Accident Claim Form

意外理賠申請書
Policy Number Name of Policyowner
保單號碼 保單持有人姓名

Email Address of Policyowner Name of Life Assured

保單持有人之電郵地址 受保人姓名
*For claim status follow up and
communication use
用作跟進理賠進度及聯絡

Name of Financial Consultant Financial Consultant Contact No.

理財顧問姓名 理財顧問聯絡電話號碼
Financial Consultant Code Division Code & Branch Office
理財顧問編號 分區編號及分行地點

Important Note 重要提示：

1. Please complete in BLOCK LETTERS. 請以正楷填寫。
2. Please submit claim application within 90 days from date of accident. 理賠申請需於意外發生後90天內遞交。
3. Please do not sign on blank or incomplete form. 請勿在空白表格或尚未填妥的表格上簽署。
4. Any changes or amendments in this form must be countersigned by the Claimant in full signature. 索償人必須在此表格內任何更改或修改的地
方簽署作實。
5. Prudential shall have the right to reject this form if you fail to fulfill Prudential’s requirement. 若閣下未能符合保誠的有關規定，保誠有權拒
絕此表格。
6. Receipt of this form by your Financial Consultants or your Broker does not constitute receipt by Prudential. 閣下的理財顧問或經紀收到此表格並
不代表保誠亦已收到。
7. If necessary, please complete and submit the “Request for Certified True Copy of Medical Receipt(s)” form to request for return of the
certified true copy (“CTC”) of the medical receipt(s) which are submitted together with this form. 如需要退回隨附之醫療費用收據之核實副本，請填
妥及交回「醫療費用收據核實副本申請書」。
Part I – Claimant’s Certificate (to be completed by Life Assured / Policyowner / Claimant)
第一部分 – 索償人報告（由受保人/保單持有人/索償人填寫）
A. Claim Details 理賠資料
Benefit(s) to claims Medical Expenses Benefit 醫療費用保障 Type of Claims
理賠類別 Temporary Disablement Benefit 暫時性傷殘保障 理賠種類 New Claim 首次理賠
Dismemberment Benefit 斷肢保障 Further Claim 再度理賠
Total Permanent Disability Benefit 完全永久傷殘保障 Pending Claim 待決理賠
Double indemnity Benefit 雙倍賠償

Have you claimed for compensation from other insurer(s) / Social Welfare
Department / Labour Department or other organization(s) for the same event? No 沒有 Yes, please provide below information
閣下有否就此事曾向其他保險公司/社會福利署/勞工處或其他機構 有，請提供下列所需的資料
申請理賠?
Insurance Company / Organization Policy Number Benefit(s) to claim Result / Status
保險公司 / 機構 保單號碼 理賠類別 結果 / 狀況

Will you claim for compensation from other insurer(s) / Social Welfare
Department / Labour Department or other organization(s) for the same event? No 沒有 Yes, please provide below information
閣下有否就此事將會向其他保險公司/社會福利署/勞工處或其他 有，請提供下列所需的資料
機構申請理賠?

Insurance Company / Organization Policy Number Benefit(s) to claim

保險公司 / 機構 保單號碼 理賠類別

Prudential Hong Kong Limited 保誠保險有限公司

Part of Prudential plc (United Kingdom) 保誠集團成員
1
LACL/ACC (05/23) CPAFRM0501
B. Life Assured Details 受保人資料

Identity Document Number

身份證明文件號碼
Residential Address
居住地址
Name of Employer
僱主（公司）名稱
Address of Employer
僱主（公司）地址
Present Occupation Present Job Duties
現職 職責
Please provide the Last Yes, change occupation since
Occupation Change Date No
/ / 已轉職
請提供最後轉職日期 沒有 有，自
Day日 Month月 Year年
Did you report sick leave to your No Yes, please
present employer? provide information Sick leave
沒有 To
(For self-employed or owner, on the right from
please state the period the 有，請提供右方 至
病假自 / / / /
insured is unable to work due to 所需資料
Day日 Month月 Year年 Day日 Month月 Year年
the injury)
有否向現僱主申請病假？ (Expected) Date returned
(returning) to work / /
(如閣下是自僱人士，請填
(預計) 復職日期 Day日 Month月 Year年
寫是次受傷令閣下不能工作
的期間)

C. Accident Details 意外詳情

Date of Accident Time of Accident
/ / AM 上午 /
意外發生之日期 意外發生之時間
Day日 Month月 Year年 PM 下午 :
Time 時間
Location of Accident
意外發生之地點
Details of Accident (Please
describe activities engaged if
applicable)
意外詳情（如適用，請形容
當時進行之活動)
Describe part(s) of body injured
and extent of injury
請說明受傷部位及傷勢
Did you report to the police? No Yes, please provide Police Station
您有否報警？ 沒有 information on the 警署地點
right
Case Ref. Number
有，請提供右方 檔案編號
所需資料
Remarks: Please attach a photocopy of the Police Report / Traffic Accident Report / Police Statement / Alcohol Test Report.
註：請附上警察報告/交通意外報告/口供紙/酒精測試報告影印本。

D. Consultation Details 診治詳情

Please list out all physicians or hospitals confined for the accident. 請列出所有因是次意外而就診之醫生或醫院資料。
Consultation Date (Day/Month/Year) Name of Physician / Hospital Contact Phone No.
就診日期（日/月/年) 醫生/醫院名稱 聯絡電話

Remarks: Please attach a copy of referral letter by your registered Physician for the claims of Chiropractor/Physiotherapy/Occupational therapy,
Diagnostic X-ray, Laboratory Tests, Home Nursing Service and written recommendation by your registered Physician/ Physiotherapist /Occupational
therapist for purchasing/renting or medical appliances.
註: 如申請脊醫治療/物理治療/職業治療、X光診斷檢查、化驗、家中護理服務之理賠，請附上主診醫生的轉介信副本；如申請購買/
租用醫療器具費用之理賠，請附上主診醫生/物理治療師/職業治療師的書面建議副本。

