GROUP HOSPITALIZATION CLAIM FORM

Name of Employer Group Policy No.

Special Please select

( _________________________________) This claim
will be processed under our Company Individual policy first, the balance will be claimed under above Group policy.
( ____________________________________) This claim
will be processed under above Group policy first, the balance will be claimed under our Company Individual policy.

INSURANCE INTERMEDIARY INFORMATION

Name of Insurance Intermediary

Insurance Intermediary Code Contact No.

IMPORTANT NOTE
- / / Please complete this form in BLOCK
LETTERS. All amendments should be endorsed by the Employee /Patient /Claimant in full signature.
- The expressions "the Company" or "our
Company" used in this form refers to China Life Insurance (Overseas) Company Limited.
- One form for one patient only.
- / / This Claim Form must
be completed and returned with all the original receipts to the Insurance Company by the Employee /Patient /Claimant within 90 days after the
discharged date otherwise claim will not be approved.
-
/ If the Patient
is at or above age 18, the Patient and Employee must complete and sign this form by his or her good self. If the Patient is under age 18, this form
should be completed and signed by the Employee or legal guardian. In the event that the Employee / Patient is physically incapacitated and prevented
from signing, this form may be completed and signed by an immediate family member with relevant relationship proof and physician's statement
provided.
- / /
If the Employee/Patient /Claimant uses a signature stamp, it must be witnessed by a witness. The personal
particulars of the witness will only be used for the purpose of processing this claim and verifying and confirming the identity of the signatory of this
form.
- Receipt of this form by your Insurance Intermediary does not constitute receipt by the
Company.
- (852) 3999 5500
313 24 If you have any queries, please feel free to contact your insurance intermediary or our
Customer Service Hotline at (852) 3999 5500 for details. Completed form(s) and required document(s) should be sent to China Life Insurance
(Overseas) Co. Ltd., 24/F, CLI Building, 313 Hennessy Road, Wan Chai, Hong Kong.
- www.chinalife.com.hk
The Company has the right to update this form from time to time and to accept or to reject the form if the Company's requirements are
not fulfilled. Please visit our website www.chinalife.com.hk to view and download the latest version of the form.
- If there is any discrepancy or inconsistency between the English version and the
Chinese version of this form, the Chinese version shall prevail.

HK-CL-GCLA-03/202212-01 P. 1 of
 Group Policy No.

– ( / / )
PART I – PARTICULARS OF CLAIM (To be completed by Employee /Patient /Claimant)
A. / INFORMATION OF EMPLOYEE / PATIENT
1 Name of Employee ( ) Name of Patient (if other than employee)
Chinese Chinese

English English

2 / I.D. Card / Passport No. of Employee / I.D. Card / Passport No. of Patient

3 Relationship with Employee

B. GENERAL INFORMATION
1 Type of claim New Claim Further Claim
Pending Claim / Review / Appeal
2 /
Did/Will you make a claim against any other insurance company for the same incident? If yes, Yes No
please indicate the name of insurance company and policy no..
Name of Insurance Company Policy No.

3 Request return of certified true copy receipt(s) Yes No

C. FOR HOSPITALIZATION DUE TO ACCIDENT
1 Date and time of the Year Month Day Hour Minute AM/PM
accident

2 Location and details of the accident

3 Please describe the part(s) of body injured and the extent of injury in details

4 Did you report to the police? If yes, please provide information on the right
Police Station Case Reference No.
Yes No

/ / /
Remarks: Please attach a photocopy of the Police Report / Traffic Accident Report / Police Statement / Alcohol Test Report.
D. FOR HOSPITALIZATION DUE TO ILLNESS
1 / Please describe the symptoms

2 / How long has the Insured been experiencing these symptoms prior to first consultation?

HK-CL-GCLA-03/202212-01 P. 2 of
 Group Policy No.

E. TREATMENT DETAILS
1 / The physician/hospital first consulted for this injury or illness.
Year Month Day / Name of physician/hospital

/ Address of physician/hospital

2 / The doctor who referred the insured to hospital / other doctors seen
for this or similar past condition
Year Month Day / Name of physician/hospital

