PruCustomer Line: 1800 -333 0 3333

DISABILITY CLAIM FORM

Important Notes
1. Please note that, under the policy terms and condition, the policy may be void if any information provided in this claim form are
made knowingly by you that it is materially false or misleading.
2. The issue of this form is in no way an admission of liability. No claim can be considered unless the medical specialist report
section is furnished at the expense of the claimant.
3. The Company reserves the rights to request for additional documents when deemed necessary.

SECTION 1
(To be completed by the Life Assured who is at least 18 years old or the Policyowner if the Life Assured is below 18 years old)

DETAILS OF POLICY

Policy Number(s) the benefit(s) you would like to claim:

DETAILS OF LIFE ASSURED

Full Name

NRIC / Passport
Date of birth Gender
No.

Address

Contact No. Email address

Name and address

Occupation
of Employer

TYPE OF CLAIM

Please tick the appropriate box for the benefit(s) you are claiming.

□ Total and Permanent Disability □ Early Stage Disability

DETAILS OF OCCUPATION / ACTIVITIES OF DAILY LIVINGS (ADLs)

Before disability After disability

Occupation

Exact nature of occupational duties

If the Life Assured is not working, please

C170621

provide a list of the daily activities.

Name and address of business and

employer

Prudential Assurance Company Singapore (Pte) Limited (Reg. No.: 199002477Z) CMTPDCLM
Postal Address: Robinson Road P.O. Box 492, Singapore 900942
Tel: 1800 – 333 0 333 Fax: 6734 9555 Website: www.prudential.com.sg
Part of Prudential Corporation plc Page 1 of 13 TPD
Monthly income

Date you last worked

Date you returned to work / Expected

date of return *
(*delete where appropriate)
DETAILS OF DISABILITY

Please complete Question 1 to 5 if disability was DUE TO ACCIDENT

1. Date of accident DD MM YY

Please circle
2. Time of accident
HR MIN
AM PM

3. Describe fully where and how did the accident happen?

4. Describe the type and extent of injury.

5. Was the accident reported to the Police? Please circle. Yes No

If Yes, please provide:

• the name of police officer and police station at which the accident was reported; and
• a copy of the police report in this claim submission.

Please complete Question 6 to 9 if disability was DUE TO ILLNESS

6. Describe fully the signs or symptoms for which doctor was consulted and/or received treatment.

7. Date when signs or symptoms first started DD MM YY

8. Date when Life Assured first consulted a doctor for above

DD MM YY
signs or symptoms.

9. Name and address of doctor(s) consulted.

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Please complete Question 10 if claim was filed on EARLY DISABILITY BENEFIT

10. If the claim was on Early Stage Disability, please indicate the Quality of Life Conditions that you are claiming for.

Please Date disability started

tick
Quality of Life Conditions
(dd/mm/yy)
Walking – The inability to walk more than 200m on a level surface continuously with or
without aids and adaptations, within 5 minutes, because of breathlessness or severe
pain.
Fine Hand Control – The inability to remove 5 paracetamol pills from a blister pack
within 60 seconds, using your hand(s) with or without aids and adaptations.

Sitting and Rising from a chair – The inability to sit and rise to a standing position from
a wheelchair or chair (both with arms) of 40cm to 45cm in height without the help of
another person.

Lifting and carrying – The inability to lift (from a bench with a height of 1m) and carry a
2kg weight for 10m and then placing it back down at bench height, with or without aids
and adaptations.

Communicating – As a result of an illness or injury, the inability to hear sounds of below

60 decibels in all frequencies of hearing or the inability to speak with sufficient clarity.

Eyesight – When tested with visual aids, vision is measured at 6/60 or worse in one of
the eyes using a Snellen eye chart.

