Medical Insurance Claim Form

09/2015
Claim Form
Medical Insurance
Agent’s Code:
Policy No.:
Information collected in this claim form shall be used in connection with the Company’s purposes and course of business only.
Please write in block letters and tick () in the appropriate boxes. Kindly attach separate sheet if space is insufficient.
Part 1: Claim Form
(To be completed by Patient and Employer)
Particulars Of Insured
i.
Name of Insured:
NRIC:
Plan:
ii. Occupation:
Age:
Date of Birth:
Sex:
iii. Name of Employer / Policy Holder:
Date of Employment(For Group Policy):
Particulars Of Patient
i.
(if patient is a Dependent)
Name of Patient:
NRIC:
ii. Relationship:
Plan:
Age:
Date of Birth:
Statement By Patient
a.
Accident
Sex:
(By Parent If Claimant is a Child below 18 years old)
i) Date and Time of Accident:
ii) Place of Accident:
iii) Brief Description of Accident:
iv) Final Diagnosis:
b. Illness
i) Symptoms First Appeared on:
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Y
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Y
Y
Y
ii) First Treatment Sought Date:
iii) Name of 1st Doctor Consulted:
iv) Name & Address of Clinic / Hospital:
v) Final Diagnosis:
c. Others
i) Is the Patient covered by any Medical / Health Insurance?
ii) Will the whole or any part of the medical expenses incurred covered by any other form of indemnity or insurance?
If Yes, Policy No.
Insurance Company
d. Claim Payment in Favour of? (Please specify the name of payee)
Policy Holder / Employer:
Insured Person / Employee / Claimant:
Subsidiary:
Others (Please Specify):
Tokio Marine Insurans (Malaysia) Berhad (149520-U)
29th Floor, Menara Dion, 27 Jalan Sultan Ismail, 50250 Kuala Lumpur, Malaysia.
T : (03) 2026 9808, 2783 8383 F : (03) 2026 9708
tokiomarine.com
Declaration on GST (To be completed by Insured who is GST Registered)
GST Registration No:
GST Registration Date:
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Y
Y
Declaration and Authorisation To Physician, Clinic or Hospital
By signing this Claim Form:
i)
I hereby declare that the answers provided above are true and complete to the best of my/our knowledge and belief.
ii)
I hereby irrevocably authorize any organization, institution or individual that has any record or knowledge of my health and medical
history or treatment or advice that has been or may hereafter be consulted, other personal information or details of related
disability, to fully disclose to TOKIO MARINE INSURANS (M) BHD or its authorized representative such information in relation to this
claim.
This authorization is irrevocable and a photocopy of it will have the same effect and validity as the original.
Acknowledgement & Declaration
Personal Data Protection Act 2010 (PDPA) Notice
i. I/We acknowledge and consent that the personal data, including any sensitive personal data, collected herein be used and processed
for the purpose of this claim and be disclosed to reinsurers; individuals or organizations associated with Tokio Marine Group, or involve
in any claim settlement; or PIAM/ISM;
ii. I/We confirm that I/we have obtained the consent of the person(s) and/or nominee(s) named herein, where applicable, and that
he/she/they has/have authorized me/us to disclose their personal data and to give consent on their behalf for the above collection,
use, process and disclosure;
iii. I/We acknowledge that I/we am/are obligated to provide the above personal data failing which my/our claim could not be processed
and that I/we am/are entitled to obtain access to, request for correction of or limit the processing of my/our personal data; and
iv. I/We acknowledge the detail Privacy Policy Statement, governing the above, posted at www.tokiomarine.com and that I/we could also
make enquiry with regard to the PDPA through email send to [email protected].
Declaration
I/We understand that it is my/our duty to take reasonable care not to make a misrepresentation in answering the questions in this Claim
Form and I/we hereby declare that I/we have fully and accurately answered the questions above.
Signature of Patient
Signature of Insured / Employer
Name:
Name & Company Stamp:
NRIC:
Date:
Date:
(Company Stamp is compulsory for Group Policy)
Notice: To ensure payment is made via e-payment, kindly complete the e-payment registration form.
Registration Form
E-Payment
Please complete the details herein this Form with capital letters and cross (X) the appropriate box.
Policy Holder
Agent
Broker
Reinsurer
Adjuster
Repairer
Lawyer
Financial Institution
Service Provider
Others
(Please specify)
Personal Details
Beneficiary Name:
Business Registration No (non-individual):
NRIC No (individual):
Address:
Telephone No:
Handphone No:
Contact Person 1:
Email:
Contact Person 2:
Email:
Banker (Please select from Appendix A)
Bank Code Bank Account Number (please ignore all dashes: ‘-’)
Documents To Be Attached Herewith This Form
For verificaton purpose, kindly attach the following supporting document that confirm the said account belongs to you/your company
Photocopy of top portion of the bank statement of Current Account, OR
Front page of the Savings Account Passbook, OR
Confirmation letter from bank
Declaration
I/We hereby authorize Tokio Marine Insurans (Malaysia) Berhad (TMIM) to credit all monies due to me/us to my/our bank account
indicated above by way of Giro Fund Transfer/Rentas and confirm that:
1 I/We hereby declare that the above is my personal account/our company account, NOT joint account and the information given is
true and accurate to the best of my knowledge and record.
2 I/We shall indemnify TMIM for any loss, damage or claims incurred as consequence of acting on such reliance.
3 I hereby give my consent to TMIM to disclose my Personal Data provided in this E Payment Registration Form to TMIM, TMIM’s service
providers and bankers and such service providers and bankers have my consent to process my Personal Data for the purpose of
effecting and administrating the electronic payments to me (including without limitation, my name, personal identification
number, contact details and any other personal data obtained hereafter collectively known as “Personal Data”).
