living assurance / epcc claim claimant's statement - At Great Eastern ...

LIVING ASSURANCE / EPCC CLAIMCLAIMANT’S STATEMENTDear Claimant,We are sorry to learn of your illness/ injury.In order for us to process your claim, we require the following:1) Claimant’s Statement.2) Clinical Abstract Application Form.3) Doctor’s Statement (refer to Note I below).4) Histopathological/ Biopsy Reports (for Cancer).5) ECG Reading & Enzyme Assays (for Heart Attack).6) CT Scan/ MRI Scan Results (for Stroke).7) All available Laboratory and Test Results (as specified in the Doctor's Statement).8) Authorisation Letter (refer to Note II below).Once we have received all the above required documents, we will process your claim and inform you of the outcome assoon as possible.If you need any help, please call our Customer Service toll-free line 1800-248-2888 or email us at Claims@Lifeisgreat.com.sg.Note:I) The Doctor’s Statement must be completed by your attending doctor and furnished at the expense of the claimanttogether with all available Laboratory and Test Results.II)III)IV)Authorisation letter has to be submitted if you are authorising another party to handle the claim (includingcollection of cheque) on your behalf.Please continue to pay your premiums until we inform you that the claim is admitted.There is a 90 days waiting period for Cancer/ Major Cancers, Heart Attack, Angioplasty & Other Invasive Treatmentfor Coronary Artery and Coronary Artery By-pass Surgery (This means that these illnesses will be covered only90 days after the policy was taken up or reinstated, whichever is the later).Submission of DocumentsPlease submit all claim documents personally at our Customer Service Centre at the ground floor,Great Eastern Centre or, through your Servicing Life Planner or, by post to:Claims DepartmentThe Great Eastern Life Assurance Company Limited1 Pickering StreetGreat Eastern Centre #13-01Singapore 048659The Great Eastern Life Assurance Company Limited (Reg. No. 1908 00011G)The Overseas Assurance Corporation Limited (Reg. No. 1920 00003W)Claims Department1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: 1800-248 2888 Fax: 6532 4406Email: Claims@lifeisgreat.com.sg Website: www.lifeisgreat.com.sg

AUTHORISATION LETTERFor Claimant’s completion :I would like the claim cheque (if claim is approved) to be :posted to me via my correspondence address.collected by my Servicing Life Planner, (NRIC No.: )Signature of Claimant : Policy No. :Name of Claimant. :Handphone/ Contact No. of Claimant. :NRIC of Claimant :Date:For Servicing Life Planner’s completion (if Claimant has authorised you to collect the cheque)I would like the claim cheque to be: -Collected at Customer Service Reception Counter at Ground Floor, Great Eastern Centre.(Please note that the cheque will be posted to the Claimant if it is not collected by the next working day after the collection date.)Dropped into my GSM Box No.at GE@Changi.*Dropped into my GSM Box No.Dropped into my GSM Box No.at GE House.*at Nankin Row.** Notes:-1. Option is available only if there are no outstanding documents to be submitted. Cheque will be delivered to your GSM Box the next working day after 12pm.2. For Life Planners who have opted for collection of cheques at Customer Service Reception Counter at Great Eastern Centre, Claims Department will contactyou when the cheque is ready.Signature of Servicing Life Planner :Name of Servicing Life Planner :Agent No. :Contact No. :For Official Use :Claim Officer : Extension No. :Pending documents / comments :Cheque / Letter released by:-Signature :Name :Date :Cheque / Letter received by:-Signature :Name :Date :The Great Eastern Life Assurance Company Limited (Reg. No. 1908 00011G)The Overseas Assurance Corporation Limited (Reg No. 1920 00003W)Claims Department1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: 1800-248 2888 Fax: 6532 4406Email: Claims@lifeisgreat.com.sg Website: www.lifeisgreat.com.sgLast updated: 30042009

CLINICAL ABSTRACT APPLICATIONImportant Note: (i) This form is required for the application of medical report from hospital/clinic and should be completed by the patientor the patient’s parent (if patient is below 21 years of age) or the patient’s next-of-kin (if patient is deceased).(ii) For request of medical report from hospital, this form is to be submitted to the Medical Records Department of thehospital.* Please delete accordinglyTo (Name of Doctor & Hospital/Clinic) Date :Dear SirName of Patient :NRIC No:Re : Application for Medical ReportI hereby authorise you to furnish * THE GREAT EASTERN LIFE ASSURANCE COMPANY LIMITED/ THE OVERSEAS ASSURANCECORPORATION LIMITED with a detailed medical report on the above named patient. This report is required for an insurance claim. I confirmthat a photocopy of the signed original Clinical Abstract Application form is as valid and effective as the original Clinical Abstract Applicationform.Yours faithfully[ ][ ]Signature of *Patient / Patient’s Parent /Patient’s Spouse / Next-Of-Kin[ ][ ]Signature of witnessName : Name :NRIC No : NRIC No :Address : Address :The Great Eastern Life Assurance Company Limited (Reg. No. 1908 00011G)The Overseas Assurance Corporation Limited (Reg. No. 1920 00003W)Claims Department1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: 1800-248 2888 Fax: 6532 4406Email: Claims@lifeisgreat.com.sg Website: www.lifeisgreat.com.sg