Prudential Hong Kong Limited 保誠保險有限公司

Part of Prudential plc (United Kingdom) 保誠集團成員
2
LACL/ACC (05/23) CPAFRM0502
E. Settlement Option 理賠支付方式
By Direct Credit to Premium Deposit Account of the policies being claimed 至理賠保單的保費儲蓄戶口
直接轉賬存款 (Only applicable to inforce policy with premium payment 只適用於生效並需繳付保費之保單)
(Only applicable to Temporary
Disablement Benefit and Medical to last claim payout account 至上一次理賠的轉賬戶口
Expenses Benefit claims to a HKD bank account opened in Hong Kong held by the Policyowner 至保單持有人於香港開立的港元戶口
只適用於暫時性傷殘保障及醫療 (Please provide account proof (i.e. copy of bank statement or bankbook bearing the name of account holder and
費用保障之理賠)
account number) 請提供賬戶證明 (即是印有賬戶持有人姓名及銀行賬號之銀行月結單或銀行存摺副本)
Bank No. Branch No Account No
銀行編號 分行編號 銀行賬戶號碼

By Cheque Deliver through Financial Consultant 由理財顧問轉遞

支票 By Ordinary Mail to the Policyowner’s correspondence address in the Company’s record
以平郵方式郵寄至保單持有人於本公司記錄上的通訊地址
Remark 註：
1. Please select only one of the settlement options for each claim submission. If unspecified or without clear instruction, claims cheque in HKD will be
delivered via Financial Consultant. 請就每宗理賠申請選擇一種理賠支付方式。如未有註明或清晰指示，理賠之港元支票將交由理財顧問轉遞。
2. Policy currency will be paid for direct credit to Premium Deposit Account. All other settlements will be made in HKD and the HKD equivalent is
based on the currency exchange rate determined by Prudential on the basis of the Company’s internal exchange rate. 經直接轉賬至保費儲蓄戶口
的理賠金額將以保單貨幣支付。所有其他理賠方法則將以港元支付，而其港元等值將會以保誠公司內部釐定之匯率折算。
3. Claims payout will be made by cheque and delivered via Financial Consultant in case of failure to direct credit to designated bank account or to Premium
Deposit Account. 如理賠金額未能成功轉至指定之銀行戶口或保費儲蓄戶口，相關理賠金額將以支票形式支付及交由理財顧問轉遞。
4. If the bank account provided in this form for claim settlement is non-HKD bank account (e.g. USD account of integrated bank account), the insurance
benefit in Hong Kong dollar will be paid to your designated bank account which may then be converted by your bank from Hong Kong dollar to the
currency of your bank account based on the exchange rate as determined by the bank. Prudential takes no responsibility for the exchange rate imposed by
your bank. 如在本表格指定作理賠金額直接轉賬存款之戶口為非港元戶口(如綜合戶口內的美元戶口)，以港元支付之保險理賠金額將入賬於閣下指定
之戶口，貴銀行可能隨即根據其釐定之匯率折算為戶口之貨幣。保誠不會就貴銀行釐定的匯率折算負上任何責任。
5. Prudential reserves the right for final decision of the claims settlement option. 保誠對理賠支付方式擁有最終的決定權。

Prudential Hong Kong Limited 保誠保險有限公司

Part of Prudential plc (United Kingdom) 保誠集團成員
3
LACL/ACC (05/23) CPAFRM0503
F. Documents Submission Checklist 所需文件檢核表 (Original documents will NOT be returned 正本恕不退還)

Document Type Medical Expenses Temporary Dismemberment Benefit Total Permanent

Benefit Disablement Benefit 斷肢保障 Disability Benefit
文件類別
醫療費用保障 暫時性傷殘保障 完全永久傷殘保障
Claim Form Part I and Part II
   
理賠申請書第一及第二部分
Claim Form Part III 
理賠申請書第三部分 For non-self-employed
# life assured claiming # #
temporary disability
benefit over 10 days
如非自僱受保人並需
索償超過10日暫時性
傷殘保障賠償
Copy of Identification Document of Life Assured &
Policyowner    
受保人及保單持有人之身份證明文件副本
Copy of Laboratory / X-Ray/ CT scan / MRI /
Pathological Report(s), if applicable    
化驗 / X-光/ 電腦掃瞄/磁力共振/病理檢驗報告
副本，如適用
Copy of Admission Note, Discharge Summary,
Discharge Certificate, Daily Medical Record &    
Temperature Sheet of hospital in Mainland China
中國內地醫院之病案首頁、入院紀錄、出院
總結、每日醫囑單及體溫表副本
Copy of Sick Leave Certificate with clear diagnosis
   
列明診斷證明之病假證明書副本
Copy of Discharge Summary / Discharge Slip
  # #
出院總結/出院紙副本
Original Medical Receipt(s) and Statement(s) of
Charges  # # #
醫療收據及收費單（費用明細表）正本
Copy of Chiropractic / Physiotherapy / Occupational
Therapy Report(s), if applicable # # # #
脊醫治療/物理治療/職業治療報告副本，如適用
Copy of Referral letter Registered Doctor / Hospital,
applicable to Chiropractic, Physiotherapy, occupational  # ○ ○
therapy and home nursing service
註冊醫生/醫院轉介信副本, 適用於脊醫治療、
物理治療、職業治療或家中護理服務
Copy of written recommendation by Registered
Doctor / Physiotherapist / Occupational Therapist,
applicable to charges in purchasing/renting of medical # ○ ○ ○
appliances
註冊醫生/物理治療師/職業治療師之書面建議
副本，適用於購買或租用醫療器具費用
Others, if applicable (for example: copy of Settlement
Advice from another insurance provider, Copy of Labor
Assessment Certificate, copy of police report, copy of # # # #
police statement, copy of income proof)
其他，如適用（如其他保險機構之理賠通知書
副本；勞工判傷紙副本；警察報告副本；
口供紙副本，入息證明副本）
 
