CUEPACS ETIQA MUTIARA PLUS Level 3 Bangunan PSM no 17B Jalan Bangsar 59200 Kuala Lumpur Tel : 0322836364/6361 Faks : 0322836272 H/p : 017-6340518 Pastikan document disahkan benar lengkap mengikut arahan sebelum dihantar agar tidak berlaku penolakan. PERKARA: BORANG PENYAKIT KRITIKAL NOTA : Nama Penuh Peserta merujuk kepada PESAKIT Sijil penyertaan TKM 0679 / TTMW4. Jika tiada tetapi menjadi ahli melebihi 60 hari peserta layak membuat tuntutan. Sila lampirkan surat pengakuan jika tiada sijil. --------------------------------------------------------------------------------------------------------------------------- Dokumen yang perlu dilampirkan: Sila sertakan dokumen-dokumen berikut bersama dengan tuntutan ini (Salinan Disahkan) : TYPES OF CLAIMS DOCUMENTS REQUIRED Critical Illness 1) Borang tuntutan Penyakit Kritikal 2) Salinan Kad Pengenalan yang disahkan 3) Laporan perubatan Penyakit Kritikal (Strok / Jantung / ESRF / Kanser / Lain-lain) yang dilengkapi oleh doktor 4) Sijil Asal / Salinan Sijil Penyertaan 5) Borang kebenaran untuk maklumat lanjut 6) Lain-lain dokumen yang berkenaan. ( Sila rujuk senarai dokumen sokongan bagi tuntutan penyakit kritikal yang berkenaan) Jika dokumen sokongan diberikan dalam salinan, dokumen tersebut mestilah disahkan oleh mereka yang dibenarkan oleh Syarikat, Pesuruhjaya Sumpah, Notary Public, Peguam, Jaksa Pendamai, Ahli Parlimen, Ketua Balai Polis, Penghulu atau Pegawai Daerah. **PERMOHONAN HENDAKLAH DIPOSKAN MENGIKUT ALAMAT KAMI DI BANGSAR DAN PERMOHONAN INI TIDAK BOLEH DIFAKSKAN KEPADA KAMI**
CRITICAL ILLNESS CLAIM FORM (GROUP CLAIM) SECTION A Every question must be fully answered. The Company reserves the right to require further information should it deem necessary. Submission of this Claim Form does not guarantee admission of liability. Contract No : Broker/Account Manager's name: Broker/ Account Manager's Contact No. : Instruction Supporting documents required Critical Illness claim form Certified copy of Participant and/or Claimant's IC Critical Illness - Statement of Medical Examiner (Stroke / Heart / End Stage Renal failure / Cancer / Others) Relevant diagnostic test results or report to support the diagnosis (Please refer page 4-5) Original certificate Other supporting document (if applicable) Name of Participant New IC No Old IC No. Age Correspondence Address Mobile Phone No. Phone No. E-mail address Fax No. Name of the Employer Address of the Employer Office Phone No. Date of Employment 1 Describe fully the symptoms for which you consulted a medical practitioner. 2 Date symptoms first commenced 3 Date you first consulted doctor for this condition 4 Name & address of doctor you first consulted for this condition 5 What was the diagnosis? 6 What treatment are you currently receiving? 7 Have you previously sufferred from, or received treatment for a similar or related illness? Yes No If yes, please give full details 8 State the name and address of your regular doctor Page 1 of 5
9 Please give details of any other doctors you have consulted in connection with this or other conditions. Date of consultation Date of admission Date of discharge Diagnosis Name of doctor & address of hospitals/clinics 10 Are there other policies in force on your life taken with other companies? Yes No If yes, please give details: Name of Company(s) Commencement date Policy no Type of coverage Sum assured 11 Please state bank account details in order for us to credit the payment directly into Claimant's bank account. Bank : Bank Branch : Bank Account Holder Name : Bank Account no.: Company Registration no : (Eg:266243D) If the above bank account is a joint account, please provide below details: Second account holder name : Second account holder NRIC : The Payment which has been made based on the account details provided by you will be deemed as full payment and we shall be discharged from any existing and future claim and demand in relation to it. DECLARATION I hereby declare that the foregoing answers and statements on the Participant are complete and true to the best of my knowledge and belief, and that I have withheld no material facts from the Etiqa Family Takaful Berhad. And I hereby authorize any medical practitioner, surgeon person, hospital, clinic and any other institution or organization to furnish to Etiqa Family Takaful Berhad or its representative any information that maybe required concerning my health conditions, for settlement of this claim. I agree that Etiqa Family Takaful Berhad or its representative may use or disclose any of the information collected or held to third parties such as reinsurers, medical examiner or medical consultant, claims investigator and etc. within or outside Malaysia for the purpose of processing the claim. I agree that a photocopy of this authorization shall be considered as effective and valid as original. Signature / Thumb print of Participant Name Signature / Thumb print of Claimant (if other than Participant) Date Date Full name Contact No Designation & Official stamp is required for Company or Bank: Signature of Witness Date Full Name NRIC No Authorised Signature of Contract Holder & Company's Stamp Full name Designation: Contact No Contact No Date
