life woman enhanced benefits claim form - Great Eastern Life

LIFE WOMAN ENHANCED BENEFITS CLAIMDOCTOR’S STATEMENTImportant Note:The below named is insured with The Overseas Assurance Corporation Limited against the happening of certain contingent eventsassociated with his / her health. A claim has been submitted and to enable us to assess the claim, we would be obliged if you wouldcomplete this doctor ’s statement. The fees for the completion of this form shall be paid by the claimant* Please delete where appropriateName of Life Assured:NRIC / Passport No.:1. When were you first consulted for this illness, and in your opinion, how long had the symptoms been present?2. What were the symptoms that the Life Assured complained and for how long had she been experiencing these symptoms?3. Is the condition for which the Life Assured is being treated in any way connected to the following?(Please tick appropriate box)Carcinoma in situ of the breastCarcinoma in situ of the cervix uteriSLE with lupus nephritisHysterectomy required as a result of cancerEctopic PregnancyDown’s syndromeSpina bifidaTetralogy of FallotTransposition of the Great VesselsDisseminated Intravascular coagulationReconstructive surgery of facial disfigurement due to accident or assaultNote:i. In the case of female cancer, carcinoma in situ or systemic lupus erythematosus, please describe in full detail and pleaseinclude evidence which led to the diagnosis being made (e.g. histopathological reports)ii.Should the claim involve a congenital anomaly, please attach supporting evidence regarding diagnosis of such (e.g. X-rays,echocardiogram)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.sg1