FEMALE CRITICAL ILLNESS CLAIM FORM

SECTION A
Every question must be fully answered. The company reserves the right to require further information should it deemed necessary.
Submission of this Claim From does not guarantee admission of liability.

Policy No: _______________________________________

Agent’s name & code: _____________________________ Agent’s contact no. : __________________

Please tick (√ ) the relevant benefit in the box below:

Female Illness Benefit
 Female cancer (breast, cervix uteri, fallopian tube, ovary,  Systemic Lupus Erythematosus (SLE) with Lupus Nephritis
uterus, vagina/vulva)
**This form is also applicable for Cancer Critical Illness Claim
(female cancer only)
 Female Carcinoma-in-situ (Carcinoma-in-situ of the breast,  Surgery of fibroid/ovarian cyst
cervix uteri, fallopian tubes, ovary, uterus, or vagina/vulva)

Recovery Benefit
 Osteoporotic fracture  Severe Rheumatoid Arthritis  Facial Reconstructive Surgery
 Skin grafting due to Burns  Skin Grafting due to Skin Cancer  Breast Lumpectomy/Mastectomy
 Breast reconstructive Surgery  Surgical Removal of Female Reproductive Organ

Other Benefit
 Limb Amputation  Severe Diabetic Nephropathy  Surgery for Type 2 Diabetic Retinopathy
 Joint replacement surgery for arthritis
Instruction – supporting documents required:
 Female Critical Illness Claim Form
 Certified true copy of Life Assured’s and Claimant’s IC
 Female Critical Illness – Statement of Medical Examiner
 Certified true copy of relevant diagnostic test results or report to support the diagnosis (please refer page 6)
 Other supporting documents (if applicable)
Additional requirements for claim under Other Benefit:
 Certified true copy of hospital bill / invoice

Name of Life Assured ____________________________________________________________________________________

New NRIC _______________________________________ Old IC No __________________________ Age _______________
Correspondence Address _________________________________________________________________________________
_________________________________________________________________________________
Mobile Phone No. ______________________ Email address _____________________________________________________
House Phone No. _________________________________________ Fax No. ______________________________________
Name of Employer _______________________________________________________________________________________
Address of Employer _____________________________________________________________________________________
_____________________________________________________________________________________
Office Phone No. _____________________________ Date of Employment: ______________________________ (dd/mm/yyyy)

Please state bank account details in order for us to credit the payment directly into Claimant’s bank account.
Account Bank _________________________ Branch ______________________ Account No. __________________________
Account Holder's Name __________________________________________________________________________________

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NRIC (as per bank account) _____________________________ Type of account : Individual Joint
Company Registration No. (If payment to company): ____________________________________________________________

1. Please fully describe the symptoms for which you consulted a medical practitioner.
______________________________________________________________________________________________
2. Please advise the date of first onset of the mentioned symptoms _______________________________ (dd/mm/yyyy)
3. Please advise the date you first consulted a doctor for this condition?___________________________ (dd/mm/yyyy)
4. Please provide the name & address of the doctor you first consulted for this condition.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
5. What was the diagnosis? __________________________________________________________________________
6. What treatment(s) are you currently receiving? _________________________________________________________
7. Have you previously suffered from, or received any treatment for a similar or related illness?
 Yes  No If yes, please give full details _______________________________________________________
8. Please provide the name and address of your regular treating doctor(s).
Normal ailments / common illness Related to the above illness
Doctor’s Name

Clinic / Hospital
Address

9. Please provide details of any previous consultations you had in connection with this or other conditions.
Date of Date of Date of Name of attending doctor
consultation admission discharge Diagnosis & address of hospital /
(dd/mm/yyyy) (dd/mm/yyyy) (dd/mm/yyyy) clinic

10. Are there any other policies in force on your life taken with other companies?  Yes  No
If yes, please provide details:
Name of Commencement
Policy No. Type of coverage Sum assured
Company(s) date (dd/mm/yyyy)

11. Goods and Service Tax (GST) Registration Details of Policy Owner
a) Name of Policy Owner ________________________________________________________________________
b) New NRIC _________________________________ Old IC No. ______________________________________
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 c) Mobile Phone No. _________________________ Office Phone No. __________________________________
House Phone No. __________________________ Fax No. _________________________________________
Email address ______________________________________________________________________________

d) Policy Owner was GST registered during inception / commencement of the insurance benefit(s) currently
claiming?  Yes  No
If yes please complete the following details:
GST Registration No. :________________________________________________________________________
Business Registration No. (If GST registered under Company): ________________________________________
GST Taxpayer Name: ________________________________________________________________________
Purpose of this insurance benefit:  Business related  Non-business related
GST Registration Date: _____________________ GST De-Registered Date: ____________________________