DETAILS OF CONSULTATION / HOSPITALIZATION

11. Please provide the details of doctor or specialist whom Life Assured has consulted in connection with his/her illness/injury :-

Name and Address of

Name of Doctor/Specialist Date of Consultations Reason(s) for Consultation
Clinic/Hospital

12. Please provide the details of Life Assured’s regular doctor and company doctor whom he/she has consulted for minor ailments
(e.g. flu, cough, fever), high blood pressure, high cholesterol, diabetes etc :-

Name and Address of

Name of Doctor/Specialist Date of Consultations Reason(s) for Consultation
Clinic/Hospital

OTHER INSURANCE

13. Does Life Assured have similar benefits with any other company? If yes, please give full details :-

Name of Insurer Type of Plan Date of Issue Sum Assured

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PAYMENT METHOD FOR CLAIM SETTLEMENT

14. Please tick one of the boxes below to indicate your preferred payment method.

□ Cheque to be mailed directly to Policyowner address

□ Cheque to be collected by Prudential Financial Consultant

□ Cheque to be mailed directly to Prudential Financial Consultant at Agency

Name and Contact No. of your appointed Prudential Financial Consultant:

Direct credit of proceeds into Policyowner’s SGD dollar bank account

□ (if you select this payment mode, you need to submit a copy of the bank book or bank statement stating account holder
name and number)

Name of Bank Branch of Bank Bank Account Number Name of Account Holder

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Name of Life Assured: NRIC / Passport No. of Life Assured:

DECLARATION

1. I understand and agree that the submission of this form does not mean that my request will be processed. I understand that any payout under
the policy shall be strictly in accordance with the policy terms and conditions.

2. I hereby declare that the information that is disclosed on this form is to the best of my knowledge and belief, true, complete and accurate, and
that no material information has been withheld or is any relevant circumstances omitted. I further acknowledge and accept that Prudential
Assurance Company Singapore (Pte) Limited (“PACS”) shall be at liberty to deny liability or recover amounts paid, whether wholly or partially, if
any of the information disclosed on this form is incomplete, untrue or incorrect in any respect or if the Policy does not provide cover on which
such claim is made.

3. I hereby warrant and represent that I have been properly authorised by the policyholder and the applicable insured(s) to s ubmit information
pertaining to such insured’s claims.

4. I acknowledge and accept that the furnishing of this form, or any other forms supplemental thereto, by PACS, is neither an ad mission that there
was any insurance in force on the life in question, nor an admission of liability nor a waiver of any of its rights and defenses.

5. I acknowledge and accept that PACS expressly reserves its rights to require or obtain further information and documentation as it deems
necessary.

6. I confirm that I have paid in full all the bill(s)/invoice(s)/receipt(s) that I have submitted to PACS for reimbursement and have not claimed and do
not intend to claim from other company(ies)/person(s).

7. I agree to produce all original bill(s)/invoice(s)/receipt(s) that were submitted for reimbursement to PACS for verification as it deems necessary.

8. For the purposes of (i) assessing, processing and/or investigating my claim(s) arising under the Policy or any of my other polic(ies) of insurance
with PACS and such other purposes ancillary or related to the assessing, processing and/or investigating of such claim(s); (ii) administering the
Policy, (iii) customer servicing, statistical analysis, conducting customer due diligence, reporting to regulatory or supervisory authorities, auditing
and recovery of any debts owing to PACS whether in relation to the Policy or any of my other polic(ies) of insurance with PACS, (iv) storage and
retention, (v) meeting requirements of prevailing internal policies of PACS, and/or (vi) as set out in PACS Privacy Notice (“Purpose”), I
authorise, agree and consent to:

a. Any person(s) or organisation(s) that has relevant information concerning the policyowner and the insured person(s) (includin g any medical
practitioner, medical/healthcare provider, financial service providers, insurance offices, government authorities/regulators, statutory boards,
employer, or investigative agencies) (“Person(s)/Organisation(s)”), to disclose, release, transfer and exchange any information with PACS
and its related corporations, respective representatives, agents, third party service providers, contractors and/or appointed
distribution/business partners (collectively referred to as “Prudential”), including without limitation, personal data, medical information,
medical history, employment and financial information, including the taking of copies of such records; and

b. Prudential collecting, using, disclosing, releasing, transferring and exchanging personal data about me, the policyowner and the insured
person(s), with the Person(s)/Organisation(s), PACS’s related group of companies, third party service providers, insurers, reinsurers,
suppliers, intermediaries, lawyers/law firms, other financial institutions, law enforcement authorities, dispute resolution centres, debt
collection agencies, loss adjustors or other third parties for the Purpose.