Copy of account proof For direct credit to Hong For direct credit to Hong ○ ○
賬戶證明副本 Kong HKD a/c only Kong HKD a/c only
如選擇直接轉賬至 如選擇直接轉賬至
香港港元戶口 香港港元戶口
 Required Documents 基本文件 # Additional Documents 附加文件 ○ Not applicable

Prudential Hong Kong Limited 保誠保險有限公司

Part of Prudential plc (United Kingdom) 保誠集團成員
4
LACL/ACC (05/23) CPAFRM0504
G. Personal Information Collection Statement (Con't) 收集個人資料聲明
Prudential Hong Kong Limited (referred to as “Company”, “our”, “we”, or “us”) take the privacy and protection of your personal information seriously. We
collect personal information from you that is necessary or helpful for us to either provide you with the product or service you have requested or to comply
with statutory or contractual requirements (including the purposes mentioned below), or even for security purpose. We may collect personal information
including, but not limited to, full name, address, contact details, contact details history, date of birth, gender, nationality, family members,
beneficiaries, identity card copy and details, travel document information, health/medical records, credit information, product history, claims history,
biometric data including but not limited to your voice pattern, fingerprint and facial images, your location information based on your device, financial and
medical information ("Personal Information") to provide you with the insurance or financial products or services. “Personal information” shall also include, but
not be limited to, the personal information relating to your beneficiaries (or any other person designated or entitled to receive any benefits under an
insurance policy), dependents, authorised representatives, company staff, and other individuals in relation to which you have provided personal information.
If you provide personal information about another person to us, you confirm that you are either their parent or guardian or you have obtained that person's
consent to provide such personal information for use and transfer by the Company for the purposes set out in this PICS. We may also collect Personal
Information about you from third parties such as other insurance companies, agents, credit reference/reporting agencies, vendors, financial institutions, fraud
prevention agencies, government agencies, medical personnel, courts or public record.
China Personal Information Protection Law (PIPL)
The PIPL Addendum supplements the Personal Information Collection Statement and applies to you if you are located in Mainland China. The PIPL
Addendum is available on our website at https://www.prudential.com.hk/en/china-personal-information-protection-law/
1. Purpose of Collection
We may use your Personal Information for the following purposes: (a) the administration of our products and services, including to provide any
relevant services as discussed with you prior to any purchase of a product or service; (b) to process your application; (c) to administer and process
insurance policies, insurance claims, medical, security and underwriting checks; (d) to process payment instructions; (e) to verify your eligibility for
insurance, financial or wealth management products and services; (f) to design and provide you with insurance, financial and related products and
services; (g) to communicate with you;
(h) to comply with any regulatory or other legal requirements or other internal business requirements (whether imposed on us or any third parties in
Section 2 below), including but not limited to anti-money laundering and Know-Your-Client obligations; (i) to investigate and settle claims and detect
and prevent fraud (whether or not relating to the policy issued in respect of this application) and/or other illegal activity, or security or technical
issues; (j) to carry out checks using agencies including credit reference agencies, tracing companies or publicly available information; (k) to provide customer
services; (l) to perform automated decision-making or profiling; (m) to perform a policy review or needs analysis; (n) to conduct research and statistical
analysis (including use of new technologies); (o) to administer lucky draws and other contests; (p) to enable us to perform our obligations to you; (q) to keep
your information on record and carry out other internal business administration; (r) with your specific consent where required for direct marketing as
explained in Section 3 below, personalise and tailor, customised promotions, messages and suggestions to you; and (s) any other purpose directly
relating to any of the above purposes. With your consent, we may also use your personal data to send you marketing communications, as described in
Section 3 below.
Some of the purposes above are necessary to allow us to perform our contractual obligations to you and to enable us to comply with applicable laws and
regulation. We may also use and share your Personal Information for the purposes described above to improve our products and services. Your Personal
Information will be stored either for as long as you (or your joint policyholder) are our customer, or longer if required by law or as is otherwise necessary.
2. Classes of Transferees
We may disclose your Personal Information to the group of companies including the Company and those of other entities whose ultimate parent company is
Prudential plc including but not limited to Prudential General Insurance Hong Kong Limited ("companies within the Prudential Group”) and their respective
insurance agents, and to our financial/medical/wellness/health business partners. We may also disclose your Personal Information to the following third
parties (within or outside Hong Kong) for the purposes outlined at Section 1 above: (a) insurance agents; (b) insurance brokers; (c) re-insurance companies; (d)
claims investigation companies; (e) organisations that consolidate claims and underwriting information for the insurance industry, fraud prevention
organisations, other insurance companies (whether directly or through fraud prevention organisations or other persons named in this paragraph) and
databases or registers (and their operators) used by the insurance industry to analyse and check information provided against existing information; (f)
third party service providers who provide administrative, telecommunications, computer, information technology, data processing and storage, customer
satisfaction analysis, payment, printing, redemption or other services to us to enable us to operate our business (including without limitation other insurers,
lawyers, bankers, accountants, professional advisors, financial institutions and trustees, auditors, IT service and platform providers, insurance intermediaries,
investment managers, agents, pension trustees (and other stakeholders), scheme advisors, introducers, and selected third party financial and insurance
product providers); (g) industry associations and federations; (h) medical bill review companies; (i) your joint policy or investment holder; (j) researchers; (k)
credit reference agencies; (l) debt collection agencies; (m) partnering financial institutions and partnerships; and (n) financial crime prevention agencies,
any legal, regulatory, law enforcement or government bodies and the courts. We may also disclose your Personal Information to an actual or proposed
assignee or participant in connection with a transaction with another company which affects the control, governance, structure and/or management of
all or a substantial part of our business, or if required to satisfy applicable legal or regulatory requirements. With your consent, we may also disclose
your personal data to third parties to allow them to send you marketing communications, as described below.
3. Use and Transfer of Personal Data for Direct Marketing Purposes
With your consent, we intend to use your name and contact details for promotional and marketing purpose including sending marketing
communications and conducting direct marketing to you by electronic and non-electronic means including by post, in relation to the following products,
services and subjects, and we require your consent in order to do so: insurance; annuities; retirement schemes; pensions; wealth and financial management;
estate management; investment; financial; medical/wellness/health related products, reward/loyalty programme services and subjects ("Classes of Marketing
Subjects").
We also intend to transfer your name and contact details to our insurance agents, other companies within the Prudential Group and their respective insurance
agents, our Business Partners, and our Marketing Partners, to enable them to market any of the Classes of Marketing Subjects to you, and your written
consent is required in order for us to do so. We may provide your personal data to such transferees for gain.
If you change your mind, and / or you would like to opt-out of receiving direct marketing, you can advise our Data Protection Officer at [email protected].
4. Consequence of failing to provide Personal Information
Unless otherwise specified by us, it is mandatory for you to provide the Personal Information requested by us. If you do not provide such Personal Information,
we may not be able to provide you the product or service that you’ve requested.
5. Access and Correction Rights
Under the Personal Data (Privacy) Ordinance (the "Ordinance"), you have the right to request access to and correction of any Personal Information that you
provide to us. If want to exercise your rights, or if you require any other information, you can advise our Data Protection Officer at [email protected]
or contact us using the details on “Contact Us” section of the Company website (https://www.prudential.com.hk/scws/pages/en/contact-us/contact-us-
home/index.html) or our Privacy Notice.
If you move/moved to a European Union (“EU”) jurisdiction, we may be required to provide you with further information, and you may have additional
rights, under the EU General Data Protection Regulation. This information and these rights are set out in the Privacy Notice on our Company website.
We update our Privacy Notice from time to time. We encourage you to familiarise yourself with the Privacy Notice on our Company website. The Privacy
Notice is available on our Company website at https://www.prudential.com.hk/scws/pages/en/privacy-policy/index.html. By completing and progressing with
this form, you confirm that you have read and understood this PICS.
Business Partners means our service providers who provide administrative, telecommunications, computer, information technology, data processing
and storage, customer satisfaction analysis, payment, printing, redemption or other services to us to enable us to operate our business, accountants, auditors,
IT service and platform providers, insurance intermediaries, reinsurers, investment managers, agents, pension trustees (and other stakeholders), scheme
advisors, introducers, selected third party financial and insurance product providers, and our legal advisers.
Marketing Partners means our service providers who provide administrative, telecommunications, computer, payment, printing, third-party rewards/
loyalty/privileges programs, medical/health/wellness related products, redemption or other services to us to enable us to operate our business, insurance
intermediaries, pension trustees (and other stakeholders), scheme advisors, introducers and selected third party financial and insurance product providers.

