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HASECRI PICS (06/2014) MAJOR ILLNESS/CRITICAL ILLNESS/TERMINAL ILLNESS/CANCER/LADY PROTECTION CLAIM FORM To : Hang Seng Insurance Company Limited Policy No. Claim Application for Major Illness / Critical Illness Benefit Claim Application forTerminal Illness Benefit Claim Application for Carcinoma-In-Situ Benefit Claim Application for Early Stage Cancer Benefit Claim Application for Cancer Benefit – Claim Application for Lady Protection Plan – Female Disease – Claim Application for Lady Protection Plan – Congenital Anomalies – Claim Application for Lady Protection Plan – Pregnancy Complications – Claim Application for Lady Protection Plan – Accidental Cosmetic Surgery Benefit CLAIMS DOCUMENTS CHECKLIST Part I is fully completed signed by the Policyholder/Insured Part II is fully completed signed by the Attending Physician with chop (this report required to be applied by the claimant at his/her own cost) Copy of Pathological, Laboratory, Ultrasonogram, X-Ray, CT X– Scan, MRI and Diagnostic Written Report (s) (if applicable) Copy of Policyholder Insured’s Identity Card Copy of Bank Account Proof (applicable for Policyholder’s sole name bank account other than Policyholder’s premium deduction account) Notes 1. 90 A claim must be made within 90 days of the Insured becoming aware that he is suffering from an illness or from the date of diagnosis and whilst this Policy is in force. If the claim is not made within that period, we will not be liable to pay unless it is shown that it was not reasonably possible to make such a claim, and that t