Hsbc Disability Claim Form

Disability/Accidental Dismemberment Claim Form 喪失工作能力／意外傷殘賠償申請書 Policy No. 保單號碼:

Date 日期:

Please specify any other insurances with HSBC? 請註明在è豐有否投保其他保險？ Life Policy No. Non-Life Policy No. 人壽保險號碼: 非人壽保險號碼: New Claim 首次索償

Medical Policy No. 醫療保險號碼:

Further Claim 再度索償

Notes: 注意： Documents required to be submitted with this form: 以下文件請連同此表格一併交回： 1. Attending Physician’s Report completed by the atteding Physician (To be obtained by the Claimant). 主診醫生填寫之賠償申請書（此報告需由申請人負責索取）。 2. All copy of sick leave certificate and treatment proof. 所有副本之病假紙及治療證明文件。 3. Workmen Compensation Sheet, if any. 判傷紙，如有。

Part I : To be completed by the Insured 第一部分 : 由受保人填寫 A. Details of Life Insured* 受保人資料* 1. Name of Life Insured in English (Surname first) 英文姓名

2.

Chinese Name 中文姓名

4. HKID No. / Passport No. 香港身分證或護照號碼

5.

Mr 先生 Mrs 太太

3.

Ms 女士 Miss 小姐

Age 年歲

6. Correspondence Address 通訊地址 7. Telephone No. 聯絡電話號碼（Day time 日間）

（Night time 晚間）

B. Details of Employment 就業資料（If more than one occupation, please state all 倘若有其他職業，請詳細列出） 8. Position 職位

9.

Industry 行業

10. Job Activities 工作範圍

11.

Indoor 戶內 Outdoor 戶外 Indoor & Outdoor 戶內及戶外

12. Employer’s Name, Address & Telephone No. 僱主名稱、地址及電話 13 Did you provide a sick leave certificate to your employer? 曾否向僱主遞交病假證明書？ 14. Date you last worked 最後工作日期（DD 日／MM 月／YYYY 年）

Yes 有

No 沒有

15. Date you returned to work 何時恢復工作（DD 日／MM 月／YYYY年） (If not, then give expected date of return)（如否，祈望何時可恢復工作）

C. Reason of Disability 喪失工作能力的原因 16. Disability was due to accident 因意外而導致喪失工作能力： (a) Date and time of accident 意外日期及時間（DD 日／MM 月／YYYY 年 and am上午／pm 下午） (b) Where and how did it happen? 意外地點及經過 (c) Part of body injured and type of injury 受傷部位及傷勢 (d) Was the accident reported to your employer or to the police? If so, please provide details. 曾否向僱主或警方申報是次意外？若有，請提供有 關資料。 17. Disability was due to illness 因疾病而導致喪失工作能力： (a) Describe the illness and give a brief description of the symptoms 所患病症及其病徵 (b) How long had you been having these symptoms prior to visiting physician? 受保人在首次就診前該等病徵已存在多久？ (c) Details of consultation 診治詳情 (i) The first physician consulted for illness 首次就診的醫生資料： Name of Physician/Hospital & Address 醫生／醫院名稱及地址 Admission Date 求診日期（DD 日／MM 月／YYYY 年） (ii) The physician who referred the insured to hospital 建議入院的醫生資料： Name of Physician/Hospital & Address 醫生／醫院名稱及地址

HSBC Life (International) Limited F豐人壽保險（國際）有限公司

Incorporated in Bermuda with limited liability 於百慕達註冊成立之有限公司 Hong Kong SAR Office： 18/F, Tower 1, HSBC Centre, 1 Sham Mong Road, Kowloon, Hong Kong 香港特別行政區地址：香港九龍深旺道 1號è豐中心 1座 18樓

INHK009R5 (0308) D

Admission Date 求診日期（DD 日／MM 月／YYYY 年） Please ✔ the appropriate box. 請在適當的方格內加上 ✔ 號。 * If a claim is made on the Payor’s disability, please complete this form with respect to the disabled Payor instead of Insured. 若此為付款人喪失工作能力之賠償申請書，請以付款人 資料回答。

C. Reason of Disability (Cont’d) 喪失工作能力原因（續） 18. Details of physician(s) consulted or hospital(s) to which admitted for current disability 曾就診之醫生姓名或醫院詳情： Physician & Hospital 醫生及醫院 Name 姓名

Address 地址

Admission No.

