GROUP CRITICAL ILLNESS CLAIM FORM

Transcription

1 GROUP CRITICAL ILLNESS CLAIM FORM Dear insure employee / spouse or hil ( life insure ), We are sorry to learn about your illness. In orer for us to proess your laim, we require the following: (1) Group Critial Illness Claim Form (2) Group Critial Illness Claim Meial Report (meial fee to be borne by life insure) (3) Copy of NRIC / Passport of life insure (to be ertifie by Employer) (4) Consent Form for Meial Report (5) Histopathologial / biopsy reports (for aner) (6) ECG reaing & enzymes assays (for heart attak) (7) CT san / MRI san results (for stroke) (8) Available laboratory an test results One we have reeive all the above require ouments, we will proess your laim an inform you of the outome as soon as possible. te: This form is to be omplete for making a laim of benefits uner Drea Disease / Critial Illness an Terminal Illness.

2 GROUP CRITICAL ILLNESS CLAIM FORM IMPORTANT NOTES : (1) The issue of this laim form is not an amission of liability. (2) This laim form is to be omplete by life insure. (3) Tokio Marine Life Insurane Singapore Lt. reserves the right to request for aitional meial reports when it eems neessary. PART 1 : TO BE COMPLETED BY THE EMPLOYER / COMPANY Name of employer: Name of employee: Group poliy no: Subsiiary / ost entre: NRIC / Passport no.: Gener: Male Female Date of birth: Marital status: Designation: Date of employment : Plan: Personal Data tie We represent, warrant an unertake that olletive onsents have been obtaine from eah of our employees an their respetive life assures an/or epenents, to allow Tokio Marine Life Insurane Singapore Lt. an Tokio Marine Insurane Singapore Lt ( Tokio Marine Insurane Group ) to ollet, use, proess an islose the personal ata in aorane with the terms an onitions as state in the insurane appliation form or Tokio Marine Insurane Group s Data Protetion Poliy available at whih we / they have rea, unerstoo an agree to the same. Company s Stamp an Authorize Signature Name: Designation: NRIC / Passport. Date TO BE COMPLETED BY PATIENT PART 2 : DETAILS Name of patient : Relationship to employee : NRIC. / Passport no. : Date of birth : Oupation : Gener: Male Female PART 3 : DETAILS OF CLAIM 3.1 Desribe fully the symptoms & resulting iagnosis : 3.2 Date when i you first onsulte a otor for the above symptoms : 3.3 How long i you have the symptoms before he / she onsulte a otor? 3.4 Desribe fully the nature an extent of your illness : Signature of life insure (to be signe by patient s parent or legal guarian if patient is below 21 years ol) Date Page 1 of 3

3 3.5 If onsultation was ue to an aient, esribe fully the nature of your injuries an how it happene : 3.6 Have you previously suffere from or reeive treatment for a similar / relate illness? If yes, please provie etails : 3.7 Have you been treate or iagnose for this onition outsie Singapore? If yes, please provie etails : 3.8 Please provie etails of otor(s) whom you have onsulte in onnetion to your illness : Name of otor / hospital Aress Date of first onsultation / hospitalisation 3.9 Please provie etails of your regular otor(s), ate an reason(s) of onsultation : Name of otor Aress Date of onsultation Reason(s) of onsultation Signature of life insure (to be signe by patient s parent or legal guarian if patient is below 21 years ol) Date Page 2 of 3

4 PART 4 : OTHER INSURANCES 4.1 Are you insure with other insurane ompany(ies)? If yes, please provie the following etails : Name of insurane ompany Date of issue Sum insure Type of plan Claim amount Claim notifie Personal Data tie I / We agree an onsent that Tokio Marine Life Insurane Singapore Lt. an Tokio Marine Insurane Singapore Lt ( Tokio Marine Insurane Group ) may ollet, use, proess an islose the personal ata in aorane with the terms an onitions as state in the insurane appliation form an/or the Tokio Marine Insurane Group s Data Protetion Poliy available at whih I / we have rea, unerstoo an agree to the same. Delaration I / We elare that all answers given by me / us in this form are, to the best of my / our knowlege an belief, true an omplete. I / We hereby also authorize: (a) any meial soure, insurane offie, or organization to release to or when requeste to o so by the Tokio Marine Insurane Group, any relevant information onerning the below-name assure, an; (b) the Tokio Marine Insurane Group to release to any meial soure, insurane offie, or organization, any relevant information onerning the below-name assure, at any time. A photoopy of this authorization shall have the same effet as the original. Signature of patient (to be signe by patient s parent or legal guarian if patient is below 21 years ol) Date Name of patient : Aress: NRIC.: Relationship to employee: Contat (s) : Page 3 of 3

