Accident Claim Form Hospitalization Claim Form by chenmeixiu


									                                           Accident Claim Form / Hospitalization Claim Form
                                           (For Accidental Medical Expenses Benefit & all types of Hospital Benefits Riders)

Part I (to be completed by Insured / Claimant)
For any query while completing this form, please refer to the Completion Guideline or your agent.
Type of Claim                               Accident Claim                                          Hospitalization Claim

A. Insured's Particulars
  Policy No.                                      Life Insured (Surname first)                                                              ID No.
                                                                                                                                                                           (     )
  Sex                                                                Age                                                    Date of Birth

  Mailing Address                                                                                                                           Telephone No.

  Email Address                                                                                                                             Mobile Phone No.

  Occupation                                                         Name of Employer and Address

B. Payment Instruction
  Make Payment by                  HK Currency             Policy Currency            Direct Credit Payment**    Bank Account No.

C. Accident / Hospitalization Reason
   (For Accident Claim, please complete questions 1 to 3 & 6 below)
   (For Hospitalization Claim due to illness, please complete questions 4 to 6 below.)
  1. When & where did the accident occur?

  2. How did the accident occur?

  3. Part of body injured (e.g. Left ankle etc.)

  4. Give a brief description of Insured's symptoms.

  5. How long had he/she been experiencing these symptoms prior to the first consultation?

  6. Give details of consultations.                                                 Date                         Name(s) and Address of Doctor / Hospital

        (a) The doctor first consulted for this illness / accident            (a)

        (b) The doctor who referred the Insured to hospital                   (b)

        (c) All other doctors consulted during this illness / accident        (c)

        (d) Doctors seen for any similar condition in the past                (d)

D. Other Insurance Coverage
  1. Does the Insured have any other insurance policy covering the case? If "Yes" , please state: name of the insurance company and policy number.             Yes       No

  2. Does the Insured have any Social Welfare Benefits? If “Yes”, please state: name and give the payment details copy to us.                                  Yes       No

E. For Agent's Use Only
  Agent Name                                                                                                 Agent code & Location

                                                                                                                                                                     L-CL-36 (FEB 07)
ING Life Insurance Company (Bermuda) Limited
Incorporated in Bermuda with limited liability
                                         Accident Claim Form / Hospitalization Claim Form
                                         (For Accidental Medical Expenses Benefit & all types of Hospital Benefits Riders)

F. Declaration and Authorization
 1. The above particulars and answers are complete and true, and this questionnaire will form part of the contract of the desired insurance on my life. I also authorize the Company to obtain,
    if necessary, confidential reports from any doctor/clinic/hospital that I have referred above.
 2. Any personal data of myself or the insured (if different) collected and held by the Company may be used, stored, disclosed and transferred (whether within or outside Hong Kong) to such
    individuals/organizations associated with the Company. These include reinsurers, claims investigators and industry associations/federations for the purposes of (i) assess and evaluate this
    claim; (ii) provide all services related to this claim; (iii) any promotion of service by the Company and its affiliated companies and (iv) communicating with me or the Insured (if different) for such
 3. I understand that I have or the Insured (if different) has the right to request access to and to request correction (if appropriate) of any personal information concerning myself or the Insured
    (if different) held by the Company or be given reasons for any refusal of access. I also understand that the Company has the right to charge a reasonable fee for process of any access.
     {Note : Any request for access or correction can be made in writing and addressed to the Head of Claims Department at 9/F, ING Tower, 308 Des Voeux Road Central, Hong Kong.}

 1. any registered practitioner, hospital, clinic, insurance company, government institution or other organization that has record or knowledge of my or the Insured’s (if different) health and medical
    history or any treatment or advice and that has been or may hereafter be consulted to disclose to ING Life Insurance Company (Bermuda) Limited in relation to this claim.
 2. the Company or any of its approved medical examiners or laboratories to perform necessary medical assessment and tests to evaluate my or the Insured’s health status in relation to this claim.

 [Note : This authorization shall bind my and the Insured’s successors and assigns and remain valid notwithstanding my or the Insured’s death or incapacity in so far as legally possible. A photocopy
 of this Authorization shall be as valid as the original].

 Data Protection - The Company has appointed a Data Protection Officer to handle any enquiries relating to your personal information. If you would like to obtain a copy of the ING Life Insurance
 Co (Bermuda) Ltd Personal Data Policy and Practices, please write to the Corporate Data Protection Officer at 1/F, ING Tower, 308 Des Voeux Road Central, Hong Kong.

 Date (MM/DD/YY)                                                                                          Place

 Signature of Claimant                                                                                    Signature of Close Relative of Insured (if applicable)
Part II - to be completed by the attending Physician/Surgeon at the Claimant's Own Expenses

  (1)    Name of Patient

  (2)    Hospitalization
         Name of Hospital

         Date of Admission                                                            Date of Discharge

  (3)    Surgical procedure

         Date of operation                                                     Name of the procedure


  (4)    Chief complaints of the patient relating to this hospitalization/surgery

  (5)    Diagnosis of conditions

  (6)    Brief discharge summary: (including treatments, investigation procedures, results; and/or any complications and follow up plan.)

  (7)    Date of the accident occurred or symptom first appeared.

  (8)    Date of first consultation for this condition or related illness

  (9)    To the best of your knowledge, has the patient ever had the same or similar conditions or symptoms relating thereto?

         No                Yes          Please state dates and describe

  (10)   Is the patient referred by another doctor?
         No                Yes          Name and address of the referral doctor

  Name of Attending Physician / Specialist (with qualifications)                      Address


  Signature of Attending Physician/Specialist                                         Date

                                             This claim form is endorsed by the Hong Kong Medical Association and
                                          the Medical Insurance Association of the Hong Kong Federation of Insurers.
                                         Accident Claim Form / Hospitalization Claim Form
                                         (For Accidental Medical Expenses Benefit & all types of Hospital Benefits Riders)

To avoid the delay of process, please follow this section and check that all required claims document are attached.

                                                                                   Check List

                                                                                                                                                             Yes       No

          Has the Insured / Claimant fully completed the Claim Form?

           Has the Insured’s attending physician fully completed the Claim Form Part II?

           Has the Insured attached the following document:-

           1) Original Medical Receipts

           2) All Lab Test Reports

           3) Ultra-sound Reports

           4) ECG Reports

           5) X-ray Reports

           6) Others information

          Do you need to retrun all documents to the patient?

           Total No. of receipts attached and total claim amount:

          Bonesetter / physiotherapist / chiropractor:

          Registered Medical Practitioner:

          Hospital Expenses:

                                                                                  Completion Guideline

1.   Please read the questions carefully before answer. All the answers provided on this claim form must be true, complete and accurate.

2.   If the Insured / Policyowner is unable to sign, this form should be signed by a close relative and submit proof of relationship with the Insured / Policyowner.

3.   Unless special request filed and approved by the Company, otherwise, all the payment of claim normally are payable by cheque in Policy Currency to Policyowner.

4.   This Claim Form with other required documents MUST be sent to the Company within 90 days from the date of incident. Any Claim Form submitted after the above 90 days period is
     deemed as “Late Submission” and explanation MUST be provided. Otherwise, the Company is obligated to refuse the claim application.

** Direct Credit Payment
   Limited to Policyowner’s Bank Accounts in Hong Kong and Payment limit is HK$10,000. A copy of bank book or bank statement MUST be provided, unless Bank Accounts are the same
   with DDA of Monthly Premium paid.

                                                                                                                                                                        L-CL-36 (FEB 07)
ING Life Insurance Company (Bermuda) Limited
Incorporated in Bermuda with limited liability

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