9. Where any personal data (“3rd Party Personal Data”) relating to another person (“Individual”) (including without limitation, insured persons,
family members, and beneficiaries) is disclosed by me or permitted by me to be disclosed in accordance with Clause 8 above, I represent and
warrant that I have obtained the consent of the Individual for Prudential to collect and use the 3rd Party Personal Data and to disclose the 3rd
Party Personal Data to the persons enumerated above, whether in Singapore or elsewhere, for the Purpose stated above and in P ACS Privacy
Notice.

10. I understand that I can refer to PACS Privacy Notice, which is available at https://www.prudential.com.sg/Privacy-Notice for more information on
contacting PACS for Feedback, Access, Correction and Withdrawal of using my/our personal data.

I understand that if I am an European Union (“EU”) resident individual (i.e. my residential address is based in any of the EU countries), I can
refer to PACS Privacy Notice for more information on the rights available to me under the GDPR.

11. I agree to indemnify Prudential for all losses and damages that Prudential may suffer in the event that I am in breach of any representation and
warranty provided to me herein.

12. I agree to receive communication on the claim by email, SMS and/or hard copies by post.

13. I agree that this (i) Prudential shall have full access to the information stated in this form, and (ii) this authorisation and declaration shall form
part of my proposed application for the relevant insurance benefits, and a photocopy of this form shall be treated as valid a nd binding as if it
were the original.

Date and signature of Life Assured

(Policyowner to sign if Life Assured is below age 18 years) Date and signature of Policyowner

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Name of Patient NRIC/Passport No. of Patient

SECTION 2 MEDICAL SPECIALIST REPORT

TOTAL AND PERMANENT DISABILITY / EARLY DISABILITY
(To be completed by Life assured’s attending medical specialist.

Name of Specialist MCR No.

Field of Specialty

Name of Medical Institution

Part I

1. Date when patient first consulted you for the condition? DD MM YY

2. When was the last consultation? DD MM YY

3. What were the presenting symptoms when you first saw the patient?

4. When did the above symptoms first present? DD MM YY

If the date is unknown, please state how long the symptoms had been present prior to the date of first consultation.

5. What were your clinical and physical/mental findings when you first saw patient?

6. Please provide exact diagnosis :

7. What is /are the underlying cause(s)?

Signature & Practice Stamp of the Medical Specialist who filled up Section 2 Date
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8. Date of diagnosis. DD MM YY

9. Date the patient / patient’s next of kin was informed of the

DD MM YY
diagnosis.

10. What was the exact information regarding diagnosis that patient or patient’s next-of-kin was informed of?

11. Please provide the details of patient’s treatments (including any investigations/surgery administered) and his/her response to
these treatments in chronological order. To enclose copies of the reports.

Date of treatment
Details of treatment Investigation/Surgery Patient’s treatment progress
(dd/mm/yy)

12. Please provide details of the medications prescribed and if any medicines have been titrated since the initial onset of disability.

13. Were you the doctor who first diagnosed the patient with this condition? Please circle. Yes No

14. If Yes, over what period do your records extend? From To

(dd/mm/yy) (dd/mm/yy)

15. If you are not the first doctor who diagnosed the patient with this condition, please provide:

a. Name and address of the doctor who first made the diagnosis or had treated the patient for this condition.

b. Date the diagnosis was made by the previous doctor. DD MM YY

c. When was the referral made for the patient to see you? DD MM YY

d. What was the reason for referral to see you? Please attach a copy of the referral letter.

e. Please provide name and practice address of referral doctor.