5 GROUP CRITICAL ILLNESS CLAIM MEDICAL REPORT Name of Patient : NRIC / Passport : (as state in NRIC / Passport) INSTRUCTIONS: Please tik [ ] in the appropriate box an omplete the relevant setions in respet to the illness laime. Please submit ONLY the relevant setions to us upon ompletion. Setions to be omplete 1. Major Caners 1 & HIV Due To Bloo Transfusion an Oupational Aquire HIV 2. Stroke 1 & Loss of Inepenene Existene 1 & 4 Setions to be omplete 1 & Heart Attak of Speifie Severity 1 & Loss of Speeh 1 & Coronary Artery By-pass Surgery / Angioplasty & Other Invasive Treatment for Coronary Artery 1 & Major Burns 1 & Kiney Failure 1 & Major Hea Trauma 1 & Alzheimer s Disease / Severe Dementia 1 & Major Organ / Bone Marrow Transplantation 7. Aplasti Anaemia 1 & Motor Neurone Disease 1 & Apalli Synrome 1 & Multiple Slerosis 1 & Baterial Meningitis 1 & Musular Dystrophy 1 & Benign Brain Tumour 1 & Paralysis (Loss Of Use Of Limbs) 1 & Blinness (Loss of Sight) 1 & Parkinson s Disease 1 & Coma 1 & Periarial Disease 1 & Deafness (Loss of Hearing) 1 & Poliomyelitis 1 & Primary Pulmonary Hypertension 1 & Viral Enephalitis 1 & Progressive Sleroerma 1 & En Stage Liver Disease 1 & Surgery To Aorta 1 & En Stage Lung Disease 1 & Systemi Lupus Erythematosus with Lupus Nephritis 18 Fulminant Hepatitis 1 & Terminal Illness 1 & Heart Valve Surgery 1 & 5 Please enlose opies of Histopathology / Biopsy Report (for Caner), ECG Reaing & Enzymes Assays (for Heart Attak), CT San / MRI San results (for Stroke an Benign Brain Tumour) an all laboratory an Test results, et an any relevant hospital reports that are available. 1 & 27 1 & 35 Date : Page 1 of 22

6 SECTION 1 : GENERAL INFORMATION a Are you the patient s regular otor? If, sine : If, kinly provie the Name an Aress of the patient s regular otor (if known to you): b When i patient first onsult you for this illness? Please state symptoms presente an the ate symptoms first appeare as follows : Symptoms Presente Date symptoms first starte Duration of symptoms Please provie full an exat etails of the iagnosis an its linial basis. e f What is the ate of iagnosis? What is the ate when iagnosis was first mae known to the patient? g Has the patient previously suffere from the onition esribe above or any relate illness? If, kinly provie the etails below: Illness Date of First Diagnosis Name an Aress of Attening Dotor h Is there anything in the patient s personal meial history or family history whih woul have inrease the risk of the above illness? If yes, please give full etails inluing the ate of iagnosis an name & aress of attening otor. i Is the patient suffering from other signifiant illness(es) / onition(s)? If, kinly provie the etails below: j Please give etails of the patient s past an present smoking habits, inluing the uration an number of igarettes smoke per ay. Date : Page 2 of 22

7 SECTION 2 : HEART ATTACK OF SPECIFIED SEVERITY a Please state the ate where Heart Attak was first iagnose b Was there a urrent history of hest pain an / or shortness of breath? e f g h Where there any hanges in the ECG iniative of a myoarial infartion? Was there a serial elevation of aria enzymes oumente? Was there a eath of a portion of the heart musle? Was there elevation of Troponin (T or I) oumente? If, please state = Troponin Reaing : Date : Was left ventriular ejetion fration (LVEF) taken 3 months or more after the event? i If, please state = LVEF % : Date : j Date of return to normal ativities : SECTION 3 : APALLIC SYNDROME a Is there presene of universal nerosis of the brain ortex with the brainstem intat? If, esribe the neurologial amage. b Di the appalli synrome persist for at least one month sine its onset? If, please state the uration for whih it persiste: Is the patient s onition in any way relate or ue to AIDS or HIV relate illness? If, please provie etails. SECTION 4 : LOSS OF INDEPENDENT EXISTENCE a Is the patient able to perform (whether aie* or unaie) for a ontinuous perio of at least 6 months the followings: (i) Ability to wash in the bath or shower (inluing getting into an out of the bath or shower) or wash satisfatorily by other means Ability to put on, take off, seure an unfasten all garments an, as appropriate, any braes, artifiial limbs or other surgial applianes (iii) Ability to move from a be to an upright hair or wheelhair an vie versa (iv) Ability to use the lavatory or otherwise manage bowel an blaer funtions so as to maintain a satisfatory level of personal hygiene (v) Ability to move inoors from room to room on level surfaes (vi) Ability to fee oneself one foo has been prepare an mae available * Aie shall mean with the ai of speial equipment, evie an / or apparatus an not pertaining to human ai Date : Page 3 of 22