LIVING ASSURANCE / EPCC CLAIMCLAIMANT’S STATEMENTImportant Note: (1) The Great Eastern Life Assurance Company Limited And/ Or The Overseas Assurance Corporation Limited hereby referred toas “The Company”.(2) To be completed by the Policyholder.* Please delete where appropriate1 POLICY (IES) ISSUED BY THIS COMPANYGreat Eastern Life Policy No(s).:Overseas Assurance Corporation Policy No(s).:2 DETAILS OF POLICYHOLDERTitle:Name(According toNRIC/ Passport):Mr/ Mrs/ Madam/ Ms/ Miss/ DrResidentialAddress:Postal Code:NRIC No:E-mail Address:Occupation:Home Tel:Office Tel:HP/ Pgr No:Claims Acknowledgement Update via SMS : YES/ NO* (Kindly note that this SMS facility is available for Great Eastern Life policies only).3 DETAILS OF LIFE ASSURED (if different from (2))Title:Name(According toNRIC/ Passport):Mr/ Mrs/ Madam/ Ms/ Miss/ DrResidentialAddress:Postal Code:NRIC No:Occupation:E-mail Address:Home Tel:Office Tel:HP/ Pgr No:4 NATURE OF CLAIM AND RELATED DETAILS(a)Describe fully the symptoms for which the Life Assured consulted a doctor.DateSignature of PolicyholderThe Great Eastern Life Assurance Company Limited (Reg. No. 1908 00011G)Claims Department1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: 1800-248 2888 Fax: 6532 4406Email: Claims@lifeisgreat.com.sg Website: www.lifeisgreat.com.sgCLMLAPCLA/V1/20091/3

(b)How long did the Life Assured have the symptoms before he/ she consulted a doctor?(c)Date when the Life Assured FIRST consulted a doctor:Day Month Year(d)Name and address of the doctor whom the Life Assured first consulted for the illness or injury:(e)If consultation was for illness, describe fully the extent and nature of the Life Assured’s illness.(f)If consultation was due to an accident, describe fully the nature of the Life Assured’s injuries and how it happened.(g) Has the Life Assured previously suffered from or received treatment for a similar or related illness? YES / NO*If “YES”, please give full details.(h) Does the Life Assured suffer from any other medical condition? YES / NO*If “YES”, please give details:Description of Medical ConditionDate(s) Diagnosed(DD/MM/YY)Name and Address of Attending Doctor(s)5 RECORD OF MEDICAL CONSULTATIONS(a)Provide the details of any doctors who have been consulted in connection with the Life Assured’s illness:Name(s)Name(s) of Clinic(s)/ Hospital(s) and AddressDate(s) of First ConsultationDateSignature of PolicyholderClaims Department1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: 1800-248 2888 Fax: 6532 4406Email: Claims@lifeisgreat.com.sg Website: www.lifeisgreat.com.sgCLMLAPCLA/V1/20092/3

(b)Provide the name(s) and address(es) of the Life Assured’s regular doctor(s).Date(s) of ConsultationName(s) Address(es)(DD/MM/YY)Reason(s) for Consultation6 GENERAL(a) Has any of the Life Assured’s blood relatives suffered from a similar or related illness? YES / NO*If “YES”, please state.Relationship of RelativeName of IllnessDate Illness First Diagnosed7 OTHER INSURANCEIs the Life Assured claiming from any other insurance company or other sources in respect of this illness/ injury?If “YES”, provide the following information.YES / NO*Name of InsurerDate of Issue Sum Type of Plan Claim Claim ClaimAssuredAmount Notified Paid(YES/ NO) (YES/ NO)DECLARATIONI declare that the answers given by me in this Form are in every respect true and correct and that no material information has beenwithheld nor any relevant circumstances omitted. I agree to the Company seeking information in connection with this claim from anysource and I authorise the giving of such information. A photocopy of this authorisation is as valid as the original.Signature of PolicyholderName:NRIC/ Passport No:Date:Claims Department1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: 1800-248 2888 Fax: 6532 4406Email: Claims@lifeisgreat.com.sg Website: www.lifeisgreat.com.sgCLMLAPCLA/V1/20093/3

