permanent disablement form for celcom personal accident ... - MAA

MAA Takaful Berhad, Menara MAA, 15th Floor, 12, Jalan Dewan Bahasa, 50460 Kuala Lumpur.Tel: 03-2146 8000 Fax: 03-21430033 Call Centre: 1-300-88-MAA/622, 2146 9999PERMANENT DISABLEMENT FORM FOR CELCOM PERSONAL ACCIDENT CLAIMSAny costs incurred for the completion of this form is at the expense of the Participant.Participants Name _____________________________________________________________________________Patients Name ________________________________________________________________________________Certificate No_______________________NRIC No ________________________ Date of Birth_________________Describe occupation at time disability commenced _____________________________________________________MEDICAL PRACTITIONER’S STATEMENT TO TAKAFUL OPERATOR1. State briefly the nature and severity of the injuries.__________________________________________________________________________________________________________________________________________________________________________________________2(a). Has the patient been totally disabled and continuously prevented from performing any work or engaging in anyoccupation or profession for wages, compensation or profit?_____________________________________________________________________________________________(b) If so, on what date did such disability begin? _____________________________________________(dd/mm/yy).(c ) Is the patient still disabled? Yes / No3. State briefly the disability suffered_____________________________________________________________________________________________4. Treatments rendered by you since _______________________________________________________________5. Is the patient at present wheelchair bound / using any walking aid to move around? ________________________6.(a) Does the disability render the patient permanently disabled without any hope whatsoever of recovery to thatdisability? Yes / No(b) If yes, please refer to the Table of Compensation overleaf and indicate the percentage of permanentdisablement applicable ___________________ (%)7. In your opinion, could the patient without injury to his health, resume any work or will ever be capable of doingany work, occupation or profession? If so, on what date will the patient be able to resume such work? (dd/mm/yy)_____________________________________________________________________________________________8. Please give additional information including X-rays, neurological examinations in detail (muscle power tone andreflexes of the affected side at present if applicable) etc. that will enable the Company to determine the merits ofthis claim._____________________________________________________________________________________________I certify that the answers to the above questions are truthful and just to the best of my professional knowledge andjudgment.Signature of Examiner _______________________ Name of Examiner ___________________________Hospital/Clinic Official Stamp ________________________Date ______________________________________CF-GCS-012

Kematian atau Hilang Upaya KekalDeath and Permanent DisablementKehilangan jari hantu - tiga (3) ruas--------------------------------------Loss of middle finger three (3) phalanges- dua (2) ruas---------------------------------------two (2) phalanges- satu (1) ruas--------------------------------------one (1) phalanxKehilangan jari manis - tiga (3) ruas----------------------------------------Loss of ring finger three (3) phalanges- dua (2) ruas----------------------------------------two (2) phalanges- satu (1) ruas--------------------------------------one (1) phalanxKehilangan jari kelingking - tiga (3) ruas-----------------------------------Loss of little finger three (3) phalanges- dua (2) ruas------------------------------------two (2) phalanges- satu (1) ruas-----------------------------------one (1) phalanxKehilangan metacarpus - pertama atau kedua (tambahan)------------Loss of metacarpals first or second (additional)- ketiga, keempat atau kelima (tambahan)-third, fourth or fifth (additional)Kehilangan ibu jari - semua ruas ---------------------------------------Loss of toesall phalanges- dua (2) ibu jari kedua-dua ruas-------------two (2) great, both phalanges- ibu jari, satu (1) ruas----------------------------great one (1) phalanx- selain ibu jari, jika lebih dari satu (1) jari,setiap satu-----------------------------------------other than great, if more than one (1) toelost, eachKehilangan pendengaran - kedua-dua belah telinga--------------------Loss of hearingboth ears- satu (1) telinga---------------------------------one (1) earKehilangan upaya tutur----------------------------------------------------------Loss of speechJumlah PerlindunganSum Covered--------------- ------------------------------------------------------------------6%--------------- -----------------------------------------------------------------4%--------------- ------------------------------------------------------------------2%--------------- ------------------------------------------------------------------5%--------------- ------------------------------------------------------------------4%--------------- ------------------------------------------------------------------2%--------------- ------------------------------------------------------------------4%--------------- ------------------------------------------------------------------3%--------------- ------------------------------------------------------------------2%--------------- ------------------------------------------------------------------3%--------------- ------------------------------------------------------------------2%--------------- ------------------------------------------------------------------15%--------------- -------------------------------------------------------------------5%--------------- -------------------------------------------------------------------2%--------------- -------------------------------------------------------------------1%--------------- ------------------------------------------------------------------75%--------------- ------------------------------------------------------------------15%--------------- ------------------------------------------------------------------50%CF-GCS-012