/ Address of physician/hospital

3 Date of admission Date of discharge

Year Month Day Year Month Day

F. CLAIM DOCUMENT CHECKLIST

- Basic Documents (
) Additional Documents (if applicable)
- / Our company reserves the right to request for original documents or
other supplementary documents / information if deemed necessary.
- No original documents will be returned.
( )
Claim Document (Documents can be certified at our Company’s Customer Service Centres) Hospital Benefit
Part I of this form completed and signed by your good self
Part II of this form completed and signed by attending physician with chop
/ / ( )
Copy of discharge slip/sick leave certificate/medical certificate with clear exact diagnosis (applicable to hospitalization in hospitals under
the Hospital Authority of Hong Kong)
( ) Copy of discharge summary (applicable to hospitalization in Mainland China hospital)
Original hospital receipt and statement of account
( / /
X ) Copy of diagnostic report and laboratory test report during hospitalization (such as pathological report, blood
test report, PET Scan/CT Scan/MRI report, ECG report, ultrasound report and X-ray report etc.)
Copy of settlement advice from other insurers/ parties
Certified True Copy of receipts issued by other insurers/ parties
G. ( / )
CREDIT CARD AUTHORIZATION FOR SHORTFALL COLLECTION (THIS SECTION IS MANADATORY FOR APPLICATION OF GROUP
HOSPITALIZATION/ DAY SURGERY DIRECT BILLING SERVICE CASE IN HONG KONG HOSPITALS)

/
If the expenses which China Life Insurance (Overseas) Company Limited (hereinafter called
“the Company”) paid directly to the hospital exceeds the eligible amount of qualified claim or the relevant shortfall or expenses is not included in the benefit coverage, this authorization
form will authorize the Company to debit the relevant shortfall or expenses from the below credit card account. The credit card holder must be the Employee /Patient. If there is
shortfall after claim adjudication, the Company will debit the shortfall amount from the credit card account 14 days after the issuance of "Personal Payment Breakdown".
/ : :
Cardholder's Name: Cardholder I.D. Card/Passport No.: Cardholder's Signature:
: :
Credit Card Account No.: Credit Card Expiry Date:
:
Visa
*: Cardholder's Contact Phone No.:
Mastercard
Credit Card Type: :
UnionPay Year Month Day
Name of Bank:
Employee
Relationship between cardholder and patient

(Please tick the appropriate box) Patient

HK-CL-GCLA-03/202212-01 P. 3 of
 Group Policy No.

G. ( / )( )
CREDIT CARD AUTHORIZATION FOR SHORTFALL COLLECTION (THIS SECTION IS MANADATORY FOR APPLICATION OF GROUP
HOSPITALIZATION/ DAY SURGERY DIRECT BILLING SERVICE CASE IN HONG KONG HOSPITALS) (Continued)
/ /

I/We, the Employee/Patient, Hereby declare that above credit card information provided is complete and true, and agree to authorise and instruct China Life Insurance (Overseas)
Company Limited to debit the outstanding shortfall or expenses (if applicable) from my above credit card account.
* Visa Only accept Visa, Mastercard and UnionPay issued by banks in Hong Kong.

H. PERSONAL INFORMATION COLLECTION STATEMENT

“ ”

“ ”

1. “ ”

2.
3. ( ) /

4.

5.
6. / /
7. /
8.
9.

10.
11.
12.
13. 112
14.

1.
2.

3.

4.

5.
6.
7.

8.
9.

“
”

HK-CL-GCLA-03/202212-01 P. 4 of
 Group Policy No.

H. ( )PERSONAL INFORMATION COLLECTION STATEMENT(Continued)

1.
2.
(a)
(b)
3.
(a)
(b)
(c) 2
(d)
(e) 2
4. 1 3

5.

