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CUEPACS ETIQA MUTIARA PLUS

Level 3 Bangunan PSM no 17B Jalan Bangsar 59200 Kuala Lumpur Tel : 0322836364/6361 Faks : 0322836272 H/p : 017-6340518

Pastikan document disahkan benar lengkap mengikut arahan sebelum dihantar agar tidak

berlaku penolakan.

PERKARA: BORANG PENYAKIT KRITIKAL

NOTA : Nama Penuh Peserta merujuk kepada PESAKIT

Sijil penyertaan TKM 0679 / TTMW4. Jika tiada tetapi menjadi ahli melebihi 60 hari

peserta layak membuat tuntutan. Sila lampirkan surat pengakuan jika tiada sijil.

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Dokumen yang perlu dilampirkan:

Sila sertakan dokumen-dokumen berikut bersama dengan tuntutan ini (Salinan Disahkan) :

TYPES OF CLAIMS DOCUMENTS REQUIRED

Critical Illness

1) Borang tuntutan Penyakit Kritikal 2) Salinan Kad Pengenalan yang disahkan 3) Laporan perubatan – Penyakit Kritikal (Strok /

Jantung / ESRF / Kanser / Lain-lain) yang dilengkapi oleh doktor

4) Sijil Asal / Salinan Sijil Penyertaan 5) Borang kebenaran untuk maklumat lanjut 6) Lain-lain dokumen yang berkenaan.

( Sila rujuk senarai dokumen sokongan bagi tuntutan penyakit kritikal yang berkenaan)

Jika dokumen sokongan diberikan dalam salinan, dokumen tersebut mestilah disahkan oleh

mereka yang dibenarkan oleh Syarikat, Pesuruhjaya Sumpah, ‘Notary Public’, Peguam, Jaksa

Pendamai, Ahli Parlimen, Ketua Balai Polis, Penghulu atau Pegawai Daerah.

**PERMOHONAN HENDAKLAH DIPOSKAN MENGIKUT ALAMAT KAMI DI BANGSAR DAN

PERMOHONAN INI TIDAK BOLEH DIFAKSKAN KEPADA KAMI**

CRITICAL ILLNESS CLAIM FORM (GROUP CLAIM)

SECTION A

Contract No :________________________________________

Broker/Account Manager's name: Broker/ Account Manager's Contact No. :

Instruction – Supporting documents required

Critical Illness claim form

Certified copy of Participant and/or Claimant's IC

Critical Illness - Statement of Medical Examiner (Stroke / Heart / End Stage Renal failure / Cancer / Others)

Relevant diagnostic test results or report to support the diagnosis (Please refer page 4-5)

Original certificate

Other supporting document (if applicable)

Name of Participant

New IC No Old IC No. Age

Correspondence Address

Mobile Phone No. E-mail address

Phone No. Fax No.

Name of the Employer

Address of the Employer

Office Phone No.

Date of Employment (dd/mm/yyyy)

1 Describe fully the symptoms for which you consulted a medical practitioner.

2 Date symptoms first commenced (dd/mm/yyyy)

3 Date you first consulted doctor for this condition (dd/mm/yyyy)

4 Name & address of doctor you first consulted for this condition

5 What was the diagnosis?

6 What treatment are you currently receiving?

7 Have you previously sufferred from, or received treatment for a similar or related illness? Yes No

If yes, please give full details

8 State the name and address of your regular doctor

Page 1 of 5

Every question must be fully answered. The Company reserves the right to require further information should it deem necessary. Submission of this

Claim Form does not guarantee admission of liability.

9 Please give details of any other doctors you have consulted in connection with this or other conditions.

10 Are there other policies in force on your life taken with other companies ? Yes No

If yes, please give details:

11 Please state bank account details in order for us to credit the payment directly into Claimant's bank account.

Bank : Bank Branch :

Bank Account Holder Name : Bank Account no.:

Company Registration no : (Eg:266243D)

If the above bank account is a joint account, please provide below details:

Second account holder name : ________________________________ Second account holder NRIC : ___________________

The Payment which has been made based on the account details provided by you will be deemed as full payment and we shall be

discharged from any existing and future claim and demand in relation to it.