8 SECTION 5 : HEART VALVE SURGERY a b What is the ate of onset of the heart valve efets? Was surgery performe to repair or replae the heart valve abnormality? If, please state the surgial proeure use to orret the valvular problem (i.e. open heart surgery, perutaneous intravasular balloon valvuloplasty with OR without thoraotomy et) What was the ate of the surgery? e Was there any eployment of : (i) new valve perutaneous evie (iii) prosthesis f Has the patient suffere or is suffering from any relate illnesses e.g. hypertension, vasular isease et SECTION 6 : PROGRESSIVE SCLERODERMA a Please provie a esription of the extent of the illness. b Does the illness involve the followings: (i) skin with eposits of alium (alinosis) skin thikening of the fingers or toes (sleroatyly) (iii) the esophagus (iv) telangietasia (ilate apillaries) an Raynau s Phenomenon ausing artery spasms in the extremities (v) heart (vi) lungs (vii) kineys Please provie the results of investigations one an attah opy of the serology an biopsy report (if any) Date : Page 4 of 22

9 a SECTION 7 : CORONARY ARTERY BY-PASS SURGERY / ANGIOPLASTY / CAD Please esribe the full an exat iagnosis of the heart onition leaing to surgery: b Whih are the oronary arteries involve an what is the egree of narrowing (%) in respet of eah involve artery? Please state the type of surgery performe [i.e. Angioplasty, Coronary Artery By-Pass Surgery, Keyhole surgery, Atheretomy, Transmyarial Laser Revasularisation, Enhane External Counterpulsation or Minimally Invasive Diret Coronary Artery Bypass (MIDCAB) If a Coronary Artery By-Pass surgery was performe: (i) please state the number of grafts an site of grafts inserte: was open-heart surgery performe? e (iii) what is the ate of the surgery? Please provie the name of surgeon who perform the surgery an the name & aress of hospital where the surgery was performe f Has the patient previously suffere from the above illnesses or any other ariovasular iseases? g Please give etails of the patient s meial history whih woul have inrease the risk of oronary artery isease (eg Hypertension, Hyperlipiaemia, Diabetes) SECTION 8 : SURGERY TO AORTA a b On what ate i the patient first beome aware of the onition neessitating surgery? What was the type of surgery performe? When was the surgery performe? Was exision an surgial replaement of the isease aorta with a graft performe? e Was the surgery performe using minimally invasive or intra arterial tehniques? f Was there enlargement of the aorta? If, please state the iameter of enlargement in millimetres: g Has the patient suffere or is suffering from any relate illnesses e.g. hypertension, angina, vasular isease, enoaritis et Date : Page 5 of 22

10 a SECTION 9 : STROKE Please esribe the episoe: (i) Date of episoe Nature of the episoe an uration of the aute symptoms: (iii) (iv) Is the patient able to resume normal ativities? If, please state the ate he/she has returne OR is expete to return to normal ativities: If, please state the patient s urrent physial an mental limitations an the ate of your assessment: Date of Assessment Neurologial Limitations (v) When is the ate of the patient s next review with you? b (i) Was there any eviene of neurologial efiit 6 weeks after the ate of stroke iagnosis? If, please provie etails: Are these neurologial efiits likely to be permanent? (iii) Has there been an infartion of brain tissue, haemorrhage or embolisation from an extraranial soure? (iv) Are the investigations or finings onsistent with the iagnosis of a NEW stroke? If, please provie etails: (i) Is this a Transient Ishaemi Attak? Is the brain amage ue to an aient or injury, infetion, vasulitis or inflammatory isease? (iii) Is the illness a vasular isease affeting the eye or opti nerve? (iv) Is the urrent onition a result of ishaemi isorers of the vestibular system? Was an arteriogram arrie out? If, please state the ate of arteriogram: e (i) Was surgery arrie out to orret intraranial aneurysm or arterio-venous malformation? If, please state the ate of surgery: Was surgery one via raniotomy? If, please state the type of surgery performe: f Was there surgial shunt insertion from the ventriles of the brain to relieve raise pressure in the erebrospinal flui? If, please state the ate of insertion: g (i) Was there narrowing of the aroti artery? If, please state the perentage of narrowing : % Was Enarteretomy of the aroti artery absolutely neessary? If, please state the atual ate where Enarteretomy was performe: Date : Page 6 of 22