Signature & Practice Stamp of the Medical Specialist who filled up Section 2 Date
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PART II

1. Date of last consultation DD MM YY

2. What were the symptoms and complaints reported by patient during the last consultation?

3. What were your clinical and physical/mental findings when you last saw patient?

4. Based on the last consultation assessment of patient’s disability, please describe the nature and severity of patient’s
physical/mental impairment in respect of this illness or injury.

5. As a result of the illness or injury, please state if patient’s physical/mental impairment (as described in Question 4 above) had led
to any of the following confinement requiring constant care and medical attention.
Period of Confinement
Type of Confinement Please circle
From(dd/mm/yy) To (dd/mm/yy)

a. Home (Please specify) Yes No

b. Hospital (Please specify) Yes No

c. Bed Yes No

d. Wheelchair Yes No

e. Others (Please specify) Yes No

6. Is the patient able to perform (whether aided or unaided) the following Activities of Daily Living:

Please circle if the Period of inability to perform

Activity patient can perform
the listed activity? From (dd/mm/yy) To (dd/mm/yy)

Washing or bathing
Ability to wash in the bath or shower (including getting into and
Yes No
out of the bath or shower) or wash by other means. e.g. to wash
the back, to wash hair

Dressing
Ability to put on, take off, secure and unfasten all garments
(upper and lower) and, as appropriate, any braces, artificial Yes No
limbs or other surgical or medical appliances. e.g. to button
clothes, to put on trousers

Signature & Practice Stamp of the Medical Specialist who filled up Section 2 Date

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 Please circle if the Period of inability to perform
Activity patient can perform
the listed activity? From (dd/mm/yy) To (dd/mm/yy)

Feeding
Ability to feed oneself food after it has been prepared and made Yes No
available. e.g. to scoop food, to put food into mouth

Toileting
Ability to use the lavatory or manage bowel and bladder
Yes No
functions through the use of protective undergarments or
surgical appliances if appropriate. e.g. to get on or off the toilet

Transferring
Ability to move from a lying position on the bed to an upright
Yes No
chair or wheelchair, and vice versa. e.g. to be lifted up from lying
position to sitting position from bed

Mobility
Ability to move indoors from room to room on level surfaces. Yes No
e.g. to be supervised by someone closely in case of fall

7. Please evaluate patient’s level of functional ability based on the date of last consultation.

Date of evaluation Please circle if the Date from which help

was required Please provide
Activity patient can perform the
(dd/mm/yy) activity? details.
(dd/mm/yy)

Walking
Walk more than 200m on a level surface
continuously within 5 minutes, without Yes No
having to stop because of breathlessness
or severe pain.

Fine Hand Control

To remove 5 paracetamol pills from a
Yes No
blister pack within 60 seconds using your
hand(s).

Siting and Rising from a chair

To sit and rise to a standing position from
Yes No
a wheelchair or chair (both with arms) of
40cm to 45cm in height.

Lifting and Carrying

To lift (from a bench with a height of 1
Yes No
metre) and carry a 2kg weight for 10m and
then placing it back down at bench height.

Communicating
To hear sounds of below 60 decibels in all
frequencies of hearing or the ability to Yes No
speak with sufficient clarity. Please attach
ENT report.

Eyesight
Vision is measured at 6/60 or worse in one
of the eyes using a Snellen eye chart, Yes No
when tested with visual aids. Please
attach Opthalmologist report.

Signature & Practice Stamp of the Medical Specialist who filled up Section 2 Date

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8. To the best of your knowledge and Hospital records, what is the occupation and nature of duties reported by patient before
he/she suffered the physical/mental incapacity?

9. To what extent does his/her physical/mental incapacity prevent him/her from performing all the normal duties of his/her usual
occupation?

