HOSPITALISATION CLAIM FORM - Great Eastern

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

HOSPITALISATION CLAIMCLAIMANT’S STATEMENTImportant Note:* Please delete where appropriate(1) The Great Eastern Life Assurance Company Limited And/ Or The Overseas Assurance Corporation Limited hereby referred toas “The Company”.(2) The Company does not admit liability by the mere issue of this or any other form.(3) The Doctor’s Statement must be furnished (at the expense of the Policyholder) if the claim amount exceeds S$2,000 or thedeductible amount for SupremeHealth/ MaxHealth Claim/ Premier Health Plan (with deductible).(4) To be completed by the Policyholder.1 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:NRIC No:E-mail Address:Postal Code:Residential Status at the point of treatment: Singaporean / Singapore PR / Foreigners*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 DIRECT CREDITING OF CLAIMS (Excludes OAC Claims)Name of Bank Branch of Bank Bank Account Number Account Holder’s nameImportant Notes: -Direct Crediting will only be applicable for claims (excluding reimbursement to CPF Board) up to S$10,000 to a local bank account. Claimamounts will only be direct credited to the Policyholder’s bank account. A cheque will be issued if claim is above S$10,000.The Company will continue to credit all further claim benefits payable for the same event to the above bank account, unless otherwisenotified by the Policyholder.4 DETAILS OF LIFE ASSURED (if different from (2))Title:Mr/ Mrs/ Madam/ Ms/ Miss/ DrName(According toNRIC/ Passport):ResidentialAddress:Postal Code:NRIC No:E-mail Address:Residential Status at the point of treatment: Singaporean / Singapore PR / Foreigners*Home Tel: Office Tel: HP/ Pgr No:DateSignature of PolicyholderThe 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.sgCLMHSPCLA/V2/20091/4

5 DETAILS OF LIFE ASSURED’S OCCUPATIONOccupation:Name of Employer:Address of Employer:Postal Code:Description of Duties:6 CONDITION (IF DUE TO ILLNESS OR INJURY)(a)Describe fully the symptoms for which the Life Assured consulted a doctor.(b)When did the Life Assured have the symptoms before he/ she consulted a doctor?Day Month Year(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)Describe fully the extent and nature of the illness or injury.(f)What is the hospital/ doctor’s diagnosis?(g) Was surgery performed for this condition? YES / NO*If “YES”, please specify.Nature of Surgical Operation(s)Date(s) Performed(D/M/Y)SurgicalTableDateSignature 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.sgCLMHSPCLA/V2/20092/4

7 ACCIDENT (IF APPLICABLE)Day Month Year(a) Date of Accident: (b) Time of Accident:(c)(d)Place of Accident:Detailed description of Accident:(e)Name(s) and telephone no(s) of witness(es):Name of WitnessTelephone No.8 HOSPITALISATION(a) How was the Life Assured admitted to the hospital? [ please tick ]Referral by a General Practitioner/ Specialist/ Other Hospital*Please provide the name and address of doctor/ hospital:A & E department9 DETAILS OF REGULAR DOCTOR(S)(a)Name(s) and address(es) of the Life Assured’s regular/ company doctor(s):Name(s)Address(es)Date(s) ofConsultationReason(s) for Consultation(b)(i) Does the Life Assured have the same medical condition previously or any other medical conditions not stated above?YES / NO*(ii) If “YES”, please state:Date of Onset:Day Month Year Day Month YearDate of Diagnosis:Medical condition:Medical treatment received:DateSignature 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.sgCLMHSPCLA/V2/20093/4

10 OTHER INSURANCEIs the Life Assured claiming for medical expenses from any other sources (e.g. employer, other medical insurances)?If “YES”, please provide the following information.YES / NO*Name of Employer, Insurance Company, etcDate of IssueType of PlanClaimAmountClaimNotified(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. By filling the details of my bank account in Section 3 above, I authorise the Companyto credit any claim proceeds of not more than S$10,000 into my designated bank account. A photocopy of this authorisation is as validas 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.sgCLMHSPCLA/V2/20094/4