Admission Date

求診或住院號碼

求診或住院日期

19. Are you currently insured for disability benefit with any other insurance company? If the answer is “Yes”, please complete the following. 是否有其他喪失工作能力保障於其他保險公司？若答案為「是」，請填寫下列有關資料。 Yes 是 Name of Insurance Company 保險公司名稱

Amount of Life Insurance 人壽保險額數

Type of Disability Benefit 喪失工作能力保障種類

No 否

Policy No. 保單號碼

D. Personal Information Collection Statement 收集個人資料聲明 The information you provide to us is collected to enable us and any of our affiliated companies to carry on business and may be used for the purpose of: 1) any insurance, banking, provident fund scheme or financial related products or services, 2) any sales or marketing, or any alterations, variations, cancellation or renewal of such products or services listed in 1 above; and 3) any claims or investigation or analysis of such claims; and 4) exercising any right of subrogation, if applicable. Further, the information you provide to us may be transferred (in and outside the Hong Kong Special Administrative Region) to the following organisations: 1) any of the company or companies within the HSBC Group for the purpose of insurance, banking or other businesses of the affiliated company concerned; 2) any related company, or any other company carrying on insurance or reinsurance related business, or an intermediary, or a claim or investigation or other service provider providing services relevant to insurance business, for any of the above or related purposes; 3) any association, federation or similar organisation of insurance companies (“Federation”) that exists or is formed from time to time for any of the above or related purposes or to enable Federation to carry out its regulatory functions or such other functions that may be assigned to the Federation from time to time and are reasonably required in the interest of the insurance industry or any member(s) of the Federation; 4) any members of the Federation by the Federation for any of the above or related purposes. Moreover, we are hereby authorised to obtain access to and/or to verify any of your data with the information collected by the Federation from the insurance industry. You have the right to obtain access to and to request correction of any personal information concerning yourself held by us, and to request, without charge, to opt out from receiving any direct marketing materials from us. Requests for such access and opt-out can be made in writing to the Compliance Officer, 18/F, Tower 1, HSBC Centre, 1 Sham Mong Road, Kowloon, Hong Kong. 您提供的資料，為本公司及相關聯公司提供其業務所需，並可能使用於下列 目的：1) 任何與保險、銀行、公積金計劃或財務有關的產品或服務，2) 上述第一項該等產品或服務的任何銷售或推廣，或任何更改、變更、取 消或續期；及 3) 任何索償，或該等索償的調查或分析；及 4) 行使任何代位權，如適用。 您提供的資料亦可能移轉（無論在香港特別行政區以內 或以外）予：1) 任何è豐集團的公司用作與保險、銀行或相關聯公司之其他業務；2) 任何有關的公司，或任何其他從事與保險或再保險業務有關 的公司，或中介人或索償或調查或其他提供與保險業務有關的服務提供者，以達到任何上述或有關目的；3) 現存或不時成立的任何保險公司協 會或聯會或類同組織（聯會），以達到任何上述或有關目的，或以便聯會執行其監管職能，或其他基於保險業或任何聯會會員的利益而不時在合理 要求下賦予聯會的職能；4) 或透過聯會移轉予任何聯會的會員，以達到任何上述或有關目的。此外，本公司亦據此獲授權由聯會從保險業內收 集的資料中查閱及／或核對您任何資料。您有權要求查閱及更正由本公司持有有關您的個人資料，及免費要求不收取任何直接推廣資料。有關要 求，可用書面寄香港九龍深旺道1號è豐中心1座18樓，向本公司審核主任提出。