11 SECTION 10 : MAJOR CANCERS a Please esribe the extent of the isease: (i) What is the histologial iagnosis of the isease? What is the staging of the Tumour? Please provie full etails using appropriate staging lassifiation (eg. TMN lassifiation) b (i) Is the isease ompletely loalize? Was there invasion of ajaent tissues? (iii) Were regional lymph noes involve? (iv) Were there istant metastases? To be omplete ONLY if iagnosis is pre-malignant or non-invasive, skin aner, prostate aner, thyroi an blaer aner or hroni lymphoyti leukaemia: (i) Is the onition arinoma-in situ? Is the onition Cervial Dysplasia CIN 1, CIN 2 or CIN 3 (severe ysplasia without arinoma-in situ)? (iii) Is the onition Hyperkeratoses, basal ell an squamous skin aners? (iv) Is the onition melanoma of less than 1.5mm Breslow thikness or less than Clark Level 3? If, please provie full etails of size, thikness (Breslow thikness) an epth of invasion (Clark Level): (v) Is the onition Chroni Lymphoyti Leukaemia lassifie as lesser than RAI Stage 3? (vi) Is the onition Prostate aner esribe as TNM lassifiation T1 (i.e. T1a, T1b, T1) or equivalent or lesser? (vii) Is the onition Papillary miro-arinoma of the Thyroi of less than 1m size in iameter? (viii) Is the onition Papillary miro-arinoma of the Blaer? (ix) Is the tumour in the presene of HIV infetion? Please provie etails of treatment aministere (e.g. surgery, hemotherapy, raiotherapy et) e What is the nature of the surgery performe (e.g. mastetomy, prostatetomy, gastretomy et)? Please speify if there was full or partial resetion an kinly provie a opy of the operation report to us. f g When was the surgery performe? Has the patient ever suffere from aner, malignant, pre-malignant or other relate onitions or risk fators? If, please provie full etails with ates of onsultation an the resulting iagnosis: Date : Page 7 of 22

12 SECTION 11 : ALZHEIMER S DISEASE / SEVERE DEMENTIA a Please esribe the extent of the isease: (i) Is there eviene of eterioration or loss of intelletual apaity? Is there abnormal behaviour resulting in signifiant reution in mental an soial funtioning requiring the ontinuous supervision of patient? If, please esribe the behaviour: (iii) Was there permanent linial loss of the ability to o the following: Remember Reason b Pereive, unerstan, express an give effet to ieas Di the eterioration or loss of intelletual apaity arise from neurosis, psyhiatri illnesses or alohol relate brain amage? If, please provie us with the etails : Was there eviene of ognitive impairment for at least 6 months? If, please state the type of ognitive impairments an its uration: Please provie etails of any investigations performe inluing the type of Alzheimer s test (e.g. Mini-mental exam) an its sore e (i) Is the urrent onition arises from non-organi iseases suh as neurosis an psyhiatri illnesses? Is the urrent onition a ase of rug or alohol relate brain amage f Was there any memory impairment in the following ognitive areas? If, please tik the box an state the exat ate of onset: Date of Onset (i) (iii) (iv) Aphasia Aproxia Agnosia Disturbane in exeutive funtioning g Please provie the ate of last assessment : Is the patient urrently plae on isease moifying treatment an uner your ontinuous are? If, please provie us with the treatment regime an state the frequeny of onsultation(s) with your lini : Date : Page 8 of 22

13 SECTION 12 : APLASTIC ANAEMIA a Please provie full etails of tests an results whih have been performe to establish the iagnosis of Aplasti Anaemia b What is the ause of patient s aplasti anaemia? (i) Aute reversible bone marrow failure Chroni persistent bone marrow failure Was any of the following present? If yes, please provie us with the relevant laboratory results. (i) Anaemia Neutropenia (iii) Thromboytopenia What is the nature of treatment? (i) Bloo prout transfusions Marrow stimulating agents (iii) Immunosuppressive agents (iv) Bone marrow transplantation e Is the urrent onition in any way attributable to HIV infetion or AIDS? If, please provie us with the etails SECTION 13 : BACTERIAL MENINGITIS a Was the iagnosis onfirme by the presene of baterial infetion in erebrospinal flui by lumbar punture? b Has the patient returne to normal ativities? If, please provie the ate. What are the patient s present limitations, physial an mental? Were there any neurologial efiit whih has laste for at least 6 weeks? Are these neurologial efiits likely to be permanent? If, please provie etails of the efiits. e Was the onition present ue to HIV / AIDS infetions? Date : Page 9 of 22

