Hsbc Major Illness Cancer Claim Form

Major Illness Claim Form 嚴重疾病賠償申請書 Policy No. 保單號碼:

Date 日期:

Please specify any other insurances with HSBC? 請註明在 Life Policy No. 人壽保險號碼:

豐有否投保其他保險？

Non-Life Policy No. 非人壽保險號碼:

Medical Policy No. 醫療保險號碼:

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 attending 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. Pathological Report. 病理報告。

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 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、地址及電話號碼

C. Reason for Claim 賠償原因 13. Due to accident 因意外 (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 14. Due to illness 因患病 (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 Physican/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 Physican/Hospital & Address 醫生／醫院名稱及地址

Please ✔ the appropriate box. 請在適當的方格內加上 ✔ 號。

HSBC Life (International) Limited 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 豐中心 1座 18樓

LI105 v05/0308 (0308) D

Admission Date 求診日期（DD 日／MM 月／YYYY 年）

C. Reason for Claim (Cont’d) 賠償原因（續） (iii) Please give details of all physician(s) consulted or hospital(s) to which Life Insured was admitted during this illness 曾診治此病的其他醫生資料： Physician/Hospital 醫生／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

(iv) Physician(s) seen for any similar condition in the past 過往診治同類病況的醫生資料： Physician/Hospital 醫生／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

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 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 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 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。

Signature of Life Insured 受保人簽署

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

LI105 v05/0308 (0308) D

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 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:

Part II : Attending Physician’s Report — Major Illness Claim Form (To be Completed by Physician at Claimant’s Expense) 第二部分： 醫療報告 — 嚴重疾病賠償申請書 （由主診醫生填寫，費用由索償人支付）

Policy No. 保單號碼:

1. Name of Patient (Surname first)

2.

HKID/Passport No.

3.

Date Admitted (DD/MM/YYYY)

4. Date Discharged (DD/MM/YYYY)

5.

Admission No.

6.

Ward No.

7.

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

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

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

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

8.

(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 existed before the first consultation?

9.

Had the patient previously seen any other doctors regarding these symptoms? If so, please give details.

10. (a) What was the significant physical findings?

(b) What was the diagnosis? How was it diagnosed?

(d)

If you are not the first doctor who diagnosed this illness, please provide the name and address of the doctor who informed the patient of the disease.

LI105a v03/0606 (0606) D

(c) Did you inform the patient of the diagnosis? If “yes”, when did you do so?

11. Hospitalisation Name of Hospital

Date of Admission

Surgical Procedure Done

Date of Discharge

Hospital Discharge Summary

12. Has the patient ever been treated for the same / related conditions or for any other serious disorder? If so, please provide dates and names of any other doctors / hospitals attended. Date

Disease / Disorder

Details of Treatment(s) / Hospitalisation(s)

Name of Physician / Hospital

13. (a) Does the patient smoke? If “yes”, please give details of type, quantity & duration.

(b) Is the patient a carrier of any type of hepatitis virus? When was it diagnosed? What was the type?

(c) Does the patient drink? If “yes”, please give details of type, quantity & duration.

This is not the end (Please complete the “Major Illness Claim Form — Continuation of Part II”)

1.

Claim Form Part I and II must be completed by the Insured / Claimant and the Attending Physician, respectively.

2.

With regard to all types of major illness, the “Major Illness Claim Form — Continuation of Part II” must be completed and returned.

3.

References, such as patient Cards, Diagnostic, Laboratory or Pathology Reports, should be submitted.

4.

Proof of claim should be furnished within 90 days of the first diagnosis of any major illness. If no proof is received within 90 days, it must be shown that proof was received as soon as was reasonably possible, or no benefit will be paid.

LI105a v03/0606 (0606) D

Guide for filing a Major Illness insurance claim form:

Major Illness Claim Form Continuation of Part II To be completed by the Attending Doctor at the Insured expense CANCER In order for a claim to be valid, the following definition must be fulfilled: Cancer Cancer is the presence of uncontrolled growth and spread of malignant cells and invasion of tissue. Incontrovertible evidence of the invasion of tissue of definite histology of malignant growth must be produced. The term cancer also includes leukaemia, lymphomas and hodgkin’s disease. Excluded are non-invasive carcinomas in situ, any skin cancer except malignant melanomas, localised non-invasive tumours showing only early malignant changes and tumours in the presence of any human-immunodeficiency virus. Name of Patient

HKID / Passport No.

Sex (M / F)

Age

1. How would you comment on the patient’s past medical history?

2. Prior to your diagnosis, was there any diagnostic test, such as CEA, cytologic examination, biopsy or frozen section done for him / her? If yes, please provide the following details. (Please provide us with copies of these reports / results if applicable) DATE

TYPE(S) OF TEST

RESULTS / DIAGNOSIS

3. Has the patient previously suffered from the related conditions of this illness? If yes, please give dates of consultation, details of conditions and diagnosis. DATE

CONDITIONS

DIAGNOSIS

4. We understand that the patient has been diagnosed to have tumor or malignant disease. Please describe the severity of the illness with respect to the following areas: a. What is the site and / or organ involved? b. What is the histology of the tumor or the malignant disease? c. What staging classification is used & what is the tumor staging in this patient? d. Is the disease completely localized? e. Is there invasion of adjacent tissues?

HSBC Life (International) Limited

Incorporated in Bermuda with limited liability Hong Kong SAR Office : 18/F, Tower 1, HSBC Centre, 1 Sham Mong Road, Kowloon, Hong Kong

LI131 v03/0308 (0308) D

f. Are regional lymph nodes involved?

g. Is there any distant metastasis?

h. If the diagnosis is leukaemia, is it chronic lymphocytic leukaemia?

i.

If the diagnosis is skin cancer, is it malignant melanoma?

j.

Please provide the result of tumour marker.

5. According to your record, did the patient present with a history of other major illness / disorders that was related to his / her current injury / sufferings? If yes, please give details.

6. How would you describe the patient’s current medical condition? Are there any other neurological deficits that would result directly from the incident? If so, how long do you think they will last?

7. With respect to the patient’s occupation, how would it be affected by his / her illness?

8. Would you consider the patient to be disabled? Totally / partially disabled for original occupation or any occupation? Why?

9. Please list the type(s) of treatments and medications that you have prescribed to the patient for his / her illness.

10. When did you last see the patient? What was his / her condition at that time?

11. Are there any additional information that you would like to supplement the above?

Declaration I hereby certify that I have personally examined and treated the patient in connection with the above illness / dismemberment and that the facts 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. Signature of Physician

Name of Physician

Qualification

Telephone No.

Hospital’s Stamp

Date

Name of Hospital

Address of Hospital