
No K/P

Name _______________________________
Nama
NRIC No _____________________________
No K/P

N Address ___________________________________
Alamat

Address ______________________________
Alamat

Tel No ____________________________________
No tel

Tel No ______________________________
No tel

Nov 2014 v2