14 SECTION 14 : BENIGN BRAIN TUMOUR a Has the tumour ause an inrease in the intraranial pressure? If, please provie the etaile loation of the tumour. b Is the tumour life threatening? Has the tumour ause amage to the brain? If yes, please provie etails. Has the patient unergone surgial removal? If, please state the type an exat ate the surgery was perform (i) (iii) Transphenoial Transnasal Hypophysetomy Open raniotomy e If the surgial removal is not performe, has the tumour ause permanent neurologial efiit? If, please provie etails of the efiits. f Is the patient s onition a yst, granuloma, vasular malformation or haematoma? g Is the patient s tumour in the pituitary glan or spinal or? h Is the tumour onfirme by imaging stuies suh as CT san or MRI? SECTION 15 : BLINDNESS (LOSS OF SIGHT) a What was the ate of onset? b What is the urrent visual auity of both eyes, using the Snellen eye hart? Left eye: What forms of treatment were renere? Right eye: Is the urrent blinness in both eyes permanent an irreversible? e Will further surgery improve his / her sight? If, what kin of surgery will be neessary an what is the tentative ate of surgery? f Is the onition resulting from alohol or rug misuse? If, please provie us with the etails. Date : Page 10 of 22

15 a b SECTION 16 : What was the ate of onset? COMA How was the iagnosis establishe? Please inlue a opy of iagnosti investigation reports (eg eletroenephalography (EEG), Magneti Resonane Imaging (MRI), Position Emission Tomography (PET) et) Was there any reation or response to external stimuli or internal nees persisting ontinuously with the use of a life support system for: (i) at least 48 hours? at least 72 hours? (iii) at least 96 hours? Was there brain amage resulting in permanent neurologial efiit? e Has the sequelae laste more than 30 ays from the onset of the oma? f g Has the patient experiene reurrent unprovoke toni-loni or gran mal seizures an be known to be resistant to optimal therapy as onfirme by rug-serum level testing? If, what is the frequeny of attak per week? Is the patient taking presribe anti-epilepti (anti-onvulsant) meiations? If, please state the type(s) of meiation an perio he has been on suh meiation: attaks per week h Woul you onsier the patient to be on optimal rug therapy? If, please state the type(s) an reommene uration of suh therapy: i Is the onition resulting from alohol, rug misuse or meially inue oma? If, please provie us with the etails. SECTION 17 : DEAFNESS (LOSS OF HEARING) a What was the ate of onset? b Was the iagnosis onfirme by an auiometri an soun-threshol? Is the loss of hearing onsiere irreversible? e Is there a loss in all frequenies of hearing of: (i) at least 60 eibels at least 80 eibles Has the patient unergone surgery to: (i) rain avernous sinus thrombosis insert implant ue to permanent amage of ohlea or auitory nerve If, please state the atual ate of surgery: Date : Page 11 of 22

16 SECTION 18 : VIRAL ENCEPHALITIS a Was the onition ause by viral infetion? b Was the patient hospitalise? If, please provie the exat ates an uration of amission: Has the patient returne to normal ativities? If, please provie the ate. What are the patient s present limitations, physial an mental? e Was there any signifiant an serious permanent neurologial efiit? If, please provie etails of the efiit. f Are the permanent neurologial efiits oumente for at least 6 weeks? If, please provie etails. g Was the onition present ue to HIV / AIDS infetions? SECTION 19 : END STAGE LIVER DISEASE a Was there en stage liver failure? If, please state the ate of iagnosis b Was there eviene of permanent jaunie? Was there eviene of asites? Was there eviene of hepati enephalopathy? e Was there partial hepatetomy of at least one entire lobe of the liver? If, please state the exat ate of surgery f Was there irrhosis of the liver? If, please provie us with the HAI-Knoell Sores together with the liver biopsy result g. What was the ause of the liver failure? h Was the liver isease seonary to alohol or rug abuse? If, please provie etails: i What is the urrent onition of the patient an the prognosis? Date : Page 12 of 22

17 SECTION 20 : END STAGE LUNG DISEASE a (i) Has the patient s lung isease reahe en-stage? If yes, please state the exat ate: What is the FEV1 test result of the patient? (iii) Is the patient unergoing extensive an permanent oxygen therapy for hypoxemia? (iv) What is the Arterial bloo gas analyses (PaO 2) of the patient? b (i) Is there eviene of aute attak of severe asthma with persistent status of asthmatius? If yes, please state the exat ate an etails: Was the patient hospitalise an require assiste ventilation with a mehanial ventilator for a ontinuous perio of at least 4 hours? If, please explain: Please provie us with the first an subsequent ates where the patient onsulte you for pulmonary emboli: Date Sign an symptoms Treatment Provie Patient s response to treatment Name an Aress of Attening Dotor Has the patient unergone surgery to: (i) Insert vena ava filter ue to oumente proof of reurrent pulmonary emboli Completely remover of one lung as a result of an aient or an illness If, please state the atual ate of surgery: SECTION 21 : TERMINAL ILLNESS a What is the iagnosis an prognosis of patient s illness? b In your opinion, is the onition highly likely to lea to eath within 12 months? If, please provie your basis. Is the onition present as a result of HIV / AIDS? Date : Page 13 of 22