LIVING ASSURANCE / EPCC CLAIMDOCTOR’S STATEMENTImportant Note:* Please delete where appropriateThe below named is insured with The Great Eastern Life Assurance Co Ltd And / Or The Overseas Assurance Corporation Limitedagainst the happening of certain contingent events associated with his / her health. A claim has been submitted in connection withCHRONIC LUNG DISEASE / END STAGE LUNG DISEASE / SEVERE ASTHMA. To enable us to assess the claim, we would beobliged if you would complete this Doctor’s Statement. The fees for the completion of this form shall be paid by the claimant.Name of Life Assured:NRIC / Passport No.:1. Are you the Life Assured’s usual medical doctor? YES / NO*If “YES”, since what date?Day Month Year2. (a) Date when Life Assured first consulted you for End Stage Lung Failure/Severe Asthma/Lung Condition:(Please circle the appropriate condition)Day Month Year(b)Please state symptoms presented and date symptoms first appeared.Symptoms Presented at First ConsultationDate Symptoms First Started(D/M/Y)What is the source of this information?Patient / Referring Doctor / Others*If “Others”, please specify:(c)Please provide full and exact diagnosis of the Life Assured’s condition.(d)Date when illness/condition was FIRST diagnosed:Day Month Year(e)Diagnosis was first made by (name of doctor):(f)Date when Life Assured first became aware of the illness/condition:Day Month YearDateSignature of DoctorThe Great Eastern Life Assurance Company Limited (Reg. No. 1908 00011G)Claims Department1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: 1800-248 2888 Fax: 6532 4406Email: Claims@lifeisgreat.com.sg Website: www.lifeisgreat.com.sgCLMLAPDOCLD/V1/20091/5

3. (a) Has the Life Assured’s lung disease reach end-stage? YES / NO*If “YES”, please provide the date when End Stage Lung Disease was FIRST diagnosed:Day Month Year(b)Please provide details of all investigations carried out, particularly pulmonary function tests including dates and results. (Pleaseinclude current FEV 1 and vital capacity readings.)(c) Does the Life Assured require extensive and permanent oxygen therapy for hypoxemia? YES / NO*If “YES”, please provide the start date:Day Month Year(d) Is there dyspnea at rest? YES / NO*(e) Is Life Assured’s PaO2 < 55 mmHG? YES / NO*If “YES”, please provide full details of all arterial blood gas analysis results.This section is applicable to severe asthma condition only.4. (a) Is there evidence of acute attack of severe asthma with persistent status asthmaticus? YES / NO*If “YES”, please provide details.(b)Was the Life Assured hospitalised and required assisted ventilation with a mechanical ventilator for a continuous period of at least4 hours? YES / NO*If “YES”, please explain.DateSignature of DoctorClaims Department1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: 1800-248 2888 Fax: 6532 4406Email: Claims@lifeisgreat.com.sg Website: www.lifeisgreat.com.sgCLMLAPDOCLD/V1/20092/5

This section is applicable to pulmonary emboli condition only.5. (a) Date when Life Assured first consulted you for pulmonary emboli:Day Month Year(b)Date of any subsequent pulmonary embolism. Please provide dates of every recurrence.Date Medical Condition Treatment Provided Patient’s ResponseName and Addressof the doctor(c) Is there surgical insertion of vena-cava filter? YES / NO*If “YES”, please state the following:(i)Date of surgery:Day Month Year(ii) Was the surgery absolutely necessary? YES / NO*(iii) Is there other alternate treatment which could also treat the Life Assured’s condition? YES / NO*If “YES”, please state the type of treatment.This section is applicable to pneumonectomy or complete surgical removal of a lung condition only.6. (a) Date of surgery:Day Month Year(b)Reason(s) for requiring this surgery.(c) Was the surgery absolutely necessary? Please attach a copy of surgery and histology report. YES / NO*DateSignature of DoctorClaims Department1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: 1800-248 2888 Fax: 6532 4406Email: Claims@lifeisgreat.com.sg Website: www.lifeisgreat.com.sgCLMLAPDOCLD/V1/20093/5

7. (a) Has the Life Assured previously suffered from any illness related to the lung disease? YES / NO*If “YES”, please give dates of consultations, the diagnosis, the name and address of the doctor who made the diagnosis andsource of information.(b) Is there anything in the Life Assured’s family history which would have increased the risk of lung disease? YES / NO*If “YES”, please give full details including the relationship, nature of illness, date of diagnosis and source of information.(c)Please give details of the Life Assured’s habits in relation to cigarette smoking, including the duration of smoking habits, numberof cigarettes smoked per day and source of information.(d) Is the Life Assured suffering or has suffered from any other significant illnesses? YES / NO*If “YES”, please state illness, date of first diagnosis and name and address of attending doctor.8. (a) Did the Life Assured consult any other doctor for illness or its symptoms BEFORE he/she consulted you? YES / NO*If “YES”, please give name(s) and address(es) of the doctor(s) whom he / she consulted.Name of DoctorName of Clinic / Hospital and AddressDateSignature of DoctorClaims Department1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: 1800-248 2888 Fax: 6532 4406Email: Claims@lifeisgreat.com.sg Website: www.lifeisgreat.com.sgCLMLAPDOCLD/V1/20094/5

(b)Please provide the names and addresses of any hospital or clinic to which the Life Assured was referred, together with the namesof the consultants attended.9. Please state and attach copies of all relevant hospital reports, laboratory and test results.10. Please provide us with any other additional information that will enable the Company to assess this claim.DateSignature & Official Stamp of DoctorClaims Department1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: 1800-248 2888 Fax: 6532 4406Email: Claims@lifeisgreat.com.sg Website: www.lifeisgreat.com.sgCLMLAPDOCLD/V1/20095/5