Page 2 of 5 LETTER OF AUTHORISATION / CONSENT TO OBTAIN FURTHER INFORMATION (MAKLUMAT PERUBATAN) To Whom It May Concern, Contract No Dear Sir / Madam, I hereby authorise and give my consent to any medical practitioner, physician, surgeon, clinic, hospital, medical centre, Insurance company or other organisation, institution or individual concerned ("the Information Provider(s)") that may have any records or knowledge of employment, financial, health or medical history of myself ("the Participant') and to provide such information to Etiqa Family Takaful Berhad or its authorised agents and/or employees. I expressly waived all provisions of law or professional ethics forbidding the Information Provider(s) from disclosing any such information acquired on myself in a professional and/or client capacity and I further release the Information Provider(s) and its agent/staff from any liability whatsoever that may rise, in supplying such information requested by the Etiqa Family Takaful Berhad. This authorisation / consent is irrevocable and a copy of it will have the same effect and validity as the original. Signature / Thumb print of Participant Name NRIC Old IC Birth Cert No. (if minor) Signature of Contract holder (If Participant is a minor) Name NRIC Old IC Tel No Tel No. Date Date Page 3 of 5
Additional Requirements For Critical Illness Claim Critical Illness Stroke Heart Attack End Stage Kidney Failure Cancer Coronary Artery By-Pass Surgery End Stage Liver Failure Fulminant Viral Hepatitis Coma Benign Brain Tumour Paralysis / Paraplegia Blindness / Total Loss of Sight Deafness / Total Loss of Hearing Major Burns End Stage Lung Disease Encephalitis Major Organ / Bone Marrow Transplant Angioplasty and Other Invasive Treatments for Major Coronary Artery Disease Loss of Speech Brain Surgery Heart Valve Surgery Additional Required Medical Evidence 1. CT Scan / MRI of Brain report 2. Doctor s Statement to be completed by Consultant Neurologist (for current condition at least 6 months after the stroke) 1. Cardiac Enzymes Assay results (CK-MB) 2. Electrocardiography report (ECG) 3. Tropinin T result, if any 4. Doctor s Statement to be completed by Consultant Cardiologist 1. Dialysis appointment card / receipts 2. Blood test results 3. Doctor s Statement to be completed by Consultant Nephrologist 1. Histopathology/biopsy report (where applicable) 2. Bone Marrow Aspiration report (leukemia) 3. CT Scan / MRI report (where applicable) 1. Coronary Artery By-Pass Surgery Report 1. Liver Function Test 2. CT Scan of Liver 3. All laboratory, pathology, hepatitis screening, ultrasound & histology report 1. CT Scan report of Liver 2. Liver Function Test results 3. Any other laboratory or pathology reports 1. Medical receipt for the usage of life support (Oxygen) 2. Doctor s Statement to be completed by Consultant Neurologist 1. CT Scan / MRI of Brain report 2. Histopathology/biopsy report 1. X-ray / CT Scan / MRI report, if available 2. Doctor s Statement to be completed by Consultant Neurologist 1. Visual Acuity report on both eyes to be done by an ophthalmologist 2. Doctor s Statement to be completed by an Ophthalmologist 1. Audiometry test and Sound Threshold test results 1. Total Body Surface Assessment report 1. Pulmonary Function test 2. FEV 1 test 3. Relevant medical reports 1. CT Scan / MRI of Brain 2. Doctor s Statement to be completed by Consultant Neurologist 1. Surgery report 1. Coronary Angiogram report 2. Surgery report 1. Medical evidence from ENT specialist to confirm illness or injury to vocal cords 2. Doctor s Statement to be completed by speech pathologist / therapist 1. Brain Surgery report 1. Heart Valve Surgery report Page 4 of 5
