TAKAFUL IKHLAS FAMILY BERHAD
Registration No. 200201025412 (593075-U)
IKHLAS Point, Tower 11A, Avenue 5, Bangsar South,
No. 8, Jalan Kerinchi, 59200 Kuala Lumpur
Tel : 03-2723 9999 Fax : 03-2723 9998
IKHLAS Care : 03 2723 9696 Website: www.takaful-ikhlas.com.my
(Licensed under Islamic Financial Services Act 2013 and regulated by Bank Negara Malaysia)
BORANG TUNTUTAN - HOSPITAL DAN PEMBEDAHAN
CLAIM FORM - HOSPITAL & SURGICAL
Peringatan / Reminders
Penerimaan borang ini bukanlah bermakna dengan sendirinya tanggungan akan diakui oleh syarikat.
Acceptance of this form does not mean admission of liability by the company.
NO. SIJIL / CERTIFICATE NO. :
Jenis-jenis tuntutan (sila tandakan √ di petak yang berkenaan) Type of claims (please tick √ in the related box provided)
Boleh tanda () lebih dari 1 petak
You may tick (√) more than 1 box
Rawatan Hospital / Pembedahan Harian Manfaat Kanser / Dialisis Buah Pinggang Keseluruhan Diagnosis Kali Pertama
Hospitalisation / Day Care Surgery Lump Sum Cancer / Kidney Dialysis Benefit Upon First Diagnosis
(Sila lengkapkan laporan perubatan pada Bahagian G/
Bilik dan Penginapan yang Tidak Digunakan
Please complete the medical report as per Section G) Unutilised Room and Board
Rawatan Sebelum & Selepas Masuk Hospital Rawatan Luar Kanser /Dialisis Buah Pinggang / Physiotherapy
Pre & Post Hospitalisation Outpatient Cancer / Kidney Dialysis / Physiotherapy
Rawatan Kecemasan Pesakit Luar Akibat Kemalangan
Elaun Tunai Hospital Kerajaan
Emergency Accidental Outpatient Treatment Government Hospital Daily Cash Allowance
Lain-lain, sila nyatakan
Others, please state
A.
MAKLUMAT PESERTA / PARTICIPANT'S DETAILS
1 a.
Nama Peserta / Name of Participant :
b.
No. Kad Pengenalan/ NRIC No. : Baru/ New : Lama/ Old :
c.
Pekerjaan Semasa/ Present Occupation :
d. Nama Majikan & Alamat :
Name of Employer & Address :
2 Alamat Surat Menyurat Semasa :
Current Correspondence Address :
3 No. Telefon : a.
Telefon Bimbit / H/p : c. Pejabat / Office :
Telephone No. : b. Rumah / House : d. Sambungan/ Extention No. :
4
E-Mel/ E-Mail :
5
Nama Bank/ Name of Bank :
6 No. Akaun Bank Peserta / W aris : Contoh: MBB0001.
Participant/ Beneficiary Bank Account No. : E.g: MBB0001.
** Sila lampirkan salinan muka hadapan buku bank / ** Please enclose a copy of the front page of the saving book.
B.
MAKLUMAT ORANG YANG DILINDUNGI / PERSON COVERED'S PERSONAL DETAILS
1
Nama Orang yang dilindungi (jika berbeza dengan A) / Name of Person covered (if differs from A) :
2
No. Kad Pengenalan/ NRIC No. : Baru/ New : Lama/ Old :
3
Alamat / Address :
4
E-Mel/ E-Mail :
C.
MAKLUMAT WAKIL TAKAFUL / AGENT'S INFORMATION
1
Nama W akil Takaful / Agent's Name :
Kod W akil Takaful / Agent's Code :
2
No. Telefon / Telephone No. : a. Pejabat / Office : b. Telefon Bimbit / H/p :
3
E-Mel/ E-Mail :
Poskod / Postcode :
Negeri /
State
:
Negeri / State :
Bandar / Town :
Poskod / Postcode :
Bandar / Town :
D.
MAKLUMAT PENYAKIT/ DIAGNOSIS INFORMATION
(Sila isikan keterangan pada bahagian yang berkaitan sahaja) Please complete the information in the relevant section
1 a) Nama Hospital :
Hospital's Name
b) Tarikh Rawatan / Masuk W ad : c) Tarikh Keluar W ad :
Date Of Treatment / Admission HH/DD BB/MM TT/YY Date Of Discharge : HH/DD
BB/MM
TT/YY
d) Apakah diagnosis yang telah dimaklumkan kepada anda oleh doktor yang merawat ?
What was the diagnosis informed to you by the attending doctor ?
2
Sila nyatakan tarikh kali pertama/ Please state the exact date (first date)
a)
menerima rawatan/ received treatment :
HH/DD
BB/MM TT/YY
b)
disahkan mendapat penyakit tersebut/ diagnosed with the illness :
HH/DD BB/MM TT/YY
3 Sila nyatakan punca asal mendapatkan rawatan atau rujukan dari doktor tersebut
Please state the reason for seeking treatment or referral from the said doctoror
4 Jika diakibatkan oleh kemalangan, sila nyatakan seperti berikut:
If accidental case please state the following: HH/DD BB/MM TT/YY
a)
Tarikh kemalangan/ Date of accident : Masa:
Time: am/pm
b) Bagaimana kemalangan berlaku :
Details description of the accident :
*Sila lampirkan salinan laporan polis/ laporan bedah siasat (jika ada)
* Please enclose a copy of police report or post mortem report (if any)
E.
