Notice :

Being furnished or acknowledgment receipt of this form by the Company does not amount to admission of liability.

This claim form is furnished or acknowledged on a without prejudice basis.

The “Company” herein refers to “Gibraltar BSN Life Berhad”
Notis :



Pengemukaan atau pengesahan penerimaan borang ini oleh pihak Syarikat tidak dimaksudkan sebagai pengakuan
liabiliti.
Borang permohonan ini dikemukakan atau diterima tanpa prasangka.
Pihak “Syarikat” merujuk kepada “Gibraltar BSN Life Berhad”
TOTAL AND PERMANENT DISABILITY CLAIM FORM
ATTENDING PHYSICIAN’S MEDICAL REPORT
1.
Patient’s Details
Policy No.
Name of patient
NRIC No
Age
Sex
Occupation
2. PLEASE COMPLETE THIS SECTION IF THE CONDITION WAS DUE TO AN ACCIDENT:
(a) Please state the date and time of the accident
Date :
Time:
(b) Please described in detail how the accident happened ?
(c) Was the accident reported to police?
If YES, please furnish which police station and the police officer in
charged name.
 Yes
 No
Station:
Police Officer’s Name:
(d) Was the patient under the influence of alcohol/drugs at the
time of accident?
If YES, please state the blood alcohol level or drug type and quantity
consumed?
 Yes
(e) Is the condition self -inflicted?
 Yes
3. INITIAL CONSULTATION
(a) Date of first consultation
(b) What were the symptoms
presented on the date of first
consultation?
(c) Please state the date when the
symptoms first appeared?
(d) Did the patient see other medical
practitioners prior to seeing you for the
current condition?
If YES, please state name & address.
(e) What is the diagnosis made?
(f) The diagnosis was made by (name
of the doctor):
(g) Date of the diagnosis:
(h) What was the date when the
diagnosis made known to the patient
or to the patient’s family?
1
 No
Remark:
 No
4. DISABILITY DETAILS
(a)
Please describe fully the nature and the severity of his/her disabilities during the first consultation date.
Date of First Consultation :
Description:
(b)
Please describe fully the nature and the severity of his/her disabilities during the last consultation date.
Date of Last Consultation:
Description:
(c)
Does the patient has full power of all limbs?
 Yes
 No
If NO, please specify the affected limbs and the current power of limbs.
Right arm :
Right leg :
Left arm :
Left leg :
(d)
Please also state in respect of mental abilities and cognition.
(d)(i) Is further recovery expected by counseling /medication/
rehabilitation.
(e)
Would he/she able to perform the following Activities of Daily Living without assistance:
a.
b.
c.
d.
e.
f.
(f)
(d)(ii)
Can he/she able to fully comprehend conversation?
Can he/she communicate with others effectively?
Dressing
Eating
Bathing/Washing
Continence
Transfer
Mobility






Yes
Yes
Yes
Yes
Yes
Yes






No
No
No
No
No
No
Is there improvement to the disability, or is it stagnant or deteriorating?
Is FULL recovery expected? If YES please state approximate time required.
If NOT, please state the extent of recovery expected and the time length.
(g)
Is he/she confined to home, hospital or other institution that provides constant care and medical attention?
 Yes
 No
If YES, since when (DD/MM/YYYY):
Gibraltar BSN Life Berhad [277714-A]
Bangunan Gibraltar BSN, 16, Jalan Tun Tan Siew Sin, 50050 Kuala Lumpur, Malaysia
P.O. Box 10845, 50726 Kuala Lumpur
General Line / Talian Am: 03-2687 2000 Customer Service / Khidmat Pelanggan: 03-2687 2020 Fax / Faks: 03-2026 6097
www.GibraltarBSN.com Email / E-mel: [email protected]
2
TPD PART II/v0.3/2015
5. OCCUPATION DETAILS
(a)
What was his/her occupation before the disability?
(b)
What is the nature of duties of his/her occupation?
(c)
Would he/she be able to perform all the normal
duties of his occupation?
If YES, when is he/she expected to return to his/her usual
occupation?
 Yes
(d)
If he/she is not able to perform his/her normal
occupation, would he/she be able to engage in any other
occupation?
 Yes
 No
Date:
 No
If YES,
(i)
What type of occupation that he/she will be able to
do/engage to obtain wages, compensation or profit.
(ii) When is he/she expected or has suffered from any
other significant illnesses.
Date:
(e)
Is the patient suffering or has suffered from any
other significant illnesses. If YES, please provide details and
onset.
 Yes
(f)
Is he/she physically or mentally incapacitated from
ever continuing in any employment ?
 Yes
 No
(g)
If she is mentally incapacitated, would she be able of
receiving or handling money?
 Yes
 No
(h)
 Yes
 No
Is he/she terminally ill?
 No
Details:
Declaration
I hereby certify that I have personally examined and treated the patient for his/her
injuries/illness/disease described above and that the facts as stated above
represent my medical findings and opinion of his/her condition.
Notice :

All reports are to be submitted directly in a sealed
envelope to the address stated below and stamped
“Private & Confidential”.
The Claims Department
Bangunan Gibraltar BSN,
16 Jalan Tun Tan Siew Sin,
50050 Kuala Lumpur, Malaysia
P.O.Box 10845, 50726 Kuala Lumpur

All expenses in procuring this medical report shall
be borne by the patient.
__________________________________
Signature of Attending Physician
Name:
Qualification :
Official Stamp :
Address :
Date :
Gibraltar BSN Life Berhad [277714-A]
Bangunan Gibraltar BSN, 16, Jalan Tun Tan Siew Sin, 50050 Kuala Lumpur, Malaysia
P.O. Box 10845, 50726 Kuala Lumpur
General Line / Talian Am: 03-2687 2000 Customer Service / Khidmat Pelanggan: 03-2687 2020 Fax / Faks: 03-2026 6097
www.GibraltarBSN.com Email / E-mel: [email protected]
3
TPD PART II/v0.3/2015