Prudential Hong Kong Limited 保誠保險有限公司

Part of Prudential plc (United Kingdom) 保誠集團成員
5
LACL/ACC (05/23) CPAFRM0505
G. Personal Information Collection Statement (Con't) 收集個人資料聲明 ( 續 )

保誠保險有限公司（簡稱「本公司」或「我們」）認真對待閣下個人資料的私隱及保護。為使我們可以向閣下提供閣下要求的產品或
服務，或為遵守法定及合約要求，我們會向閣下收集必要或有幫助的個人資料。為向閣下提供保險或金融產品或服務 , 遵守法定或合
同要求（以下概述的其他目的），及保安目的，我們可能會向閣下收集個人資料，包括但不限於全名、地址、聯絡資料、過往聯絡
資料、出生日期、性別、國籍、家庭成員、受益人、身分證副本及資料、旅遊證件資料、健康 / 醫療紀錄、信貸資料、過往產品紀
錄、過往索償紀錄、生物辨識資料，包括但不限於閣下的聲音模式、指紋及面部圖像、基於閣下的流動或其他電子裝置收集閣下
的位置資料、財務及醫療資料（「個人資料」）。「個人資料」將包括但不限於與有關以下人士的個人資料：閣下的受益人（或任何
其他根據保單被指定或有權獲得任何利益的人）、收養人、授權代表、公司職員和閣下曾提供其個人資料的其他人士。如閣下向我們
提供其他人士的個人資料，即表示閣下確認閣下是該人的父母或監護人或閣下已取得該人士的同意以提供個人資料供本公司按此收集
個人資料聲明的目的使用和轉移。我們亦可能會從第三方，如其他保險公司、代理、信貸資料服務 / 報告機構、供應商、金融機構、
防欺詐機構、政府機構、醫務人員、法院或公開紀錄，收集關於閣下的個人資料。
《中華人民共和國個人信息保護法》
中 國 內 地 補 充 內 容 是 對 本 個 人 信 息 收 集 聲 明 的 補 充， 如 果 您 在 中 國 內 地 則 適 用 此 補 充 內 容。 您 可 在 本 網 站
https://www.prudential.com.hk/tc/china-personal-information-protection-law/ 查閱中國內地補充內容。