4 I understand that I have the right, upon payment of a prescribed fee, to request access to my Personal Data that is being processed
by TMIM and to request correction of my Personal Data. Such request shall be submitted to the Head of Finance, TMIM; and
5 I understand that the supply of my Personal Data herein is voluntary and it is necessary for TMIM to process my Personal Data for
effecting and administrating the electronic payments to me.
Authorized Signature
Signature of Insured / Employer
Name:
Name & Company Stamp:
Position:
Date:
Date:
(Company Stamp is compulsory for Group Policy)
(PLEASE RETURN ORIGINAL SIGNED FORM TO TMIM)
FOR OFFICE USE ONLY:
To be completed by relevant department:
Department/branch:
MO Code:
Agent Name:
Client Code:
Agent Code:
Verified by:
Signature/Date:
To be completed by Finance department:
Date received:
Signature/Date:
Data Entry by Finance:
Signature/Date:
Verified by Finance:
Appendix A
LIST OF BANKERS - for E-Payment Registration Form
Banker
Bank Code
Banker
Bank Code
1
AFFIN BANK BERHAD
PHBM
14
DEUSTCHE BANK
DEUT
2
AGRO Bank ( Bank Pertanian M’sia Bhd )
AGOB
15
HONG LEONG BANK BERHAD
HLBB
3
ALLIANCE BANK MALAYSIA BERHAD
MFBB
16
HSBC BANK MALAYSIA BERHAD
HBMB
4
AL-RAJHI BANKING & INVESTMENT CORPORATION (MSIA) BHD
RJHI
17
J.P. MORGAN CHASE BANK BERHAD
CHAS
5
AMBANK BERHAD
ARBK
18
KUWAIT FINANCE HOUSE (M) BERHAD
KFHO
6
BANK ISLAM MALAYSIA BERHAD
BIMB
19
MALAYAN BANKING BERHAD
MBBE
7
BANK KERJASAMA RAKYAT BERHAD
BKRM
20
OCBC BANK (M) BERHAD
OCBC
8
BANK MUALAMAT BERHAD
BMMB
21
PUBLIC BANK BERHAD
PBBE
9
BANK OF AMERICA
BOFA
22
RHB BANK BERHAD
RHBB
10
BANK OF TOKYO-MITSUBISHI UFG (MALAYSIA) BERHAD
BOTK
23
ROYAL BANK OF SCOTLAND BHD
ABNA
11
BANK SIMPANAN NASIONAL
BSNA
24
STANDARD CHARTERED BANK MSIA BHD
SCBL
12
CIMB BANK BERHAD
CIBB
25
SUMIMOTO MITSUI BANKING CORPORATION MALAYSIA BERHAD
SMBC
13
CITIBANK BERHAD
CITI
26
UNITED OVERSEAS BANK
UOVB
Part 2: Medical Report
1.
2.
(To be completed by Attending Physician / Surgeon)
a. Patient Name:
b. Age:
c. NRIC:
d. Sex:
Admission Date and Time:
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3.
Discharge Date and Time:
4.
a. Symptoms / Conditions requiring admission:
Male
(Time)
am
pm
(Time)
am
pm
Yes
No
Female
b. Patient’s BP / Temp. / Pulse:
c. How long is patient aware of the condition:
d. Date symptoms first appeared:
e. Date first consulted:
5.
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a. Any previous consultation / treatment / hospitalisation for this
symptom / illness or related conditions, or other disorders
Whether in this hospital or any other facilities?
Name and Address of doctors previously consulted by the patient for the condition:
b. Was this patient referred to you? If yes, please provide details below:
c. If this condition existed before symptoms became apparent to the patient, please indicate in your professional opinion how
long has the condition existed:
d. Can the condition be managed under the Outpatient basis:
If no, please provide reasons of admission:
6.
Yes
No
Yes
No
Yes
No
a. Final Diagnosis:
b. Cause and pathology underlying the present diagnosis:
c. Any possibility of relapse:
Is follow up required?
7.
Admission requires:
Hospitalisation
8.
Day Care Surgery
On Patient’s Request
Is the illness / condition related to ( please tick () if YES ):
Pregnancy / Childbirth / Infertility / Caesarean Section /
Miscarriage or any complications arising therefrom
Cosmetic Reason / Dental Care / Refractive Errors
Correction
Congenital / Hereditary Diseases
AIDS / STD / VD / HIV
Influence of Drugs / Alcohol
Self-inflicted Injuries / Violation of Laws / Strike / Riots
Nervous / Mental / Emotional / Sleeping Disorder
None of the above
Please provide details:
9.
a. Treatment given / investigation done (please supply copy of all investigation results):
b. Surgical procedures performed:
c. MMA code / PHFSR code:
d. Date of surgery / procedure:
10. Any other medical / surgical conditions present:
Yes, details below:
No
a.
b.
11. a. Was the patient pregnant at the time of hospitalisation? (For Female only)
b. Was the illness caused directly or indirectly by pregnancy/child birth/
caesarian section/abortion miscarriage and all complications arising therefrom?
12. a. If hospitalisation was due to injury, please describe circumstances and cause of injury:
b. Please indicate date/time of accident:
No
Yes, details below
No
Yes, details below
No
(Time)
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13.
Yes, ______ months
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Y
am
pm
Y
In the case of DEATH, please advise Date/Time and Cause of death:
14. I hereby certify that I have personally examined and treated the Patient for his/her injury/illness described above and that
the facts as stated above represent my medical opinion of his/her condition.
Date
Name & Signature of Attending Doctor
Doctor / Hospital Stamp