18 SECTION 22 : FULMINANT HEPATITIS a (i) Please provie full an exat etails of the iagnosis inluing the viru(s) involve. What is the approximate ate of onset? (iii) Is there a rapily ereasing liver size? (iv) Is there a submassive to massive nerosis of the liver? (v) Is there a rapily eterioration of liver funtion? (vi) Is there eepening jaunie? (vii) is there hepati enephalopathy? b (i) Has the patient unergone biliary trat reonstrution surgery involving holeohoenterostomy (holeohojejunostomy or holeohouoenostomy) for the treatment of biliary trat isease, inluing biliary atresia? If, please state the atual ate of surgery: Is the biliary trat isease NOT amenable by other surgial or enosopi measures? (iii) Is the proeure onsiere the most appropriate treatment? (iv) Is patient s urrent onition a onsequene of gall stone isease or holangitis? (i) Is patient s onition of hroni primary slerosing holangitis onfirme by holangiogram? Is there progressive obliteration of the bile uts? (iii) Is there permanent jaunie? (iv) Is there a nee for immunosuppressive treatment, rug therapy for intratable pruritis or ballon ilation or stenting of the bile uts? If, please provie the etails: (v) Is patient s urrent onition a onsequene of biliary surgery, gall stone isease, infetion, inflammatory bowel isease or other seonary preipitants? If, please provie the etails: What is the urrent onition of the patient an what is the prognosis? Date : Page 14 of 22

19 SECTION 23 : HIV DUE TO BLOOD TRANSFUSION & OCCUPATIONALLY ACQUIRED a (i) Was the infetion ue to : bloo transfusion? organ transplant? physial or sexual assault? Was the bloo transfusion or organ transplant meially neessary or given as part of meial treatment? (iii) Di the inient of infetion our in Singapore? (iv) If, please provie the exat ate an etails: Was the infetion resulte from any other means inluing sexual ativity an the use of intravenous rugs? If, please state the likely ause: (v) Was the inient of infetion establishe to involve a efinite soure of the HIV infete fluis? (vi) Was the inient of infetion reporte to the appropriate authority? (vii) Is the Institution where the bloo transfusion or organ transplant was performe able to trae the origin of the HIV tainte bloo? b. Is the patient suffering from Thalassaemia Major or Haemophilia?. Is the oupation of the patient a meial pratitioner, houseman, meial stuent, state registere nurse, meial laboratory tehniian, entist (surgeon an nurse) or parameial worker, working in meial entre or lini in Singapore? If, please state the atual oupation an name of employer or Institution: (i) Was there an aient whilst the patient was arrying out the normal professional uties of his oupation in Singapore? If, please state the ate of aient: Was the aient involve a efinite soure of the HIV infete fluis? e (i) Was an HIV antiboy test one before the inient of infetion? If, what was the result? Was an HIV antiboy test one after the inient of infetion? If, what was the result? Date : Page 15 of 22

20 SECTION 24 : KIDNEY FAILURE a (i) Has the patient s renal isease reahe en-stage? Is there hroni renal failure of both kineys? (iii) Is the renal failure reversible? b (i) Is the patient unergoing regular peritoneal ialysis or haemoialysis? If, what was the ate of ommenement? Has renal transplantation been performe? If, when was it one? (i) Was the patient a reipient of the renal transplant? Is the renal ialysis / transplantation require as a life-saving proeure? (iii) Was there erease renal funtion of at least egfr less than 15ml/min/1.73m2 boy surfae? If, i it persist for a perio of at least 6 months an what are the etails: SECTION 25 : a (i) What is the ate of onset? LOSS OF SPEECH Is the loss of speeh onsiere total an irreoverable? (iii) Has the inability to speak establishe for a ontinuous perio of 12 months? (iv) Were there any assoiate neurologial or psyhiatri onitions ontributing to the patient s loss of speeh? If, please provie etails. b What was the ause of the loss of speeh? (i) Has traheostomy been performe? If, what is purpose of suh treatment an when was it one? Was traheostomy performe for treatment of lung or airway isease or as a ventilator support measure following major trauma or burns? If, please provie the etails: (iii) Was the patient uner the are of meial speialist in a esignate intensive are unit (ICU)? If, how many ays was he/she ware in ICU: (iv) Is the traheostomy require to remain in plae an funtional for a perio of at least 3 months? Date : Page 16 of 22