313 24
(+852) 3999 5519 (+852) 2892 0520

China Life Insurance (Overseas) Company Limited (incorporated in the People’s Republic of China with limited liability) (the “Company”) recognizes its responsibilities in relation to
the collection, holding, processing or use of personal data under the Personal Data (Privacy) Ordinance. Personal data will be collected only for lawful and relevant purposes and all
practicable steps will be taken to ensure that personal data held by the Company is accurate. The Company will take all practicable steps to ensure security of the personal data and
to avoid unauthorized or accidental access, erasure or other use.
The provision of your personal data is voluntary. Please note that if you do not provide us with the required personal information, the Company may not be able to provide your
requested information, products or services.
In this Personal Information Collection Statement (“PICS”), the following terms shall have these following meanings:-
“Our affiliates” means any subsidiary undertaking of the Company, any associated company of the Company, and parent undertaking of the Company, any subsidiary undertaking of
parent undertaking, any associated companies undertaking of parent undertaking, for the avoidance doubt, undertaking within the group of China Life Insurance (Group) Company
(“Our affiliates” shall be construed accordingly).
Purpose: From time to time it is necessary for us to use your personal data for the following purposes:
1. offering, providing and marketing to you the products/services of the Company, our affiliates or our co-branding partners (see “Use of Personal Data for Direct Marketing Purposes”
below), and administering, maintaining, managing and operating such products/services;
2. processing and evaluating any applications or requests made by you for products/services offered by the Company and our affiliates;
3. providing subsequent services (including but not limited to health inspection / management) to you and administering the policies issued including but not limited to additions,
alterations, variations, cancellation, renewal or reinstatement;
4. any purposes in connection with any claims made by or against or otherwise involving you or other claimants in respect of any products/services provided by the Company and/or
our affiliates, including investigation of claims; detect and prevent fraud (whether or not relating to the policy issued in respect of this application);
5. evaluating your financial needs;
6. designing new or enhancing existing products/services of the Company and/or our affiliates;
7. conducting market or actuarial research for statistical or similar purposes undertaken by the Company and/or our affiliates, the financial services industry or our respective
regulators;
8. investigating any data held which relates to you from time to time for any of the purposes listed herein;
9. meeting requirements imposed by any applicable, present, existing or future law, rules, regulations, codes of practice or guidelines or assisting with law enforcement purposes,
investigations by police or other government or regulatory authorities in Hong Kong or elsewhere;
10. conducting identity and/or credit checks and/or debt collection;
11. carrying out other services in connection with the operation of the Company’s business;
12. sending out administrative communications about any account you may have with the Company or about future changes to this PICS;
13. performing relevant due diligence procedures in accordance with the Common Reporting Standard (or Automatic Exchange of Financial Account Information) as set out in the
Inland Revenue Ordinance (Cap. 112); and
14. Other purposes directly relating to any of the above.
Transfer of personal data: Personal data will be kept confidential but, subject to the provisions of any applicable law, may be transferred to:
1. any of our affiliates;
2. any person (including private investigators and claims investigation companies) in connection with any claims made by or against or otherwise involving you in respect of any
products/services provided by the Company and/or our affiliates;
3. any agent, contractor or third party who provide services in connection with the product/services provided by the Company and/or our affiliates, including any reinsurance company,
insurance intermediary, fund management company , health management institution or financial institution;

HK-CL-GCLA-03/202212-01 P. 5 of
 Group Policy No.

H. ( )PERSONAL INFORMATION COLLECTION STATEMENT(Continued)

4. any agent, contractor or third party who provides administrative, technology, data processing, telecommunications, computer, payment, debt collection, call centre services, direct
marketing services or other services to the Company and/or our affiliates in connection with the operation of its business;
5. other companies who help gather your information or communicate with you, such as research companies and credit reference agencies or, in the event of default, debt collection
agencies;
6. any actual or proposed assignee, transferee, participant or sub-participant of our rights or business;
7. any government department or other appropriate governmental or regulatory authority (which may be further transferred to governmental or regulatory authority of certain other
jurisdiction(s)) to whom the Company and/or our affiliates are requested or required by any applicable, present, existing or future law, rules, regulations, codes of practice or
guidelines to make disclosures;
8. any financial services provider industry association or federation;
9. any person preventing and detecting insurance fraud, who may collect and use the personal data only as reasonably necessary to carry out the purposes of preventing and
detecting insurance fraud: insurance adjusters, agents and brokers; employers; health care professionals; hospitals; accountants; financial advisors; solicitors; fraud prevention
organisations; other insurance companies (whether directly or through fraud prevention organisation 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.
Your personal data may be provided to any of the above parties who may be located in Hong Kong or outside of Hong Kong, and in this regard you consent to the transfer of your data
outside of Hong Kong.
Transfer of your personal data will only be made for one or more of the purposes specified above. For our policy on using your personal data for promotional or marketing purposes,
please see the section entitled “Use of Personal Data for Direct Marketing Purposes”.
Use of Personal Data for Direct Marketing Purposes: The Company intends to:
1. Use your name, contact details, products and services portfolio information, transaction pattern and behaviour , financial background and demographic data held by the Company
from time to time for direct marketing;
2. Conduct direct marketing (including providing reward, loyalty or privileges programmes) in relation to the following classes of products and services that the Company, our affiliates
and our co-branding partners may offer:
(a) insurance, annuities, banking, wealth management, retirement plans, investment, financial services, credit cards, securities and related products and services; and
(b) health, wellness and medical, food and beverage, sporting activities, memberships and related products and services;
3. The above products and services may be provided by the Company and/or:
(a) any of our affiliates;
(b) third party financial institutions;
(c) the Company, our affiliates and our co-branding partners providing the products and services set out in 2;
(d) third party reward, loyalty or privileges programme providers; and
(e) external service providers supporting the Company or any of the above listed entities in providing the products and services set out in 2.
4. In addition to marketing the above products and services, the Company also intends to provide the data described in 1 above to all or any of the persons described in 3 above
for use by them in marketing those products and services;
5. The Company requires your written consent (which includes an indication of no objection) to use and provide the data to the third parties as set out above for any promotional or
marketing purpose.
You may withdraw your consent to the use and provision to a third party of your personal data for direct marketing purposes at any time, and thereafter the Company shall, without
charge to you, cease to use such data for direct marketing purposes. If you wish to withdraw your consent, please contact the Company’s Personal Data Protection Officer (details
below).
Access and correction of personal data: Under the Personal Data (Privacy) Ordinance, you have the right to ascertain whether the Company holds your personal data, to correct
any data that is inaccurate, and to ascertain the Company's policies and practices in relation to personal data. You may also request the Company to inform you of the type of personal
data held by it.
Requests for access and correction or for information regarding policies and practices and types of data held should be addressed in writing to:
The Personal Data Protection Officer
China Life Insurance (Overseas) Company Limited
24/F, CLI Building, 313 Hennessy Road,
Wan Chai, Hong Kong
Telephone: (+852) 3999 5519 Fax: (+852) 2892 0520
The Company have the right to charge a reasonable fee for the processing of any data request.
/ “ ” /
/