HOSPITALISATION 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 and to enable us toassess the claim, we would be obliged if you would complete this Doctor’s Statement. The fees for the completion of this form shall bepaid by the claimant.Name of Life Assured:NRIC/ Passport No.:1. (a) Has the Life Assured consulted any other doctors/ hospitals prior to first consultation with you? YES / NO*If “YES”, please provide name and address of the doctor(s)/ hospital(s).(b) Are you the Life Assured’s usual medical doctor? YES / NO*If “YES”, since when?Day Month Year2. (a) Date of first consultation for the current condition:Day Month Year(b)(c)Date(s) of subsequent consultation:Please state symptoms presented and date symptoms first appeared.Symptoms Presented at First ConsultationDate Symptoms First Started(DD/MM/YY)What is the source of this information?Life Assured/ Referring Doctor/ Others*If “Others”, please specify the name of the person and relationship to the Life Assured:(d)Diagnosis:(e)Date of FIRST Diagnosis:Day Month Year(f)(g)Diagnosis was first made by (name of doctor):Date diagnosis was made known to the Life Assured:Day Month Year(h)What was the exact information conveyed to the Life Assured?DateSignature of DoctorThe 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.sgCLMHSPDOC/V1/20091/4

(i) Is the condition a result of an accident? YES / NO*(i)If “YES”, describe in detail how the accident happened.(ii)Date of accident:Day Month Year(iii) Was the Life Assured under the influence of alcohol/ drugs at the time of accident? YES / NO*If “YES”, please state the blood alcohol content/ drug type and quality consumed:(iv) Did the injuries result from a self-inflicted act? YES / NO*If “YES”, please give full description.(j)Type of treatment/ medication given and the response.(k)Please tick if the following were done/ will be done.Gamma Knife Radiotherapy Stereotactic Radiotherapy ErythropoietinChemotherapy Kidney dialysis Cyclosporin Immunotherapy(l) Is the current treatment related to the following conditions? YES / NO*If “YES”, please tick the box(es):Infertility Subfertility Abortion Birth control SterilisationImpotence test or treatmentPregnancy, childbirth, miscarriage or their sequelaeComplications of Pregnancy or childbirthAlcoholism Drug addiction Drug abuseRoutine eye examinationRefractive errors of the eyesDepression Mental disorder Functional disorderHereditary conditions Birth defects Congenital sickness or abnormalitiesObesity Weight reduction Weight improvementAIDS or any illness caused by or related to HIVSexually-transmitted diseaseDateSignature 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.sgCLMHSPDOC/V1/20092/4

If you have ticked any of the boxes, please give full details.(m) Is the Life Assured still on follow-up treatment?If “YES”, please specify the type of treatment/ medication.YES / NO*(n)How frequent does the Life Assured seek treatment since discharge from hospital?(o)What is the expected length of follow up?3. Please state the periods of hospitalisations.Name of HospitalPeriod(s) of HospitalisationPeriod(s) of Intensive CareFromToFromTo4. (a) Was surgery performed for this condition? YES / NO*If “YES”, please specify.Nature of Surgical Operation(s)Date(s) Performed(DD/MM/YY)SurgicalTable No.(b) Is further surgery likely to be required? YES / NO*If “YES”,Day Month Year(i) please specify the tentative date of surgery:(ii) please specify the type of surgery to be performed: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.sgCLMHSPDOC/V1/20093/4

(c) Is the surgery performed an elective cosmetic or plastic surgery? YES / NO*If “YES”, please provide details.5. (a) Has the Life Assured previously suffered from the same illness in respect of which he/ she is claiming now? YES / NO*If “YES”, please state:(i) Date when illness was first diagnosed:Day Month Year(ii)Name and address of the doctor who first treated him/ her.(iii) Has the Life Assured fully recovered from the previous illness before the current episode? YES / NO*(b) Has the Life Assured been admitted to any hospital before, either for the same or different cause? YES / NO*If “YES”, please state.Period(s) ofHospitalisationDiagnosisHospitalName(s) of Attending Doctor(s)(c) Is the Life Assured suffering or has suffered from any other significant illnesses? YES / NO*If “YES”, please state.Brief Description of Illness(es)Date(s) of FirstDiagnosis (DD/MM/YY)Name & Address of Attending Doctor6. 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.sgCLMHSPDOC/V1/20094/4