Note: Etiqa Life Insurance Berhad will rely on the above information provided by you for tax credit purposes provided under the
Goods and Services Tax Act 2014. Etiqa Life Insurance Berhad shall not be liable for any liability, charge or penalty as a result of
relying the incorrect information. Should any action be taken against Etiqa Life Insurance Berhad and/or penalties be imposed on
Etiqa Life Insurance Berhad by any tax authority for relying the same. Etiqa Life Insurance Berhad reserves its right to be
indemnified by you to the fullest extent permitted by law any liability arising from your incorrect advise shall be payable by you.

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CLAIMANT’S DECLARATION & AUTHORISATION

I hereby declare that the foregoing answers and statements in this claim form are complete and true to the best of my knowledge and
belief, and that I have withheld no material facts from the Company.

And I hereby authorize any medical practitioner, surgeon person, hospital, clinic and any other institution or organization to furnish to
Etiqa Life Insurance Berhad or its representative any information that maybe required concerning my health conditions, for settlement
of this claim. I agree that Etiqa Life Insurance 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.

____________________________________________ __________________________________________________
Signature / Thumb print of Life Assured Signature / Thumb print of Claimant (if other than Life Assured)
Name: ______________________________________ Name: ____________________________________________
Date: _____________________________ (dd/mm/yyyy) Date: _________________________________ (dd/mm/yyyy)
Contact No.: ________________________________________
Designation & official stamp is required for Company or Bank:

____________________________________________

_________________________________________
Signature of Witness
Name: ________________________________________
NRIC: _________________________________________
Date: ______________________________ (dd/mm/yyyy)
Contact No.: ____________________________________

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LETTER OF AUTHORISATION / CONSENT

To Obtain Further Medical information

To Whom It May Concern,

Name of Life Assured: …………………………………………………………………………………………………………….

NRIC No.: ……………………………………………………………… (New) ….……………………………………….. (Old)

Policy No.: ……………………………………………………………...

I, ………………………………………………………………………..., NRIC No. …………………………………………… hereby authorize

and give my consent to any medical practitioner, physician, surgeon, nurse, medical staff, clinic, hospital, medical centre, insurance
company or organization or individual concerned (“the information provider”) that may have any record or knowledge of health or
medical history of the above stated (“Life Assured”) and to provide such information to Etiqa Life Insurance Berhad and its authorized
service provider and/or its employees in order to process my insurance claim.

I, agree, consent and allow Etiqa Life Insurance Berhad (hereinafter called “Etiqa Life Insurance”) to process my personal data
(including sensitive personal data) (‘Personal Data’) with the intention of processing this Claim Form, in compliance with the provisions
of the Personal Data Protection Act 2010.

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 arise, in supplying such information requested by the Company.

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

…………………………………………………………………………………………………….
Signature / Thumb print of Life Assured / Claimant (if Life Assured is a minor)

Name: ………………………………………………..……………………………..……………
NRIC: …………………………………………………………………………………………….
Old I/C: …………………………………………………………………………………………..
Birth Cert No (if minor): ………………………………………………………………………...
Relationship with Life Assured: ………………………………………………..………………
Contact No.: …………………………………………………………………………….……….
Date: ……………………………………………………………………….…….. (dd/mm/yyyy)

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 Additional Requirements for Female Critical Illness Claim

Female Cancer (Cancer of the 1. Histopathology report / biopsy report (where applicable)
breast, cervix uteri, fallopian tube, 2. Ultrasound / CT scan / MRI report (where applicable)
ovary, uterus or vagina/vulva)