21 SECTION 26 : MAJOR BURNS a (i) What is the ate of onset? Please state the areas affete, the perentage of surfae area an the egree of burns in eah affete area: Area Affete Perentage of surfae area Degree of burns (iii) (iv) (v) Were there Seon Degree (partial thikness of the skin) burns overing at least 20% of the surfae of the patient s boy? Were there Thir Degree (full thikness of the skin) burns overing at least 20% of the surfae of the patient s boy? Were there Thir Degree (full thikness of the skin) burns overing at least 50% of patient s fae or hea? b (i) Where an how i the aient happen resulting in the major burns? Are the burns self-inflite? If, please provie etails. (i) Is surgial ebriement uner general anaestheti require? If, when will it be performe? Is skin grafting require? If, when will it be performe? SECTION 27 : MAJOR ORGAN / BONE MARROW TRANSPLANT a (i) Whih of the organ is involve? (iii) What is the exat ate of transplant? What is the prognosis? (iv) Was the transplant resulte from an irreversible en stage failure of the relevant organ? b (i) For bone marrow transplant, is the reeipt of transplant from human bone marrow using haematopoieti stem ells preee by total bone marrow ablation? For small bowel transplant, is there reeipt of at least one meter of small bowel resulting from intestinal failure? (iii) For orneal transplant, is there reeipt of a whole ornea ue to irreversible sarring with resulting reue visual auity whih annot be orrete with other methos? Date : Page 17 of 22

22 SECTION 28 : MOTOR NEURONE DISEASE a (i) Is there progressive egeneration of: ortiospinal trats; anterior horn ells; bulbar efferent neurones whih inlue spinal musular atrophy, progressive bulbar palsy, amyotrophi lateral slerosis an primary lateral slerosis If answer to any of the above is, please provie etails: Please provie etails of the extent of neurologial efiits. (iii) Are the neurologial efiits likely to be permanent? b (i) For peripheral neuropathy, is it arising from anterior horn ells resulting in signifiant motor weakness, fasiulation an musle wasting? Is the iagnosis evient in nerve onution stuies? (iii) Is there a permanent nee for the use of walking ais or wheelhair? (i) Is the urrent onition arising from iabeti neuropathy? Is the neuropathy arising from exessive alohol onsumption? SECTION 29 : MULTIPLE SCLEROSIS a i. Is there a history of repeate relapse an remission or a steay progressive isability? ii. Are there lesions prouing well-efine neurologial efiits involving the opti nerves, brain stem an spinal or whih ourre over a ontinuous perio of : at least 3 months? at least 6 months? iii. Are there signs an symptoms of multiple lesions? iv. Was the neurologial amages ause by SLE or HIV / AIDS? If, what was the ause? b Is there a well oumente history of exaerbations an remissions of neurologial signs? If, please provie the etails, inluing ates of eah episoe: Has the patient returne to normal ativities? If, please provie the ate. What are the patient s present limitations, physial an mental? Date : Page 18 of 22

23 SECTION 30 : MUSCULAR DYSTROPHY a (i) Is there any eviene of sensory isturbane, abnormal erebrospinal flui, or iminishe tenon reflex? If, please esribe the finings: Whih are the musles involve? b (i) Was the iagnosis onfirme by an eletromyogram? Was the iagnosis onfirme by musle biopsy? Is the patient able to perform (whether aie or unaie) for a ontinuous perio of at least 6 months the followings: (i) Ability to wash in the bath or shower (inluing getting into an out of the bath or shower) or wash satisfatorily by other means Ability to put on, take off, seure an unfasten all garments an, as appropriate, any braes, artifiial limbs or other surgial applianes (iii) Ability to move from a be to an upright hair or wheelhair an vie versa (iv) Ability to use the lavatory or otherwise manage bowel an blaer funtions so as to maintain a satisfatory level of personal hygiene (v) Ability to move inoors from room to room on level surfaes (vi) Ability to fee oneself one foo has been prepare an mae available (i) For bowel an blaer ysfuntion, is there permanent ysfuntion requiring permanent regular self atheterisation or permanent urinary onuit? Has the bowel an blaer ysfuntion laste for at least 6 months? If, please provie the exat ate of onset: SECTION 31 : PARALYSIS (LOSS OF USE OF LIMBS) a i. When was the ate of onset? ii. Please state the number an limbs involve? b Is there total an irreversible loss of use of at least 1 entire limb? Was the paralysis or loss of use of limbs ue to illness or injury? Please provie etails on the ause: Was the paralysis or loss of use of limbs ause by self-inflite injuries? If, please provie etails: Date : Page 19 of 22

