HOSPITAL CLAIM FORM

(P.T.O.)

a)

a)

b)

b)

c)

d)

c)

d)

Date, Time & Location of Accident

Symptoms and complaints

For this episode, since when have these symptoms first appeared ?

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

Part(s) of body injured & degree of injury

Other than this episode, have you had any similar/related past history ?

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

(DD /MM/YY) / /

Consultation Date

Since (MM/YY) ( / )

Physician / Hospital

Physician/Hospital /

Diagnosis Patient No.

Time Location

AM /PM/

Policy No.

Residential Address Benefit(s) to Claim

New Claim

Yes, please provide details: No

No

HIP (for Direct Marketing only)

Further Claim

HC/JUHC/ SCP/MSA MCP

Life Assured

Name & Address of employer

Contact Phone No.

Employer Contact Phone No.

( )

ID / Birth Cert. No.

Present Occupation

1. If Hospitalization was due to an ACCIDENT, please state:-

2. If Hospitalization was due to an ILLNESS, please state:-

Part I - Claimant's Certificate (to be completed by Life Assured/Claimant)

Return all original receipts /sick leave certificates

Mail cheque to client

Pending Claim

Contact Phone No. Patient No.

chpfrm0101

LACL/FR001 (10/06)

Insurance Consultant Division Agent CodeContact Phone No.

Insurance Consultant's Details

Did you report to the police? ?

Yes Police Station

Case Ref. No.

Remarks: Please attach a photocopy of the Police Report/Traffic Accident Report/Police Statement/Alcohol Test Report

The Prudential Assurance Co., Ltd.25th Floor, One Exchange Square, Central, Hong Kong

25

2977 3888 2977 4249

DD/MM/YY / /

DD/MM/YY / /

3. Consultation and Hospitalization

Did you apply for compensation from another insurers/organization for the same event?

4. Concurrent Claims

Insurance Company/Organization Policy No. Result/StatusBenefit(s) to claim

Yes, please provide details: No

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" ) (whethercontained in this application or otherwise obtained) is provided and may be held, used, disclosed and transferred by the Company to any relatedcompanies/organizations or any selected parties (within or outside Hong Kong, including reinsurance and claims investigation companies and industryassociations/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 anypersonal 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 orknowledge 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 processingthis application or claims or subsequent services. To avoid any uncertainty, this authorization shall bind all my/our successors, assignees, executors andadministrators and shall remain valid notwithstanding my/our death or incapacity (including but not limited to mental incapacity.) A photocopy of thisauthorization shall be deemed to be valid as the original.

Signature of Life Assured/Claimant/

Name & I.D. No. of Life Assured/Claimant/

Date (DD/MM/YY)( / / )

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a) The Physician first consulted for this illness.

(DD/MM/YY) / /

Consultation Date Physician Contact Phone No.

Contact Phone No.

Patient No.

Hospital No./Patient No.

/

b)

c)

The Physician who referred to hospital.

(DD/MM/YY) / /

Referral Date Referral Physician

Date of confinement/consultation: From To

/

Physician / Hospital_________________________ _______________________________

(DD/MM/YY) / / (DD/MM/YY) / / /

Sick Leave Certificate with clear diagnosisLaboratory / X-ray / CT scan / MRI / Pathological Report(s)

/ X- / / /

Referral Letter by General Practitioner/Hospital /

Copy of Follow-up Consultation

Discharge Summary

Additional Documents

Checklist for Documents Submission

Claim Form Part I

Basic Required Documents

Claim Form Part II

Original Receipt(s) and Total Medical Expenses HK$

(for medical reimbursement benefit )Photocopy of Receipt(for income benefit )

Photocopy of the Identification of the Life Assured and Policyowner

Part II - Medical Certificate (to be completed by the Attending Physician, duly qualified and registered, at the claimant's own expense)- ( )

chpfrm0103

Name of Patient Age & Sex ID/Birth Cert. No./

Admitted Discharged Hospital No. / Patient No./

DD/MM/YY / / Time

DD/MM/YY / / Time DD/MM/YY / / Time

DD/MM/YY / / Time

Intensive Care Unit

Yes from to No

No

No

No

Yes, please state the date, time and reason: ,

Any home leave taken during the said hospitalization period? ?

1. a)

b)

c)

Date on which you first saw the patient for this illness or injury??

What were the symptoms the patient complained of at this first consultation??

Are you the patient's usual physician??

Yes, Medical records date back to

2. According to the patient, how long had he / she been experiencing these symptoms before the first consultation??

since OR for day(s) month(s) year(s)

3. For this episode, had the patient previously seen other physician for these symptoms?

?

4. a) Clinical diagnosis.

b) When was the patient informed of the diagnosis? ?

By (name & address of doctor):

c) How long, in your opinion, has the patient suffered from this disease before his/her first consultation??

Remarks: please attach copies of histopathology / endoscopic / diagnostic / laboratory test report/ operation summary etc.

5. a) Final diagnosis.

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

c) Surgery performed with dates and surgeon's name.

/ / / /

DD/MM/YY / /

DD/MM/YY / /

DD/MM/YY/ /

Yes, By (name & address of doctor):DD/MM/YY/ /

DD/MM/YY/ /

(P.T.O.)

7.

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

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

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

Was the patient's injury / illness directly or indirectly due to or aggravated by the following::

No

No

No

No

( ) alcoholism/alcohol/narcotics/drug

( )

( )

( )

( )

/ /( ) hazardous sport/activity ( ) cosmetic or plastic surgery

( ) ( )

( ) ( )

( ) ( )

self-inflicted injury

pregnancy/childbirth weeks

/

infertility/sterilization/termination of pregnancy/ /

others, please specify

mental disorders congenital/inherited condition/

AIDS/AIDS related complex disease/

corrective aids or treatment ofrefractive errors

body check / vaccination & immunization injections/

rehabilitation / convalescence/

Please provide details:- :-

8. Did you refer the patient to another physician/hospital? ?

9.

10.

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

a)

Yes, please provide details.

/

Details of Treatment(s)/HospitalizationConsultation Date (DD/MM/YY)

/ /

Physician / Hospital

/

Diagnosis

Did the patient has the following medical history/habit? / ?PAST

( ) asthma ( ) cardiac problem ( ) diabetes mellitus ( ) drinking habit

( ) hepatitis B ( ) hypertension ( ) unfavorable family history ( ) smoking

( ) previous operation ( ) drug addiction ( ) others, please specify

b) By whom was the above medical history first detected? /past

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

d) Current Prognosis of the above past medical history:

e) Present smoking/drinking status/

Fully recovered On treatment

Not quit Quit, since

11. Other information.

Name of Physician

Hospital Name (if applicable)( )

Address

Signature & Hospital/Physician Chop/

Qualification

Contact Phone No.

Date (DD/MM/YY)( / / )

chpfrm0104

b) Any possibility of having a relapse? Yes / No

? /

6. a) The prognosis of the condition: GOOD / FAIR / POOR: / /

DD/MM/YY / /