E. Declaration and Authorisation 聲明及授權

Signature of Life Insured/Claimant 受保人／申請人簽署

Signature of Policyholder 保單持有人簽署

Name 姓名：

Name 姓名：

HKID No. 香港身分證號碼

HKID No. 香港身分證號碼

Date 日期

Date 日期

INHK009R5 (0308) D

I hereby certify that the answers and statement given above are true and complete to the best of my knowledge and that I have withheld no material fact. 本人在此聲明以上所提供的資料均屬正確無訛且並無缺漏。 I authorise any physician, hospital, clinic, insurance company or other individual organisation or government office that has any records or knowledge of me or my health, to disclose to HSBC Life (International) Limited or its representative any information relevant to this claim. This authority shall remain valid notwithstanding my death or incapacity and a copy of this authorisation shall be as effective and valid as the original. 本人授權任何知道本人健康情況及據知任何紀錄之醫生、醫院、診所、保險公司或其他私人、政府機構向è豐人壽保險(國際)有限公司或其代表 提供本人之有關資料。此授權書於本人死亡或喪失能力後依然生效。本授權書之影印本亦屬有效。

To HSBC Life (International) Limited 致：#豐人壽保險(國際)有限公司 Date 日期:

Policy No. 保單號碼:

Part II: Attending Physician’s Report — Disability/Accidental Dismemberment Claim Form (To be completed by physician at claimant’s expense) 第二部分：醫療報告 — 喪失工作能力／意外傷殘賠償申請書 （由主診醫生填寫，費用由索償人支付） 1.

Name of patient (Surname first)

2.

5.

(a) Please state the cause of the disability.

Age

3. HKID No. / Passport No.

4.

Occupation and job duties

(b) Date on which you first saw the patient for this illness or injury. (DD/MM/YYYY)

(c) Was the patient referred to you by another doctor? If so, please indicate his / her name and address.

(d) What symptoms did the patient complain of at this first consultation?

(e) Was the patient’s presentation consistent with the symptoms and level of disability complained of?

6.

If the disability was due to illness: (a) According to the patient, how long had he / she experienced the symptoms before the first consultation?

(b) How long do you think the symptoms had been in existence before the first consultation?

Please give details of all consultations and treatments given as far as your records go back. (Alternatively, a copy of the patient’s record can be provided.) Date

8.

Complaints & Symptoms

Diagnosis

Type of Treatment Given

Duration of Treatment

(a) Names and addresses of hospitals to which patient was admitted during this disability

(b) Period of hospitalization(s): From: (DD/MM/YYYY)

To: (DD/MM/YYYY)

(c) Names and addresses of other physicians consulted during this disability.

(d) Is further hospitalisation / surgery necessary? If so, please specify.

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7.

9.

Please indicate the results of all investigation & test (such as neurological examination, laboratory tests, X-rays and Wassermann, etc.). We would appreciate receiving copies of all such test results. If insufficient space, please attach a separate list.

10. Did the injury / illness result from or was the period of disability lengthened by?

Yes

No

(a) Physical defects / congenital anomaly?

(b) Past medical history?

(c) Degenerative changes?

(d) Alcohol or drug abuse?

(e) Smoking?

(f) HIV/AIDS related condition?

(g) Prior psychiatric illness?

11. (a) Please give the date the patient was first absent from work.

(b) If the disability was interrupted, please give date(s) patient returned to work.

12. What is the present condition of the patient’s disability?

13. What treatment has been prescribed?

14. Is the patient complaint with this treatment?

15. Please advise what duties of the patient’s pre-disablement occupation he / she is: •

Able to perform

•

Unable to perform

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16. On what date did the patient return to work? Was this on a full-time or part-time basis?

17. To the best of your knowledge, has the patient ever been treated for the same / related conditions or for any other serious disorder? If so, please state when and the names of any other hospital(s) and / or physician(s) attended. Date

Disease / Disorder

Details of Treatment(s) / Hospitalisation(s)

Name of Physician / Hospital

18. Have any medical certificates been provided to any other persons, insurance companies or other companies? If so, please provide full details.

19. If the patient is still disabled, is he / she •

Motivated to return to work?

•

Motivated to undertake re-training or other rehabilitative schemes? If so, please specify.

20. Has a treatment plan been put in place to return the patient to work? If so, please provide details.

Declaration I hereby certify that I have personally examined and treated the patient in connection with the above disability and that the facts as given above present my opinion of his / her condition. I hereby certify that I have not withheld any information at the request of the patient.

Name of Physician (With Stamp)

Name of Physician

Qualification

Telephone No.

Date

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Address