1. 收集資料之目的
我們可能會使用閣下的個人資料作下列目的︰ (a) 管理我們的產品和服務，包括在購買產品或服務之前提供已與閣下討論的任何相關
服務；(b) 處理閣下的申請；(c) 管理和處理保單、保險索償、醫療、抵押和承保檢查；(d) 處理付款指示；(e) 核實閣下申請保險、金融
或財富管理產品及服務的資格；(f) 設計及為閣下提供保險、金融及相關的產品和服務；(g) 與閣下進行通訊；(h) 遵守任何監管或其他法
律規定或其他內部業務規定（不論是向我們或下述第2 部分所列的任何第三方實施），包括但不限於打擊洗錢和認識你的客戶(KYC) 義務；
(i) 就索償進行調查及和解，以及偵查及防止欺詐（不論是否有關就本申請簽發的保單）及 / 或其他非法行為或安全 / 技術問題； (j)
使用代理機構（包括信貸資料服務機構）、追蹤公司或公開可得資料以執行核查；(k) 提供客戶服務；(l) 執行自動決策或資料剖析；
(m) 進行保單審查或需求分析；(n) 進行研究和統計分析（包括使用新科技）；(o) 進行管理幸運抽獎和其他比賽；(p) 使我們能夠履行對
閣下的義務；(q) 保持閣下的資料記錄並執行其他內部業務管理；(r) 為直接市場推廣需要並在有需要時經閣下的特定同意下，如以下第
3 部分所述，為閣下量身訂製個性化的促銷、消息和建議；及 (s) 與上述任何目的直接相關的任何其他目的。經閣下同意，我們亦可能
會按照以下述第 3 部分所列使用閣下的個人資料以向閣下發出促銷通訊。
為履行對閣下的合約責任及至使我們能夠遵守適用法律及法規，上述部分目的屬必要的。我們亦可能會為上述所列的目的使用及分享
閣下的個人資料以改善我們的產品及服務。只要閣下（或閣下的聯名保單持有人）仍為我們的客戶，我們將一直保存閣下的個人資料，
或如法律有所規定或因其他原因而為必要，我們則將其保存更長時間。
2. 被資料轉交者的類別
我們可能會向該公司集團，包括本公司以及其他母公司為英國保誠集團的實體包括但不限於保誠財險有限公司（「保誠集團內的
公司」）及他們各自的保險代理，及我們的金融 / 醫療 / 保健 / 健康業務夥伴，透露閣下的個人資料。為達到上述第一部分所列明之
目的，我們亦可能會向下列第三方（在香港境內或境外）透露閣下的個人資料︰ (a) 保險代理；(b) 保險經紀；(c) 再保險公司；(d) 索償
調 查公司；(e) 為保險業整合索償及承保資料的組織、防欺詐組織、其他保險公司（不論直接或透過防欺詐組織或本段指名的其他人
士），及保險業用作分析及核查現有資料與及後提供的資料而使用的數據庫或登記冊（及其營運商）；(f) 提供行政、電訊、電腦、信
息技術、數據處理及儲存、客戶滿意度分析、付款、印刷、贖回或其他服務以令我們的業務可以運作的第三方服務供應商（包括但不限
於其他保險公司、律師、銀行家、會計師、專業顧問、金融機構及受託人、審計師、IT 服務及平台供應商、保險中介、投資經理、代
理、退休金受託人（及其他持份者）、計劃顧問、介紹人及選定的第三方金融和保險產品供應商）；(g) 行業協會及聯會；(h) 醫療賬單審查
公司； (i) 閣下的聯名保單或投資持有人；(j) 研究人員；(k) 信貸資料服務機構；(l) 收賬代理；(m) 夥伴金融機構及合作夥伴；及 (n) 預
防金融罪案機構、任何法律、監管和執法機構或政府機構及法院。在有關影響到我們全部或重大部分業務的控制權、治理、結構及 /
或管理的與另一公司的交易時，或在必須符合適用的法律或監管要求下，我們亦可能會透露閣下的個人資料予該等的實在或擬議受
讓人或參與人。經閣下同意，我們亦會向第三方透露閣下的個人資料以讓該等第三方向閣下發出促銷通訊（如下文所述）。
3. 使用及轉移個人資料作直接促銷用途
經閣下的同意，我們擬使用閣下的姓名和聯絡資料，用於宣傳和市場推廣用途，包括通過電子和非電子方式（包括郵寄）向閣下發送市
場推廣通訊和進行直接促銷，就以下產品、服務和目的，我們需要閣下的同意才可以這樣做: 保險；年金；退休計劃；退休金；財富和
財務管理；遺產管理；投資；金融；醫療 / 保健 / 健康相關產品；獎賞 / 優惠計劃服務及目的（「促銷標的類別」）。
我們亦擬將閣下的姓名和聯絡資料轉移給我們的保險代理人、保誠集團內的其他公司及其保險代理人、我們的業務合作夥伴和營銷合作
夥伴，以使他們能夠向閣下推銷任何促銷標的類別，並且需要閣下的書面同意才能這樣做。 我們可能因向此類受讓人提供閣下的個人資
料而獲得利益。
如閣下改變主意，及 / 或閣下想選擇不接受直接市場推廣，可以與我們的資料保護主任聯絡 ([email protected])。
4. 未能提供個人資料的影響
除非我們另有規定，否則閣下必須提供我們要求的個人資料。若閣下未提供有關個人資料，我們可能無法為閣下提供所要求的產品或服務。
5. 查閱和更正的權利
根據《個人資料（ 私 隱 ） 條例》（「 條 例 」），閣下有權要求查閱及更正任何閣下提供給我們的個人資料。閣下如欲行使閣
下 的 權 利 ， 或 如 閣 下 需 要 任 何 其 他 資 料 ， 請 聯 絡 我 們 ， 閣 下 可 以 發 送 電 郵 至 [email protected] 或 使 用 本 公 司 網 站
(https://www.prudential.com.hk/scws/pages/tc/contact-us/contact-us-home/index.html) 或我們的私隱通知中「聯絡我們」部分所列的資料與我們的資
料保護主任聯絡。
如閣下搬遷/ 已搬遷至歐洲聯盟（「歐盟」）司法管轄區，我們可能需要向閣下提供進一步資料，且閣下可能在歐盟《通用數據保障條例》
下享有額外權利。此類資料及此等權利均載於本公司網站上的私隱通知中。
我 們 會 不 時 更 新 我 們 的 私 隱 通 知， 並 建 議 閣 下 瀏 覽 本 公 司 網 站 以 了 解 該 私 隱 通 知。 該 私 隱 通 知 可 在 本 公 司 網 站
〔https://www.prudential.com.hk/scws/pages/tc/privacy-policy/index.html〕上查閱 。閣下填妥並繼續提交本表格，即表示閣下確認已閱讀並理解本
收集個人資料聲明。
業務合作夥伴指我們的服務供應商、提供行政、電信、電腦、信息技術、數據處理及儲存、客戶滿意度分析、支付、印刷、贖回或其他
服務予我們，以使我們能夠經營我們業務，會計師、審計師、IT 服務和平台供應商、保險中介機構、再保險承保人、投資經理、代理、
退休金受託人（和其他持分者）、計劃顧問、介紹人、核准的第三方金融和保險產品供應商以及我們的法律顧問。
營銷合作夥伴指我們的服務供應商提供行政、電信、電腦、支付、印刷、第三方獎賞 / 會員 / 優惠計劃、醫療 / 健康 / 保健相關產品、
贖回或其他服務，以使我們能夠經營我們業務、保險中介、退休金受託人（和其他持分者）、計劃顧問、介紹人和核准的第三方金融和保險
產品供應商。