DECLARATION

Signature / Thumb print of Participant Signature / Thumb print of Claimant (if other than Participant)

Name Date

Date (dd/mm/yyyy) Full name

Contact No

Designation & Official stamp is required for Company or Bank:

Signature of Witness Authorised Signature of Contract Holder & Company's Stamp

Date Full name

Full Name Designation:

NRIC No Contact No

Contact No Date

Date of consultation

(dd/mm/yyyy)Date of admission

(dd/mm/yyyy)

Sum assuredName of Company(s)

Date of discharge

(dd/mm/yyyy)

Policy no Type of coverageCommencement date

(dd/mm/yyyy)

Diagnosis Name of doctor & address of hospitals/clinics

I hereby declare that the foregoing answers and statements on the Participant are complete and true to the best of my knowledge and belief,

and that I have withheld no material facts from the Etiqa Family Takaful Berhad.

And I hereby authorize any medical practitioner, surgeon person, hospital, clinic and any other institution or organization to furnish to Etiqa

Family Takaful Berhad or its representative any information that maybe required concerning my health conditions, for settlement of this claim. I

agree that Etiqa Family Takaful Berhad or its representative may use or disclose any of the information collected or held to third parties such

as reinsurers, medical examiner or medical consultant, claims investigator and etc. within or outside Malaysia for the purpose of processing

the claim. I agree that a photocopy of this authorization shall be considered as effective and valid as original.

of 5

LETTER OF AUTHORISATION / CONSENT

TO OBTAIN FURTHER INFORMATION (MAKLUMAT PERUBATAN)

To Whom It May Concern,

Contract No

Dear Sir / Madam,

This authorisation / consent is irrevocable and a copy of it will have the same effect and validity as the original.

Signature / Thumb print of Participant Signature of Contract holder (If Participant is a minor)

Name Name

NRIC NRIC

Old IC Old IC

Birth Cert No. (if minor) Tel No

Tel No. Date (dd/mm/yyyy)

Date (dd/mm/yyyy)

Page 3 of 5

I expressly waived all provisions of law or professional ethics forbidding the Information Provider(s) from disclosing any such information

acquired on myself in a professional and/or client capacity and I further release the Information Provider(s) and its agent/staff from any liability

whatsoever that may rise, in supplying such information requested by the Etiqa Family Takaful Berhad.

I hereby authorise and give my consent to any medical practitioner, physician, surgeon, clinic, hospital, medical centre, Insurance company or

other organisation, institution or individual concerned ("the Information Provider(s)") that may have any records or knowledge of employment,

financial, health or medical history of myself ("the Participant') and to provide such information to Etiqa Family Takaful Berhad or its authorised

agents and/or employees.