24 SECTION 32 : PARKINSON S DISEASE a (i) What is the ause of the isease? b (i) Can the onition be ontrolle with meiation? If, please provie etails an exat ate where meiation was ommene: (iii) Are there signs of progressive impairment? If, please provie etails: (iv) Di Parkinson s Disease result from treatment for any other illness, or is it assoiate with any other isease e.g. Wilson s Disease or Huntington s Chorea? If, please provie etails: Is the patient able to perform (whether aie or unaie) for a ontinuous perio of at least 6 months the followings: (i) Ability to wash in the bath or shower (inluing getting into an out of the bath or shower) or wash satisfatorily by other means Ability to put on, take off, seure an unfasten all garments an, as appropriate, any braes, artifiial limbs or other surgial applianes (iii) Ability to move from a be to an upright hair or wheelhair an vie versa (iv) Ability to use the lavatory or otherwise manage bowel an blaer funtions so as to maintain a satisfatory level of personal hygiene (v) Ability to move inoors from room to room on level surfaes (vi) Ability to fee oneself one foo has been prepare an mae available (i) Is the Parkinsonism ue to: rug inue ause toxi ause SECTION 33 : POLIOMYELITIS a i. What was the ause of the isease? ii. What is the urrent onition of the patient an what is the prognosis? iii. Was there paralysis of the limb musles or respiratory musles for at least 3 months? Date : Page 20 of 22

25 SECTION 34 : PRIMARY PULMONARY HYPERTENSION a (i) Was there a yspnoea an fatigue? Is the pulmonary hypertension ue to primary ause? (iii) Is the pulmonary hypertension ue to seonary ause? (iv) Is there presene of right ventriular hypertrophy, ilation an signs of right heart failure an eompensation? (v) Was aria atherterization arrie out to establish the pulmonary hypertension? b Was the patient able to engage in any physial ativity without isomfort? Are the symptoms present even at rest? Was there permanent physial impairment whih fulfills the the NYHA lassifiation of aria impairment? If, please state the lass of impairment: NYHA Class : I / II / III / IV SECTION 35 : SYSTEMIC LUPUS ERYTHEMATOSUS WITH LUPUS NEPHRITIS a (i) Does patient s urrent onition requires systemi immunosuppressive therapy ue to involvement of multiple organ? If, please state the exat ommenement ate of the therapy : Are the following internal organs involve: kineys brain heart or periarium lungs or pleura joints in the presene of polyartiular inflammatory arthritis b (i) Was renal biopsy performe: If, please state the exat ate biopsy was one : Are both kineys involve : If, please state the lass of Lupus Nephritis in aorane with WHO lassifiation : Lupus Nephritis Class : I / II / III / IV (i) Were there isoi lupus an or those forms with haematologial involvement? If, please provie etails: Date : Page 21 of 22

26 SECTION 36 : a (i) What is the ate of aient? MAJOR HEAD TRAUMA b (i) Where an how i the aient happen resulting in the major hea trauma? Di the injury result from a self-inflite at? If, please provie etails. (iii) Was there reason to suspet that there were ontributory irumstanes whih le to the injury, e.g. uner the influene of alohol, rugs, et? If, please provie etails. (iv) Was there a polie report mae with regar to this aient? If, please provie a opy of the polie report (if available). (i) Was there any form of neurologial efiit still present 6 weeks after the ate of aient? If, please state the neurologial efiit(s). Is this neurologial efiit likely to be permanent? If, please state the ate of reovery or ate whih the patient is expete to reover from the neurologial efiit. (i) Di the patient unergo open raniotomy for treatment of epresse skull frature or major intraranial injury? If, please provie etails an attah a opy of the surgery note. If the patient ha suffere from faial injury, was there any re-onstrutive surgery above the nek to orret isfigurement (restoration or re-onstrutive of the shape an appearane of faial strutures whih are efetive, missing or amage or misshapene)? If, please provie etails of the surgery performe. e (i) Is the patient mentally inapaitate in aorane to the Mental Capaity At (Chapter 177A of Singapore)? f To be omplete ONLY if the patient ha aiental ervial spinal or injury: (i) Has the aiental ervial spinal or injury resulte in the loss of use of at least one entire limb for at least 6 weeks from the aient? If, please provie etails. Date : Page 22 of 22

27 AUTHORIZATION FORM FOR MEDICAL REPORT NAME OF PATIENT : NRIC NO. : POLICY NO. : This onsent form is require for an insurane laim. Authorization I / We hereby authorize: (a) any meial soure, insurane offie, or organization to release to or when requeste to o so by Tokio Marine Life Insurane Singapore Lt. ( Company ), any relevant information onerning the above-name patient, an; (b) the Company release to any meial soure, insurane offie, or organization, any relevant information onerning the above-name patient, at any time. A photoopy of this authorization shall have the same effet as the original. Yours faithfully Signature of *Patient / Patient s Parent / Guarian Name : Aress : NRIC. : Relationship to patient : * If the patient is below 21 years ol, this form shoul be signe by the patient s parent / guarian Page 1 of 1