“ ”

Declaration and authorization: I/We acknowledge and confirm that I/we have read and understood the Personal Information Collection Statement (“PICS”). I/We hereby give
my/our acknowledgement and agree to the use and transfer of my/our personal data by the Company in accordance with the PICS, including the use and provision of my/our personal
data for the purpose of direct marketing. I/We have obtained the consent to provide the third party information (if any) in this application. I/We acknowledge and consent to the transfer
of my/our personal data outside of Hong Kong for the purposes and to the types of transferee as set out in the PICS.
Important: Please indicate your agreement by signing on the space provided below. If you do not agree to the use and provision of your personal data for direct marketing as set out
in the section “Use of personal data in direct marketing”, please tick the box below.

“ ”

I / We do not agree with the use and provision of my / our personal data for direct marketing purposes as set out above in the Personal Information Collection Statement (see
“Use of personal data in direct marketing”) and do not wish to receive any promotional and direct marketing materials.

HK-CL-GCLA-03/202212-01 P. 6 of
 Group Policy No.

I. DECLARATION FOR ELECTRONIC RECEIPT

/ / /
I/We, the Employee/Patient/Claimant, confirm that the electronic receipt(s) submitted for this claim application is/ are the sole receipt(s). The clinic / hospital of this visit has not
ever or repeatedly issued the original paper receipt(s) for the same visit.
/ / /
I/We, the Employee/Patient/Claimant, declared and guarantee that apart from our company, I/we have not filed/ will not file the duplicate claims against other insurance
companies or institutions concerning the amount to be claimed in your company for the said electronic receipt(s).
/ / /
I/We, the Employee/Patient/Claimant, undertake that if the above statement is incorrect, I/we are willing to refund the full claim payment for the said receipt(s) to our company and bear
all related legal liabilities.

J. DECLARATION AND AUTHORIZATION

Authorization
/ / / / ( ) (1)
/ /
( ) ( ) (2) /
/ / / /
/ /

I/We, the Employee/Patient/Claimant, represent me/ us/ the Insured under 18 years old (if any) HEREBY AUTHORIZE (1) any employer, registered medical
practitioner, hospital, clinic, insurance company, bank, government institution, government department, or other organization, institution or person, that is aware
of or has any records, knowledge or information of me/us/the insured under 18 years old to disclose, release and transfer such information to China Life Insurance
(Overseas) Co. Ltd (“the Company); (2) the Company or any of its appointed medical / para-medical examiners or laboratories to perform the necessary medical
assessment and tests to evaluate the health status of myself/ ourselves/ the insured under 18 years old in relation to this claim. This authorization shall bind the
successors and assignees of me/us and remains valid notwithstanding death or incapacity. A photocopy of this authorization shall be as valid as the original.
Declaration
/ / / (1) / /
/ / (2) /

I/ We, the Employee /Patient /Claimant HEREBY DECLARE and AGREE that (1) all the foregoing statements and answers to all questions whether or not written
by my/our own hand are to the best of my/our knowledge and belief complete and true; I/We also understand that in the event of doubt as to whether a fact is
material, it should be disclosed here. (2) The Company is not bound by any statement which I/ we may have made to any person unless it is written or printed here
and is presented and approved by the Company. If any relevant persons fail to provide any information requested in this claim form, it may result in the Company’s
inability to process and deal with this claim.

