Great Eastern Life_confidential Medical Certificate (other Illnesses) _clmlamco
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CONFIDENTIAL MEDICAL CERTIFICATE (LIVING ASSURANCE) New NRIC No.
Policy No.
-
No. KP Baru
No. Polisi
Policy No.
Old NRIC/BC/Passport No.
No. Polisi
No. KP Lama/Sijil Kelahiran/Paspot
Policy No.
-
Name of Life Assured
No. Polisi
Nama Hayat yang Diasuranskan
Policy No. No. Polisi
Policy No. No. Polisi
Issued by:
*
Date:
TO BE COMPLETED BY THE MEDICAL ATTENDANT (IF THERE IS A CHARGE FOR COMPLETION OF THIS FORM IT IS THE RESPONSIBILITY OF THE CLAIMANT)
Claims Condition Suffered (Please tick ( / ) where applicable) Kidney Failure
Fulminant Hepatitis
Major Organ Transplant
Paralysis (Paraplegia, Tetraplegia)
Multiple Sclerosis
Pulmonary Hypertension
Total Permanent Blindness
Heart Valve Surgery
Total Permanent Deafness
Aorta Surgery
Loss of Speech
Alzheimer's Disease
Major Burns
Coma
Terminal Illness
Motor Neurone Disease
HIV Infection From Blood Transfusion
Parkinson's Disease
End Stage Liver Disease
End Stage Lung Disease
Aplastic Anaemia
Muscular Dystrophy
Benign Brain Tumour
Encephalitis
Poliomyelitis
Brain Surgery
Bacterial Meningitis
Apallic Syndrome
AIDS Cover of Medical Staff
Full Blown AIDS
Accidental Head Injury Resulting in Major Head Trauma 1. General Information (a)
Are you the Life Assured's usual medical physician?
Yes
No
Yes, when
No
If yes, over what period do your records extend? (b)
When were you first consulted for this illness?
(c)
Did you inform the patient of your diagnosis?
(d)
Is there anything in the Life Assured's family history which would have increased the risk of this illness?
(e)
Name and address of Doctor who referred the patient to you in connection with the condition. Name
Address
2. Details of the Life Assured's Illness. (a)
Description of condition, cause and diagnosis. Please provide full and exact details of the diagnosis. Condition of Illness
Cause of Illness
Diagnosis of Illness
CLM-LAMCO-V00-112002 Great Eastern Life Assurance (Malaysia) Berhad (93745-A) (A member of Great Eastern Holdings Limited) Head Office: Menara Great Eastern 303 Jalan Ampang 50450 Kuala Lumpur Customer Service Careline (603) 4259 8333 Agent Service Careline (603) 4259 8111 Fax (603) 4259 8198 E-mail [email protected] Website www.lifeisgreat.com.my
6141445993
(b)
To the best of your knowledge when did these symptoms first appear and what was the date of first consultation. Please provide a full history of the condition.
(c)
What are the tests that were performed that confirmed the diagnosis? Please enclose copies of all reports, X-rays, any other imaging studies, laboratory evidence and any relevant hospital reports that are available.
(d)
. Please describe the nature of treatment and medication prescribed.
(e)
Has the patient suffered or been treated for any chronic sickness or diseases other than this critical illness? If yes, please give full details.
(f)
What is the current condition of the Life Assured and what is the prognosis?
(g)
Are you completing any other forms regarding this patient for anyone else, including other insurance companies? If yes, please give details.
(h)
Any further information which in your opinion will assist us in assessing this claim.
DECLARATION I hereby certify that I have examined the above claimant and that I have answered the above questions to the best of my knowledge and belief.
Name, Address and Official Stamp Signature Date
4858445996
Policy No.
-
No. KP Baru
No. Polisi
Policy No.
Old NRIC/BC/Passport No.
No. Polisi
No. KP Lama/Sijil Kelahiran/Paspot
Policy No.
-
Name of Life Assured
No. Polisi
Nama Hayat yang Diasuranskan
Policy No. No. Polisi
Policy No. No. Polisi
Issued by:
*
Date:
TO BE COMPLETED BY THE MEDICAL ATTENDANT (IF THERE IS A CHARGE FOR COMPLETION OF THIS FORM IT IS THE RESPONSIBILITY OF THE CLAIMANT)
Claims Condition Suffered (Please tick ( / ) where applicable) Kidney Failure
Fulminant Hepatitis
Major Organ Transplant
Paralysis (Paraplegia, Tetraplegia)
Multiple Sclerosis
Pulmonary Hypertension
Total Permanent Blindness
Heart Valve Surgery
Total Permanent Deafness
Aorta Surgery
Loss of Speech
Alzheimer's Disease
Major Burns
Coma
Terminal Illness
Motor Neurone Disease
HIV Infection From Blood Transfusion
Parkinson's Disease
End Stage Liver Disease
End Stage Lung Disease
Aplastic Anaemia
Muscular Dystrophy
Benign Brain Tumour
Encephalitis
Poliomyelitis
Brain Surgery
Bacterial Meningitis
Apallic Syndrome
AIDS Cover of Medical Staff
Full Blown AIDS
Accidental Head Injury Resulting in Major Head Trauma 1. General Information (a)
Are you the Life Assured's usual medical physician?
Yes
No
Yes, when
No
If yes, over what period do your records extend? (b)
When were you first consulted for this illness?
(c)
Did you inform the patient of your diagnosis?
(d)
Is there anything in the Life Assured's family history which would have increased the risk of this illness?
(e)
Name and address of Doctor who referred the patient to you in connection with the condition. Name
Address
2. Details of the Life Assured's Illness. (a)
Description of condition, cause and diagnosis. Please provide full and exact details of the diagnosis. Condition of Illness
Cause of Illness
Diagnosis of Illness
CLM-LAMCO-V00-112002 Great Eastern Life Assurance (Malaysia) Berhad (93745-A) (A member of Great Eastern Holdings Limited) Head Office: Menara Great Eastern 303 Jalan Ampang 50450 Kuala Lumpur Customer Service Careline (603) 4259 8333 Agent Service Careline (603) 4259 8111 Fax (603) 4259 8198 E-mail [email protected] Website www.lifeisgreat.com.my
6141445993
(b)
To the best of your knowledge when did these symptoms first appear and what was the date of first consultation. Please provide a full history of the condition.
(c)
What are the tests that were performed that confirmed the diagnosis? Please enclose copies of all reports, X-rays, any other imaging studies, laboratory evidence and any relevant hospital reports that are available.
(d)
. Please describe the nature of treatment and medication prescribed.
(e)
Has the patient suffered or been treated for any chronic sickness or diseases other than this critical illness? If yes, please give full details.
(f)
What is the current condition of the Life Assured and what is the prognosis?
(g)
Are you completing any other forms regarding this patient for anyone else, including other insurance companies? If yes, please give details.
(h)
Any further information which in your opinion will assist us in assessing this claim.
DECLARATION I hereby certify that I have examined the above claimant and that I have answered the above questions to the best of my knowledge and belief.
Name, Address and Official Stamp Signature Date
4858445996
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