Prudential Hong Kong Limited 保誠保險有限公司

Part of Prudential plc (United Kingdom) 保誠集團成員
6
LACL/ACC (05/23) CPAFRM0506
Are you currently a customer in mainland China? 您現在是否是個中國內地客戶？
Yes 是
(If “Yes”, please tick below box to agree the following statement. If you disagree with this statement, we may not be able to process your request / application.
如「是」，請勾選以下選項以同意下列聲明。如您不同意以下聲明，我們可能無法處理您的指示/申請。)
By ticking this box, you agree that as an international group company, in order to provide insurance-related products or services,
we may need to store and process your personal information outside of mainland China. Please refer to our Privacy Notice
(https://www.prudential.com.hk/en/china-personal-information-protection-law/) for more information.
勾選此項，表示您同意，我們作為國際集團公司，為提供保險相關產品或服務，可能需要在中國內地境外存儲或處理您的
個人信息。更多資訊，請參閱我們的隱私聲明 (https://www.prudential.com.hk/tc/china-personal-information-protection-law/)。
No 否

H. Declaration & Authorization 聲明及授權

I / We, the Life Assured / Policyowner / Claimant, declare that the above information is true and complete to the best of my / our knowledge and belief.
I / We, the Life Assured / Policyowner / Claimant, hereby confirm my / our understanding of and agreement to the above Personal Information Collection
Statement.
I / We, the Life Assured / Policyowner / Claimant, authoriz e on behalf of myself / ourselves and the minor Life Assured (if any) that (1) any doctors, hospitals,
clinics, insurance companies, employers, organizations and persons that have any medical history or records or knowledge of me / us / the minor Life
Assured, whom I / we / the minor Life Assured have attended or may hereafter attend may disclose such information to Prudential Hong Kong Limited ("the
Company") for the purpose of assessing and processing the proposal for assurance and claims and providing subsequent services. To avoid any uncertainty,
this authorization shall binding on my / our successors, assignees, executors and administrators and shall remain valid notwithstanding my / our death or
incapacity (including but not limited to mental incapacity). A photocopy of this authorization shall be deemed to be valid as the original; (2) the Company or
any of its appointed medical examiners or laboratories may perform the necessary medical assessment and tests to underwrite and evaluate the health status
of myself / ourselves / the minor Life Assured in relation to the proposal for assurance and any claims arising therefrom.
本人 / 吾等，受保人 / 保單持有人 / 索償人，特此聲明就本人 / 吾等所知所信，以上資料均為正確無訛及完整。
本人 / 吾等，受保人 / 保單持有人 / 索償人， 在此確認本人 / 吾等明白並同意上述之收集個人資料聲明。
本人 / 吾等，受保人 / 保單持有人 / 索償人，代表本人 / 吾等及尚未成年之受保人（如有）茲授權（1）任何醫生、醫院、診
所、保險公司、僱主、機構或人士，將已經或其後存錄的有關本人 / 吾等 / 尚未成年之受保人之醫療病歷、紀錄或其他資料披露
予保誠保險有限公司（“貴公司”），作為評估及處理此投保申請及索償及提供其後服務之用。為免任何疑問，本授權書對本人 /
吾等之繼承人、受讓人、遺囑執行人及遺產管理人均具有約束力。即使本人 / 吾等死亡或無行為能力（包括但不限於精神上無行為
能 力 ），本授權書仍具約束力。本授權書之副本將被視為與正本具同樣效力；（2）貴 公 司 或 任 何 由 貴 公 司 指 定 之 醫 生 、 醫 務
人員或化
驗所，可就此投保申請或任何有關索償申請替本人 / 吾等進行所需之醫療評估及測試，以審核本人 / 吾等之健康狀況。
If Life Assured is on or above the age of 18, the form should be signed by him/her. If Life Assured is below the age of 18, the Policyowner should sign on his/her
behalf. If Life Assured and Policyowner are not able to sign on the form, the Claimant should sign on their behalf.
如受保人年滿 18 歲，則由受保人簽署。受保人未滿 18 歲，則由保單持有人簽署。如受保人及保單持有人未能簽署，則由索償人簽署。