Critical Illness Terminal Illness Bacterial Meningitis Major Head Trauma Additional Required Medical Evidence 1. All relevant investigation result in support of the diagnosis 1. CT Scan / MRI of Brain & Spine 1. Detailed medical assessment from attending doctor Other Serious Coronary Artery Disease Chronic Aplastic Anaemia Motor Neuron Disease Parkinson s Disease 1. Detailed medical assessment including Activities of Daily Living Muscular Dystrophy Surgery to Aorta Multiple Sclerosis Medullary Cystic Disease Severe Cardiomyopathy SLE with Lupus Nephritis Primary Pulmonary Arterial Hypertension Alzheimer s Disease / Irreversible Organic Degenerative Brain Disorders Occupationally Acquired Human Immunodeficiency Virus (HIV) Infection 2. CT Scan / MRI of Brain 3. Police report, if any 1. Coronary Angiogram report 1. Bone Marrow Aspiration 2. Blood test report 1. All investigation reports from Consultant Neurologist 1. Diagnostic test result 2. Doctor s Statement to be completed by Consultant Neurologist 1. Aorta Surgery report 1. Ophthalmologist s report 2. CT Scan & MRI report of Brain & Spine 3. Doctor s Statement to be completed by Consultant Neurologist 1. Abdominal Ultrasound or Abdominal CT Scan 2. Renal biopsy report 3. Urine Specific Gravity Test 4. Blood test result 5. All clinical and laboratory investigation report 1. Chest X-ray 2. Echocardiogram report 1. Urine test results 2. Blood test results 3. Kidney biopsy report 1. All clinical and laboratory investigation including cardiac catheterization 1. Diagnostic test results 1. HIV antibody test by ELISA method within 7 days of the event/accident 2. HIV antibody test by ELISA method 6 months from date of blood transfusion 3. Statement from statutory Health Authority to confirm that the disease was occupationally acquired 4. Western Blot test Page 5 of 5
CRITICAL ILLNESS (CANCER) TEMENT OF MEDICAL EXAMINER (GROUP CLAIM) 1. The following named is covered with ETIQA FAMILY TAKAFUL BERHAD against the happening of certain contingents events associated with his/her health. A claim has been submitted in connection with CANCER and to enable us to assess the claim, we would be obliged if you would complete this Statement of Medical Examiner 2. Any fees chargeable for the completion of this form shall be borne by the claimant. CONTRACT NO: Name of Participant:.. NRIC/Birth Cert No/Passport No:.. 1. (a) (b) Are you the Participant s usual doctor? Yes No If yes, since when the Participant has been consulting you?. 2. (a) Date when Participant first consulted you for this illness?.. (b) (c) (d) (e) (f) What were the symptoms presented?. How long had symptoms been present?. Please state full and exact diagnosis:. Date when illness was first diagnosed:..... Diagnose was first made by (name & address of doctor):... (g) When Participant was first informed of the diagnosis? (h) Has the Participant suffered from this illness or any related illnesses previously? Yes No If yes, please state details Date of consultation Diagnosis Treatment given (i) Please state if there is anything in the Participant s family history which would have increased the risk of illness.... (j) What stage did the disease reach? Please describe by using whichever staging classification is appropriate.. 3. (a) What was the site or organ involved and the histology of the tumour?. (b) Was it completely localized to the tissue or organ of origin? Yes No (c) Was there invasion of adjacent tissues? Yes No (d) Was there regional or distant metastasis? Yes No If yes, please describe the extent of regional nodal involvement, and/or extent of distant metastasis:... Page 1 of 2
(e) If the diagnosis is leukaemia, please provide details of the actual type:.. (f) Was a biopsy of tumour performed? Yes No (g) If yes, when was the biopsy of tumour performed?.. 4. Please advise the nature of treatment that has been carried out or of any future intention to do so. Date Treatment Name & address of hospital Prognosis 5. Has the Participant suffered from/been treated for any other illnesses related to / cause for this Critical Illness? Yes No If yes, please give full details (diagnosis & date).... 6. Did the Participant consult other doctors for this illness or its symptoms before he/she consulted you? If yes, please give details Yes No Date of attendance Name & address of doctors/hospital Illness or condition consulted 7. Please provide names and addresses of any hospital or clinic to which the Participant was referred together with the names of attended consultants. Please furnish copies of all investigation reports, including biopsy reports, cytology reports, x-rays, CT scans, imaging studies, laboratory evidence, surgical reports, etc. and any relevant medical reports that are available. DECLARATION I hereby declare that the foregoing answers and statements are complete and true to the best of my knowledge and belief. Signature : Name of Attending Oncologist: Professional Qualification(s) : Name & Address of Hospital / Clinic : Address : Official Stamp of Hospital / Clinic Telephone Number : Fax No.: E-mail : Date : Page 2 of 2