Additional Requirements For Critical Illness Claim

Critical Illness Additional Required Medical Evidence

Stroke

Heart Attack

End Stage Kidney Failure

Cancer

Coronary Artery By-Pass Surgery

End Stage Liver Failure

Fulminant Viral Hepatitis

Coma

Benign Brain Tumour

Paralysis / Paraplegia

Blindness / Total Loss of Sight

Deafness / Total Loss of Hearing

Major Burns 1. Total Body Surface Assessment report

End Stage Lung Disease

Encephalitis

Major Organ / Bone Marrow Transplant

Loss of Speech

2. Doctor’s Statement to be completed by speech pathologist / therapist

Brain Surgery

Heart Valve Surgery

Page 4 of 5

Angioplasty and Other Invasive Treatments for

Major Coronary Artery Disease

1. Brain Surgery report

1. Heart Valve Surgery report

2. FEV 1 test

1. Medical evidence from ENT specialist to confirm illness or injury to vocal cords

1. Coronary Angiogram report

3. Relevant medical reports

1. CT Scan / MRI of Brain

2. Doctor’s Statement to be completed by Consultant Neurologist

1. Surgery report

2. Surgery report

1. Visual Acuity report on both eyes to be done by an ophthalmologist

2. Doctor’s Statement to be completed by an Ophthalmologist

1. Audiometry test and Sound Threshold test results

1. Pulmonary Function test

1. X-ray / CT Scan / MRI report, if available


2. CT Scan of Liver

3. All laboratory, pathology, hepatitis screening, ultrasound & histology report

1. CT Scan report of Liver

2. Liver Function Test results

3. Any other laboratory or pathology reports

1. Medical receipt for the usage of life support (Oxygen)


1. CT Scan / MRI of Brain report

2. Histopathology/biopsy report

3. Doctor’s Statement to be completed by Consultant Nephrologist

1. Histopathology/biopsy report (where applicable)

2. Bone Marrow Aspiration report (leukemia)

3. CT Scan / MRI report (where applicable)

1. Coronary Artery By-Pass Surgery Report

1. Liver Function Test

2. Blood test results

2. Electrocardiography report (ECG)

3. Tropinin T result, if any

4. Doctor’s Statement to be completed by Consultant Cardiologist

current condition at least 6 months after the stroke)

1. CT Scan / MRI of Brain report

1. Dialysis appointment card / receipts

1. Cardiac Enzymes Assay results (CK-MB)

2. Doctor’s Statement to be completed by Consultant Neurologist (for

Critical Illness Additional Required Medical Evidence

Bacterial Meningitis

Major Head Trauma

Other Serious Coronary Artery Disease

Chronic Aplastic Anaemia

Parkinson’s Disease 1. Detailed medical assessment including Activities of Daily Living

from Consultant Neurologist

Surgery to Aorta

Multiple Sclerosis

Medullary Cystic Disease

SLE with Lupus Nephritis

Primary Pulmonary Arterial Hypertension

1. HIV antibody test by ELISA method within 7 days of the event/accident

2. HIV antibody test by ELISA method 6 months from date of blood transfusion

4. Western Blot test

Page 5 of 5

Alzheimer’s Disease / Irreversible Organic

Degenerative Brain Disorders

1. Diagnostic test results

2. Renal biopsy report

3. Urine Specific Gravity Test

4. Blood test result

5. All clinical and laboratory investigation report

1. Chest X-ray

2. Echocardiogram report

Severe Cardiomyopathy

1. All clinical and laboratory investigation including cardiac catheterization

1. All relevant investigation result in support of the diagnosis

1. Abdominal Ultrasound or Abdominal CT Scan

Terminal Illness

Motor Neuron Disease

Muscular Dystrophy

2. CT Scan & MRI report of Brain & Spine

2. Blood test report

1. All investigation reports

2. CT Scan / MRI of Brain

1. Bone Marrow Aspiration

1. Detailed medical assessment from attending doctor

1. Coronary Angiogram report

3. Kidney biopsy report

2. Blood test results

1. Diagnostic test result



1. Aorta Surgery report

1. Ophthalmologist’s report

1. Urine test results

3. Police report, if any

1. CT Scan / MRI of Brain & Spine

Occupationally Acquired Human

Immunodeficiency Virus (HIV) Infection

3. Statement from statutory Health Authority to confirm that the disease was

occupationally acquired

CRITICAL ILLNESS (HEART) – STATEMENT OF MEDICAL EXAMINER (GROUP CLAIM)

1. The following named is covered with ETIQA LIFE INSURANCE BERHAD against the happening of certain contingents events

associated with his/her health. A claim has been submitted in connection with HEART and to enable us to assess the claim, we

would be obliged if you would complete this Statement of Medical Examiner

2. Any fees chargeable for the completion of this form shall be borne by the claimant.

CONTRACT/ POLICY NO. ………………………………………………………………………….

Name of Participant: ..……………………………………………………………………………………………….…………………………………..

