Medical/Hospital cash claim submission

Claimant details

Policy no. *

Name of claimant *

Name of life insured *

HKID of life insured *

Mobile no. *

Email *

I/We agree this email address will be updated and used as the communication email for ALL my life policies.

Details of hospitalization

Confinement/Clinical surgery period

Admission/clinical surgery date *

Discharge date

Symptom *

First symptom date *

Diagnosis *

Claim amount (HKD) *

Was this hospitalization caused by accident? * Yes No

Accident date *

Accident particulars *

Injured body part *

Required document(s)

Required document(s) for hospitalization claim Attending physician statement (Hospitalization) download

Notes

1. For claimed amount below HKD 20,000, the original receipt is only required upon request by our claims handler.

2. We may request for additional document(s).

3. If the original document(s) is/are required, please post to Life Claims Department, 26/F, One Island East, 18 Westlands Road, Island East, Hong Kong.

Claim payment

Bank account no.

Joint bank account is not applicable (Bank proof is required)

Bank no. *

Branch no. *

Account no. *

Name of bank account holder *

Notes

1. The claim payment shall be credited to the bank account in the name of the policyholder or life insured in accordance with the terms of your policy. To prevent any unnecessary delay, please make sure the bank account number and account holder name are correct.

2. The claim payment is remitted to a third party as a result of your provision of incorrect bank account number and/or account holder name, we shall not be liable to make any further payment regardless of whether the claim payment can be recovered.

Other insurance information

Are you insured, claiming or intend to claim similar benefit for this event from other insurance company(ies) or organization(s) (including employee compensation and group medical scheme)? * Yes No

If ‘Yes’, please provide the following information. If the claim is settled, please provide the detailed breakdown and receipts.

Policy no. *

Name of company/organization *

Type of insurance *

Please list the remaining claims with their policy no., name of insurance company/organization and type of insurance (e.g. P1234, company A, medical expenses).

Remark and enquiry from claimant

Declaration and authorization

I/We agree to Notice to customer relating to personal data(Privacy) Ordinance, Declaration for data protection, Authorization, Levy of Premium.

Yes *

Document(s) upload

Please upload the documents in pdf, png or jpg file format.