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 Code Contact 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 / /
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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
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)( / / )
chpfrm0102
a) The Physician first consulted for this illness.