NRIC/Birth Cert No/Passport No: ………………………………………………………………………………………………………………………

1. Are you the Participant’s usual doctor? Yes No

If yes, since when:……………………………………………………………………………………….(dd/mm/yyyy)

2. (a) What were the symptoms first presented? ……………………………………………………………………..………………………

(b) How long had the symptoms been present?.................................................................................................................................

3. Please state the exact diagnosis:…………………………………………………………………………………………………………………

4. When this illness was first diagnosed?……………………………………………………………….(dd/mm/yyyy)

5. When was the Participant first informed of the diagnosis? ………………………………………(dd/mm/yyyy)

6. Has the Participant suffered from this illness or any related illnesses previously? Yes No

If yes, please give details

7. Please state if there is anything in the Participant’s family history which would have increased the risk of this illness.

………………………………………………………………………………………………………………………………………………………..

8. (a)

(b)

Was there a history of typical prolonged chest pain? Yes No

Date of the first onset of episode ……………………………….. (dd/mm/yyyy)

(c)

(d)

(e)

Were there any changes in the ECG indicative of a myocardial infarction?

Was there a serial elevation of cardiac enzyme (CPK-MB) above normal limit?


Yes Yes

No

No

Date of Cardiac Enzyme taken (dd/mm/yyyy)

Cardiac Enzyme/ Biomaker reading

Reading of normal cardiac enzyme

(f) Was coronary arteriography performed? ☐ Yes ☐ No

(g) If Yes, please give details of the results

LOCATION PERCENTAGE OF NARROWING

Left Main Stem (LMS)

Left Anterior Descending (LAD)

Right Coronary Artery (RCA)

Left Circumflex Artery (LCX)

Right Circumflex Artery (RCX)

Page 1 of 2

Dates of consultation(dd/mm/yyyy) Diagnosis Treatment given

(f) i. Was coronary bypass surgery performed? Yes No

ii. Date of surgery performed. ……………………………….(dd/mm/yyyy)

iii. Please state the number and sites of grafts inserted. …………………………………………………………………………...

(g) i. Was angioplasty (PTCA) performed? Yes No

ii. Date angioplasty performed. ………………..…………….(dd/mm/yyyy)

iii. Please state the artery involved: …………………………………………………………………………………………………..

(I) i. Was heart valve surgery performed? Yes No

ii. Date of surgery performed…………………………………(dd/mm/yyyy)

iii. Please state the valve involved……………………………………………………………………………………………………..

(j) i. Was aorta surgery performed? Yes No

ii. Date of surgery performed…………………………………(dd/mm/yyyy)

iii. Please state the aorta involved……………………………………………………………………………………………………..

9. Has the Participant suffered from/has been treated for any other illnesses related to / cause for this Critical Illness? Yes No

If yes, please give full details (diagnosis & date) ………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………..

10. Did the Participant consult other doctors for this illness or its symptoms before he/she consulted you? Yes No


Date of Consultation (dd/mm/yyyy)

Name and Address of

Hospital / Clinic

Diagnosis / Illness

11. Is there anything in the family history which would have increased the risk of hypertension/diabetes/other vascular/disease/

relevant heart disorders, etc. Yes No If yes, please provide details

……………………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………………….

12. Any further information which in your opinion will assist us in assessing the claim?

………………………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………..

Please furnish copies of all investigation reports including Cardiac Enzyme Assay results (CK-MB), ECG, Troponin T, Coronary Artery Bypass surgery report, Coronary Angiogram report, PTCA report, heart valve surgery report, aorta surgery report and any relevant medical reports that are available.

DECLARATION

I hereby declare that the foregoing answers and statements are complete and true to the best of my knowledge and belief.

……………………………………………………………… ……………………………………….……………………. Signature of Consultant Cardiologist Clinic / Hospital Stamp:

…………………………………………………………….... Date: …………….………….…………………………… Name of Consultant Cardiologist

Professional Qualification: …………………………..….. Telephone Number……..………………………………

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