/ /
Day日 Month月 Year年 Signature of Policyowner / Claimant Name of Policyowner / Claimant
保單持有人/索償人簽名 保單持有人/索償人姓名

Identity Document Number of Policyowner / Claimant

保單持有人/索償人身份證明文件號碼

/ /
Day日 Month月 Year年 Signature of Life Assured Name of Life Assured
受保人簽名 受保人姓名

Identity Document Number of Life Assured

受保人身份證明文件號碼

Please DO NOT sign on BLANK form. 請勿在空白表格上簽署。

Prudential Hong Kong Limited 保誠保險有限公司

Part of Prudential plc (United Kingdom) 保誠集團成員
7
LACL/ACC (05/23) CPAFRM0507
 Policy Number 保單號碼：

Part II – Medical Certification (to be completed by the Attending Physician, duly qualified and registered, at the claimant’s expense)
第二部分 – 醫療報告（由索償人自費聘請主診註冊醫生填寫）
Patient Details 病人資料
1. Name of Patient
病人姓名
2. Identity Document Number
身份證明文件號碼
3. Age 4. Sex
年齡 性別
5. Occupation and duties
職業及職責
6. Are you the patient’s usual No 否 Yes, medical records traceable to
hysician? 是，醫療紀錄可追溯至 / /
你是否病人慣常求診的 Day日 Month月 Year年
醫生?
Consultation Details for this accident 就是次意外之求診資料
7. FIRST consultation date 8. Date of Accident
for this accident / / 意外日期 / /
病人首次就此意外向 Day日 Month月 Year年 Day日 Month月 Year年
閣下求診之日期
9. Cause of injury
意外受傷的原因
10. Part(s) of body injured
受傷部位
11. Any visible wound? No Yes, please tick where it is appropriate and provide details
有否可見傷痕 沒有 ”號及提供詳情
有，請在適當位置劃上“
Wound 傷痕 Details 詳情

Bruises 瘀痕

Swelling 腫脹

Contusion 挫傷

Laceration / abrasion / wound

割傷/擦傷/傷口
Others, please specify
其他，請註明

12. Nature and degree of injury

傷勢的性質及程度
13. Was hospitalization No Yes, please provide below information
required? 否 是，請提供以下資料
是否需要住院？
Hospitalized from / / To / /
住院日期由 Day日 Month月 Year年
至 Day日 Month月 Year年
Hospital Name
醫院名稱
14. Please state the investigations/ treatments administered (e.g. X-ray, physiotherapy, etc.) and results for this accidental injury
請列明因這次意外受傷而接受之檢查或治療項目（例如X光、物理治療等）及結果
Date (DD/MM/YYYY) Investigations / Treatments Result / Progress
日期（日/月/年) 檢查 / 治療 結果 / 進度

Remarks: Please attach copies of X-ray report / physiotherapy report / operation summary, etc..
註：請連同X-光報告 / 物理治療報告/手術撮要等副本一併交回。

Prudential Hong Kong Limited 保誠保險有限公司

Part of Prudential plc (United Kingdom) 保誠集團成員
8
LACL/ACC (05/23) CPAFRM0508
Consultation Details for this accident (Continued) 就是次意外之求診資料（續）
15. Subsequent consultation 16. Subsequent treatment
date details
隨後的診治日期 隨後的治療詳情
17. Present condition of
Injury / degree of recovery
現時受傷的情況 / 康復
程度
18. Describe the current range
of motion of the injured
area
請詳述受傷部位現時之
活動程度
19. Describe the progress of
recovery
請詳述康復進度
Recovery Progress and Impact Details 康復進度及影響資料
20. Is recovery progress No Yes, please provide Reason
complicated by other 沒有 information on the 原因
factors? right
有否其他因素影響康復 有，請提供右方
進度？ 所需資料

Treatment given
治療詳情

21. Is the patient now, or was No Yes, provide details Details

he / she at the time of 沒有 有，請提供有關 詳情
this accident suffering / 詳情
suffered from any illness,
disease or infirmity
病人現在或發生意外
當時，有否已患上任何
疾病或缺陷?
22. To the best of your No Yes, please tick where it is appropriate and provide details
knowledge, was such 否 有，請在適當位置劃上 “”號及提供詳情
accident due to or aggravated
Alcohol / narcotics / Hazardous sport / Degenerative changes /
by the following(s)?
drug abuse activity congenital abnormalities
根據閣下所知，意外是 退化/先天性異常
飲用酒精飲料/毒品/ 參與危險性運動/活動
否因下列情況而導致或
加劇? 濫用藥物
Self-inflicted injury Past injury / illness AIDS/AIDS related complex
自我傷害 過往的傷患/疾病 diseases
後天免疫力缺乏症/後天
免疫力缺乏症相關的
綜合症
Pregnancy/Childbirth/ Others, please specify details
Complications arising 其他，請詳細說明
from pregnancy
懷孕/分娩/懷孕引起
的併發症
23. Bearing in mind the declared occupation of this patient, please indicate the effect of the accident / disablement:
以病人的職業而論，請詳述此意外/傷勢對其的影響：
a) Describe on how the Severity of disability 傷殘嚴重程度
injury, disablement affect Cannot perform his/her own duties and occupation 不能從事其本身之工作或職業
the patient’s daily job
Cannot perform any kind of work and duties不能從事任何工作或職業
activity(ies)
請詳述此意外/傷勢對 Duration of disability 傷殘持續時間
其日常工作的影響 Period which patient is not able to perform some of his duties from to
喪失部分工作能力的時間 由 D日M月Y年 至 D日M月Y年