K. ( ) SIGNATURE (Please DO NOT sign on BLANK form)

( 18
) Patient (if other than *
Employee employee and aged 18 years old *Claimant Witness
or above)

Signature

Name

/ I.D.
Card / Passport No.
Year Month Day Year Month Day Year Month Day Year Month Day
Date

*
*Relationship between
Claimant and patient

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 Policy No.

– ( / / )
PART II – ATTENDING PHYSICIAN’S STATEMENT To be completed by attending physician at the Insured / Policyholder / Claimant’s own
expenses.)
A. PARTICULARS OF PATIENT
/ /
Name of patient Age/sex of patient
/ I.D / Passport No. of patient
B. CONSULTATION DETAILS
Year Month Day
1 We can trace the medical record of patient back to / /

2 Date of the accident occurred or symptoms first appeared / /

3 Date of first consultation for this condition or related illness / /

4 ( )Date of last menstruation (Only applicable for maternity benefit) / /

5 Please describe the symptoms and complaints at first consultation.

6 For hospitalization due to accident, please provide accident details

7 Is the patient referred by other

Yes No
physician? If yes, please give the name and address of the referring doctor.
Name of the referring doctor Address of the referring doctor

8 Diagnosis ICD 10 Code

C. HOSPITALIZATION DETAILS
1 Name of hospital Year Month Day
Date of admission / /
Date of discharge / /

Period in Intensive Care Unit

2 Surgical Procedure Details Date of surgery / /

Name of the Surgical Procedure CPT Code

3 Treatments, investigation procedures, results, and/or any

complications during hospitalization and post-hospitalization follow up plan.

4) Has the Insured taken any

home leave during the hospital confinement? If yes, please state the starting and ending date and time.

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D. PROFESSIONAL COMMENT
1 ( ) ?
ere the treatment(s), the medical test(s) and the length of stay in hospital (if any) directly related to the current diagnosis, and were medically
necessary and recommended by you?
Yes No
. If No, please provide details ( : ? E.g. Was the hospitalization requested by patient?)

2 / ? Can the medical test(s) and the operation procedure be done on an outpatient basis/ at day
surgery centre?
Yes No

( ): If No, please indicate the clinical risk(s) , medical reason(s)

for hospitalization and current Health Status (Co-morbidity) :

3 ? The surgery could only be performed under general anesthesia?

Yes No

For surgery under Monitored Anesthesia Care, please specify the reason for hospital stay.

4 ? Is it a case of emergency?
Yes No

Please provide details:

5 (1) (2) / (3)

Is the condition (1) a recurrent episode or (2) a complication of any chronic illness/ major disease or (3) related to any previous
conditions? If yes, please provide date of diagnosis and treatments details.

Yes No Date of diagnosis/treatments Year Month Day

( / / ) Details (including diagnosis/ treatments/ investigations and results)

6 What is the underlying cause of such illness?

7 The prognosis of the condition and any possibility of having a relapse?

8 Is the illness associated with the following?

Congenital condition Self-inflicted injury Infertility or sterilization Mental disorder
Abuse of drugs or Venereal disease Corrective aids or / Rehabilitation/
alcohol treatment of refractive errors convalescence
Cosmetic or Develop-mental / Hazardous Hereditary condition
plastic surgery abnormality sport / activity
/ Body Pregnancy, please provide expected date of delivery
check vaccination & immunization AIDS or HIV related illness
injections
Other disease, please specify None of the above

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F. OTHER MEDICAL HISTORY

1 / Does the patient have any medical history or habit as indicated below?
Asthma Cardiac problem Diabetes Mellitus
Hepatitis B Hypertension Previous operation
Drug abuse Family history of cancer Unfavorable family history
None Other disease, please specify

2 ? Had the patient previously been treated or

hospitalized due to the above disease or other major disease? If so, please specify details.
Yes No Date of diagnosis/treatments Year Month Day
Disease

/ Details of Treatment / Hospitalization

/ Name of Physician/Hospital

3 / Please provide details of drinking & smoking habit

( / / / ) Daily consumption (piece/ pack/ bottle/ can)

Drinking/ Smoking start date since Year Month Day

G. PARTICULARS OF ATTENDING PHYSICIAN

Name of Attending physician Qualification

Address Contact No.

Year Month Day

/
Signature & Stamp of Attending
Date
Physician/ Hospital

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