Systemic Lupus Erythematosus 1. Urine test

(SLE) with Lupus Nephritis 2. Blood test (Antinuclear antibody, ESR, CRP etc.)
3. Kidney / renal biopsy report
Female Carcinoma-in-situ 1. Histopathology report / biopsy report (where applicable)
(Carcinoma-in-situ of the breast, 2. Ultrasound / CT scan / MRI report (where applicable)
cervix uteri, fallopian tubes, ovary,
uterus, or vagina/vulva)
Surgery of either Fibroid or 1. Histopathology report / biopsy report (where applicable)
Ovarian Cyst. 2. Ultrasound / CT scan / MRI report (where applicable)
3. Operation report
Osteoporotic fracture 1. Dual energy X-ray absorptiometry (DXA) report / bone mineral density
score
2. Blood test report
3. Operation report
Severe Rheumatoid Arthritis 1. Blood test (Rheumatoid Factor)
2. CT scan / MRI report (where applicable)
Facial Reconstructive Surgery 1. Facial X-ray / Orthopantomogram (OPG) report (where applicable)
2. Police report (if any)
3. Operation report
Skin Grafting due to Skin Cancer 1. Histopathology report / biopsy report (where applicable)
2. Operation report
Skin Grafting due to Burns 1. Lund and Browder Body Surface Chart
2. Operation report
Breast Lumpectomy or 1. Histopathology report / biopsy report (where applicable)
Mastectomy 2. Ultrasound / CT scan / MRI report (where applicable)
3. Operation report
Breast Reconstructive Surgery 1. Histopathology report / biopsy report (where applicable)
2. Ultrasound / CT scan / MRI report (where applicable)
3. Operation report
1. Histopathology report / biopsy report (where applicable)
Surgical removal of female
2. Ultrasound / CT scan / MRI report (where applicable)
reproductive organ
3. Operation report
Limb Amputation 1. Histopathology report / biopsy report (where applicable)
2. Ultrasound / CT scan / MRI report (where applicable)
3. Operation report
4. Blood test (HbA1c)
Severe Diabetic Nephropathy 1. Blood test (HbA1c, renal function test / glomerular filtration rate)
2. Urine test
Surgery for Type 2 Diabetic 1. Fluorescent Fundus Angiography report
Retinopathy 2. Blood test (HbA1c)
Joint replacement surgery for 1. X-ray / CT scan / MRI report
arthritis 2. Operation report

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WHY YOU SHOULD CHOOSE TO RECEIVE PAYMENTS VIA DIRECT DEPOSIT INTO A BANK ACCOUNT
(E-PAYMENT / AUTO-CREDIT)?

No Question Answer
1 Why should I choose to  Faster: funds are available once the payment has been processed by the
receive funds via e- bank.
payment / auto-credit?  Convenient: removes the need to travel and deposit the cheque at the
bank as payments are credited directly into your bank account.
 Safer: misplaced, lost, fraud or expired cheques will no longer be an issue.
 Environmental friendly: printing, posting and banking in of the cheque will
no longer require.
2 Will there be any No, you can enjoy the service free of charges.
registration fee?
3 What do I have to do to You must provide your bank’s saving / current account number together with the
receive funds via e- bank’s name in the proposal/claim/benefit/surrender form during the application.
payment / auto-credit?
Alternatively, you can also provide your bank saving / current account no with the
bank’s name, latest address, mobile phone no and email address for future Benefit
payment via submission of `Request For Change Form’.
Note: The completed form and necessary documents must be submitted together
with the required supporting documents to the nearest Etiqa Branch.
4 What are the required The following documents are required for verification :
supporting documents?  A copy of your IC or passport, ;&
 A copy of the bank statement / bank account passbook / details of your
account printed from your bank’s website.
5 Is there any restriction on You can provide any of your existing active saving / current account held under your
the type of bank account name or in the case of a joint account that has your name as one of the
that can be assigned for e- accountholders. The saving or current account must be maintained with one of the
payment / auto-credit? financial institutions offering MEPS Inter-Bank GIRO (IBG) service. You may refer to
the following website for current list of IBG members
http://www.meps.com.my/faq/interbank-giro.
6 Can I change my bank Yes, you are allowed to change your bank account details by submitting the Request
account information? For Change form with the required supporting documents substantiating your
request to Etiqa. No cost will be charged for this purpose.
7. When will the funds be Payment will be made electronically into your bank account by Etiqa within 5 working
credited to my bank days once your payment has been approved.
account?
8. Will I be notified once the Yes, a notification letter will be sent to you once your payment has been approved.
Company has made the You are encouraged to provide your email address/mobile phone number as Etiqa is
payment? currently developing the electronic notification via email / SMS.
9. How will my bank account Your bank account details and other related information:
information be used and  Will be used solely for the purpose of enabling payments to be credited
will it remain confidential? directly into your bank saving / current account; and
 Is protected under the Financial Services Act 2013 that strictly prohibits the
disclosure of such information to any person unless customer or his
personal representative has given written permission.
10 What will happen to funds If funds cannot be credited into your bank account due to for example, incorrect bank
that cannot be credited into account number, closed or inactive bank account, I/C no unmatched, the cheque will
my bank account? be issued and posted to you. However, this may lead to unnecessary delay to the
payment process. To avoid this issue, please ensure that your bank account is
correct and active upon providing such information to Etiqa.
11 Do I need to provide bank If you want all your payments to be paid to the same bank account, you need to
. account information indicate so to Etiqa at the point of submitting your form.
separately for each of my
certificate if I have more
than one certificate?

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