Period which patient is not able to perform all of his duties from to
喪失全部工作能力的時間 由 D日M月Y年 至 D日M月Y年

b) Please explain the reason

why the patient cannot
return to work earlier
請詳述病人未能提早
復工之原因

Prudential Hong Kong Limited 保誠保險有限公司

Part of Prudential plc (United Kingdom) 保誠集團成員
9
LACL/ACC (05/23) CPAFRM0509
Recovery Progress and Impact Details (Continued) 康復進度及影響資料（續）
24. Please evaluate patient’s ability on the following activities of daily living (for non gainfully employed or retired life assured claiming Total
Permanent Disability Benefit only)
請評估病人就下列日常生活活動之能力（只適用於非在職或退休受保人並需索償完全永久傷殘保障）
Washing - the ability to wash in bath or shower or to wash No help is required 不需要協助
satisfactorily by other means Some help or supervision are required 偶爾需要協助或指導
洗澡 - 於浴缸洗澡或淋浴（包括進出浴缸或淋浴室）的 Need someone to help most of the time 大部分時間都需要協助
能力或以其他方式滿意及合理地完成梳洗
Not able to do ownself at all 完全無法自行完成

Dressing – the ability to put on, take off, secure and unfasten No help is required 不需要協助
all garments and, as appropriate, any braces, artificial limbs or
Some help or supervision are required 偶爾需要協助或指導
other surgical appliances
Need someone to help most of the time 大部分時間都需要協助
更換/穿著衣服 - 穿上、脫下、繫緊或鬆開各種衣服或
任何適當的支架、義肢或其他外科器具的能力。 Not able to do ownself at all 完全無法自行完成

Feeding – the ability to feed oneself once food has been No help is required 不需要協助
prepared and made available
Some help or supervision are required 偶爾需要協助或指導
進食 - 當食物準備好時，自己進食的能力。 Need someone to help most of the time 大部分時間都需要協助
Not able to do ownself at all 完全無法自行完成

Toileting – the ability to use the lavatory or otherwise manage No help is required 不需要協助
bowel and bladder function as as to maintain a satifactory level
Some help or supervision are required 偶爾需要協助或指導
of personal hygiene
Need someone to help most of the time 大部分時間都需要協助
如廁 - 使用洗手間或控制大小便，以保持滿意的個人
衛生的能力。 Not able to do ownself at all 完全無法自行完成

Transferring – the ability to move from a bed to an upright chair No help is required 不需要協助
or wheelchair and vice versa
Some help or supervision are required 偶爾需要協助或指導
移動能力 - 從床移動到直背椅子或輪椅上的能力，及從
椅子或輪椅移動到床的能力。 Need someone to help most of the time 大部分時間都需要協助
Not able to do ownself at all 完全無法自行完成

Other Related Information 其他相關資料

25. Did you refer the patient No Yes, please provide Name of the
to another physician / 否 information on the physician / hospital
hospital? right 醫生/醫院名稱
你有否轉介病人往其他 有，請提供右方
醫生或醫院？ 所需資料

Address of the
physician / hospital
醫生/醫院地址

Details for the

referral reason
詳述轉介原因

26. Had other physicians No Yes, please provide Consultation Date

treated the patient for the 否 information on the 求診日期 / /
same accident? right
Day日 Month月 Year年
病人曾否就此次意外向 有，請提供右方
其他醫生求診？ 所需資料
Name of Physician
醫生姓名

Address of Physician
醫生地址

Prudential Hong Kong Limited 保誠保險有限公司

Part of Prudential plc (United Kingdom) 保誠集團成員
10
LACL/ACC (05/23) CPAFRM0510
Physician Details 醫生資料

Name of Attending Physician Qualification

主診醫生姓名 資歷

Hospital Name (if applicable) Telephone No.

醫院名稱（如適用） 聯絡電話

Address
地址

Signature & Hospital / Date

Physician’s Chop / /
日期 Day日 Month月 Year年
醫院 / 醫生簽署及蓋印

Prudential Hong Kong Limited 保誠保險有限公司

Part of Prudential plc (United Kingdom) 保誠集團成員
11
LACL/ACC (05/23) CPAFRM0511
Part III – Confirmation of Sick Leave (Please have Insured’s Employer to complete)
第三部分 – 確認病假證明 (請受保人之僱主填寫)
Please complete this part for below claims type 以下索償種類請填妥此部分：
Required 基本
-Temporary Disablement Benefit 暫時性傷殘保障 (for non-self-employed life assured claiming temporary disability benefit over 10 days如非自僱受保人
並需索償超過10日暫時性傷殘保障賠償)
Where applicable 如適用
-Dismemberment Benefit 斷肢保障
-Total Permanent Disability Benefit 完全永久傷殘保障
Employee’s Information 僱員資料
Name
姓名

Identity Card Number

身份證明文件號碼

Position
職位

Reason of taking sick leave

休假原因

Sick Leve Period From to

病假日期 / / / /
由 至
Day日 Month月 Year年 Day日 Month月 Year年

Employer’s Information 僱主資料

Signature of Employer & Title
僱主簽署及職位

Contact Person & Contact Number

聯絡人及聯絡電話號碼

Company Address
公司地址

Company Chop
公司印章

Date (D/M/Y)
日期 (日/月/年)

Prudential Hong Kong Limited 保誠保險有限公司

Part of Prudential plc (United Kingdom) 保誠集團成員
12
LACL/ACC (05/23) CPAFRM0512