Health Claim Form Ver 1.3

HEALTH CLAIM FORM
Please state as fully and accurately as possible the information asked for below and to return this form immediately to The
Overseas Assurance Corporation Limited (“Company”) with original final bills/receipts. The acceptance of this form is not in itself an
admission of liability on the part of the Company.
SECTION A – INSURED’S DETAILS
Name of Insured
NRIC No.
Policy No.
Address
Gender: Male / Female
Contact No.
Name of Claimant
NRIC No.
Date of Birth
Address
Gender:
SECTION B – CLAIMANT’S DETAILS
Male / Female
Industry of Business
Occupation
Relationship to Insured
SECTION C – CLAIM DETAILS
1.
2.
PLEASE COMPLETE IF HOSPITALISATION WAS DUE TO
ACCIDENT:
(a) Date and Time of Accident.
(a) Date: ____________________ (D/M/Y)
(b) Nature of Accident (Describe in details, how & where it happened).
(b)
(c) Describe in details the injuries sustained, indicating the part of the body
injured and the type of injury (eg. fracture, cut, bruise, etc).
(c)
Time: _____________________
PLEASE COMPLETE IF HOSPITALISATION WAS DUE TO SICKNESS:
(a) Nature of Sickness (describe the symptoms suffered).
(a)
(b) Date of when symptoms were first noticed.
(b)
(c) Date of first consultation with a medical practitioner for this condition.
(c)
(d) Has the claimant ever seen a doctor for any similar condition in the
past?
(d)
No
Yes, Name of Doctor: __________________________
Address of Doctor/Hospital: _____________________
____________________________________________
3.
4.
5.
(a) Name of Hospital
(a)
(b) Period of Hospitalisation
(b) Date Admitted: __________________ Date Discharged: _______________
If Claimant was hospitalised outside Singapore, please give the following
information:
(a) Name of Hospital.
(a)
(b) Purpose of the overseas trip.
(b)
(c) Intended itinerary or destination.
(c)
(d) Intended duration of overseas trip.
(d) From: ___________________________
To: ________________________
Name and Address of the Claimant’s usual Doctor(s).
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DECLARATION AND AUTHORISATION
I/We hereby declare that the particulars stated above are true and correct in every detail and I/we agree that if I/we have made or in any further
declaration in respect of the same claim shall make any false or fraudulent statements or suppress conceal or falsely state any material fact
whatsoever the relevant insurance policies shall be void and all rights to recover thereunder in respect of past or future claims shall be forfeited.
Without prejudice to the consent given below in respect of my/our personal data, I/we hereby authorise any hospital physician, other person who has
attended or examined me/us, to furnish to the Company, or its authorised representatives, any and all information with respect to any illness or injury,
medical history, consultation, prescriptions or treatment, and copies of all hospital or medical records. A copy of this authorisation shall be considered
as effective and valid as the original.
PERSONAL DATA
In addition to the declaration and authorisation provided above, I/we agree and consent to the Company, its related corporations (collectively, the
"Companies"), as well as their respective representatives and agents collecting, using, disclosing and sharing amongst themselves my/our personal
data, and disclosing such personal data to the Companies' authorised service providers and relevant third parties for purposes reasonably required by
the Companies to evaluate, admit, process and/or administer my/our claims.
These purposes are set out in Great Eastern's Privacy Statement, which is accessible at http://www.greateasternlife.com/sg/en/pncpolicies.htm and
which I/we confirm I/we have read and understood.
Claimant’s signature: ________________________ Date: ______________
Insured’s signature: ________________________ Date: _____________
(See Note Below)
Note: If (a) The Policyholder is claiming on his own belief or (b) the Claimant concerned is a Child under 18 years of age - only the policyholder’s signature is required.
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NB. No claim can be admitted unless medical certificate from a duly qualified and registered medical practitioner on the form
below be furnished at the expense of the Insured.
SECTION D - ATTENDING DOCTOR’S STATEMENT
1. Name of Patient
2. NRIC No.
4. (a)
If Injury: When did Accident occur?
(a)
If Sickness: When did symptoms first appear?
(b)
State the Nature of Injury or Sickness
(Describe complications - If any).
(a)
(b)
Final Diagnosis.
(b)
(c)
Nature of Surgery (if any).
(c)
When did the Patient first receive medical attention for
this condition?
(a)
(b)
By Whom? Name of Doctor.
(b)
(c)
Address
(c)
(b)
5. (a)
6. (a)
No
7. Has the Patient ever had this or any similar condition?
3. Date of Birth
Yes,
details: _____________________________
_____________________________
_____________________________
8. Is the present condition of patient due to:
(a)
congenital anomaly?
(a)
No
Yes, specify: ____________________________
(b)
nervous or mental disorder?
(b)
No
Yes, specify: ____________________________
(c)
pregnancy/childbirth/infertility?
(c)
No
Yes, specify: ____________________________
(d)
alcohol influence?
(d)
No
Yes, specify: ____________________________
9. Period of Hospitalisation.
Date Admitted: ______________ Date Discharged: _______________
10. Name and Address of Hospital Admitted.
11. Are you the Patient’s usual Doctor?
(a)
No
Yes
If no, name and address of usual Doctor:
_____________________________________________________
_____________________________________________________
I hereby certify that I have personally examined and treated the patient for the above *injury/sickness and that the
facts as given above present my opinion of his/her condition.
Name of Doctor: ___________________________
Date: ____________________________________
________________________________
Signature & Official Stamp of Doctor
* to delete as applicable
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