10. If he/she cannot return to his/her usual occupation, can he/she engage in any other types of occupation? Yes No

a. If Yes, please provide details for the following :- b. If No, please provide details for the following

i. When do you think the patient will be able to return to i. Give details on any social, domestic or employment
work, either part-time or full-time? issues that are, or have been, impacting the patient’s
ability to work?

ii. Please describe how the physical/mental impairments

ii. What are the types of occupation he/she can engage prevent the patient from ever continuing in any
in? occupation, business or activity which pays him/her an
income.

11. Is the patient suffering from total loss of hearing in both the ears? Please circle. Yes No

a. Please provide the actual readings on the extent of hearing loss for both ears. Please provide copies of audiogram and
sound-threshold tests.

Left ear loss of hearing: decibels Right ear loss of hearing: decibels

b. Is the hearing loss irreversible? Please circle. Yes No

12. Is the patient suffering from total loss of ability to speak? Please circle. Yes No

a. Is the loss of ability to speak as a result of injury or disease to the vocal cord? Please circle. Yes No

b. Is the loss of ability to speak total and irrecoverable? Please circle. Yes No

c. Did the inability to speak last for a continuous period of 12 months? Please circle. Yes No

d. Please state the period of inability to speak. From To

(dd/mm/yy) (dd/mm/yy)

e. Is the loss of ability to speak associated with any psychiatric condition? Please circle Yes No

Signature & Practice Stamp of the Medical Specialist who filled up Section 2 Date
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13. Is the patient suffering from total and irrecoverable loss of use of both eyes? Please circle. Yes No

Please explain in details.

14. Is the patient suffering from total and irrecoverable loss of use of any two limbs, excluding hands and
Yes No
feet? Please circle.
Please explain in details.

15. Is the patient suffering from total and irrecoverable loss of use of one eye and any one limb excluding
Yes No
hands and feet? Please circle.
Please explain in details.

16. In accordance to the Singapore’s Mental Capacity Act (Cap 177A), is the patient mentally incapacitated?
Yes No
Please circle.

PART III

1. Is the patient’s disability arising directly or indirectly out of: Please circle.

a. attempted suicide or self-inflicted injuries? Yes No

b. AIDS, AIDS-related complex or infection by HIV? Yes No

c. congenital or hereditary diseases or disorder? Yes No

d. mental and personality disorders (excluding Dementia and Alzheimer’s disease)? Yes No

e. improper use of alcohol, alcohol abuse or alcohol dependence? Yes No

If you have answered Yes to any of the above Question 1(a) to 1(e), please provide details:

Diagnosis Date of diagnosis (dd/mm/yy) Name and address of treating doctor

2. Has the patient previously consulted you or any other doctor for treatment or advice for this disability
Yes No
condition or any related condition? If yes, please provide the following details:
Name and
Date of diagnosis Date when patient was Name and date of
Diagnosis address of
(dd/mm/yy) informed of diagnosis treatments
treating doctor

Signature & Practice Stamp of the Medical Specialist who filled up Section 2 Date
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3. Does the patient have or ever had any other significant health condition? If Yes, please provide following
Yes No
details:

Date when patient was Name and date of Name and address
Diagnosis Date of diagnosis
informed of diagnosis treatments of treating doctor

Name and Signature of the Medical Specialist who filled up Section 2 Date

Practice Stamp of the Medical Specialist

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SECTION 3
Attachment of Laboratory Reports

To enable us to proceed with the claim, it is mandatory to enclose all

relevant clinical, radiological, histological, operation and laboratory reports
by attaching them to this page.

Prudential Assurance Company Singapore (Pte) Limited (Reg. No.: 199002477Z)

Postal Address: Robinson Road P.O. Box 492, Singapore 900942
Tel: 1800 – 333 0 333 Fax: 6734 9555 Website: www.prudential.com.sg
Part of Prudential Corporation plc

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