LAIN LAIN TAKAFUL ATAU PAMPASAN / OTHER TAKAFUL OR COMPENSATION
Adakah Peserta membuat tuntutan atau pampasan dari syarikat insuran atau takaful yang lain? YA / YES TIDAK / NO
Is the Participant claiming the benefits under any other insurance companies or takaful operators?
Jika YA, sila berikan maklumat lanjut / If YES, please give details :
F.
PENGAKUAN OLEH PENUNTUT / DECLARATION BY THE CLAIMANT
Tandatangan Penuntut / Peserta Tandatangan Saksi
Signature of Claimant / Participant Signature of Witness
Nama/ Name : Nama/ Name :
No. KP/ NRIC No. :
Tarikh/ Date : Tarikh/ Date :
Hubungan/ Relationship :
I / We ___________________________ NRIC ___________________________ as the claimant hereby declare that all foregoing answers and information stated
above are complete and true to the best of my / our knowledge and belief and I / We have not concealed any important details from this company. I / We hereby claim
Takaful benefits and other acquisition under the relevant Takaful Plan from Takaful Ikhlas Family Berhad (hereinafter referred as the Company) and agree that all
information disclosed by the doctors treating the participant during his lifetime and all documents provided to support this claim is proof of his / her disability. Further, I
/ We agree that this form and other additional related documents and investigations or examinations by the Company cannot be interpreted or assumed as admission
of liability by the Company and is not proof of any agreement which take effect on the said person or discharged of any right or defense by the Company. I / We
hereby give consent to doctors or related parties or hospitals etc. to disclose to the Company any explaination or information which is deemed necessary with regards
to the participant.
Saya / Kami ___________________________ No. KP ___________________________ pihak yang membuat tuntutan mengakui bahawa semua jawapan dan
kenyataan yang tercatat di atas adalah lengkap dan benar sepanjang pengetahuan dan keyakinan Saya / Kami dan Saya / Kami tidak menyembunyikan atau
merahsiakan butir-butir penting dari syarikat ini. Saya / Kami dengan ini menuntut manfaat Takaful dan lain-lain perolehan di bawah Pelan Takaful yang berkenaan
daripada Takaful Ikhlas Family Berhad (selepas ini dirujuk sebagai pihak Syarikat) dan bersetuju bahawa kenyataan dan maklumat dari semua doktor yang memberi
rawatan kepada peserta semasa hayatnya dan segala dokumen lain diberi untuk menyokong ini adalah menjadi bukti keilatannya. Selanjutnya, Saya / Kami bersetuju
bahawa borang ini dan lain-lain dokumen tambahan yang diberikan mengenainya dan tindakan-tindakan siasatan dan pemeriksaan oleh pihak Syarikat tidak boleh
ditaksir atau dianggap persetujuan menanggung tuntutan oleh pihak Syarikat dan tidak membuktikan ada sesuatu aqad Takaful yang berkuatkuasa mengenai diri yang
diperkatakan atau sesuatu pelepasan sebarang hak atau pembelaan oleh pihak Syarikat. Saya / Kami dengan ini bersetuju membenarkan doktor-doktor atau lain-lain
pihak atau hospital dan sebagainya memberi kepada pihak Syarikat penerangan atau maklumat yang mungkin diperlukan mengenai peserta.
G. LAPORAN PERUBATAN UNTUK DI ISI OLEH DOKTOR YANG MERAWAT (TUNTUTAN KEMASUKAN KE HOSPITAL / PEMBEDAHAN HARIAN SAHAJA)
MEDICAL REPORT TO BE COMPLETED BY THE ATTENDING DOCTOR (FOR HOSPITALISATION CLAIM AND DAY CARE SURGERY ONLY)
Name of Hospital : MRN NO :
Address :
Name of patient :
NRIC No. :
Date and Time of Admission : Date and Time of Discharge :
DD MM YY DD MM YY
Name of Referring Doctor and Address :
Admitting Doctor : Attending Doctors : Speciality :
1a.
Diagnosis / ICD Coding : 4a. Please √ Nature of Treatment and Investigation:
OPERATION PHYSIOTHERAPY
DIETARY COUNSELLING
MEDICATIONS
X-RAY
BLOOD TESTS
OTHERS, give details
1b. Cause and Pathology (if applicable) of the above diagnosis : 4b. If more than one procedure was involved, please state Type of
Procedures performed:
NAME OF
TYPE DATE DOCTOR
i.
ii.
2a. When did patient first consult you for this condition?
iii.
2b. W as the patient previously treated for this condition?
4c. Other medical conditions present?
Since (dd mm yy)
Since (dd mm yy)
2c. How long in your professional opinion has the condition existed?
Since (dd mm yy)
DD MM YY
3 Any possibility of a relapse? 5 W as the condition
Yes No congenital nervous mental not related
6 W as the patient pregnant at the time of hospitalisation? (For Females Only)
Yes No Months
7 If the hospitalisation was due to accident, please indicate date / time of accident:
DD MM YY
8 Discharge / Follow-up instructions :
Signature and Name of Attending Doctor Hospital Stamp Date
(hrs)
(hrs)
(hrs)