This document is a template for a Personal Medical Attendant's Report (PMAR) from an insurance company. It requests medical information about a life proposed for insurance. It asks the medical attendant questions about their history with the patient, past illnesses and treatments, investigation results like blood pressure readings and tests, and other relevant medical details. The completed PMAR must be returned to the insurance company in a sealed envelope.

1. Prudential Assurance Malaysia Berhad (107655-U) Level 17 Menara Prudential, 10 Jalan Sultan Ismail, 50250 Kuala Lumpur, Malaysia. P.O.Box 10025, 50700
Kuala Lumpur. Tel (603) 2031 8228 Fax (603) 2032 3939 www.prudential.com.my Part of Prudential plc (United Kingdom)
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RAISE PMAR template version 2.0_Sept09
PERSONAL MEDICAL ATTENDANT'S REPORT
Date :
Proposal Number : From : Underwriting Section, New Business Dept
Name of Life Proposed :
Identity Card / Passport No :
Dear Doctor,
A proposal for life assurance has been received on the above-mentioned life proposed and he/she has
authorized us to refer to you as his/her Medical Adviser. We are particularly concerned with the history of
life proposer’s health condition as stated in our NB Requirement Letter attached.
Please reply in confidence to the questions below and respective Questionnaires attached (if any)
according to your personal knowledge and his/her medical records. We do not wish you to examine
him/her.
If you do not hold the previous records, nor possess any significant information, please tick this adjoining
box [ ] and return the form uncompleted. In such circumstances we regret having troubled you.
This is a computer-generated document that does not require signature.
_____________________________________________________________________________________________________
PERSONAL MEDICAL ATTENDANT'S REPORT
1a) How long have you been the medical attendant?
1b) How far do the records you hold go back?
1c) When was medical advice last sought and why?
2) What do you know of the life proposed's past and present lifestyle, smoking, drinking or other
habits?
3a) Please give particulars of illness or accidents which have required advice from you, other than that
of such trivial nature as to have no bearing on life expectancy.
Date Nature of condition Treatment Duration Period off
work

2. Prudential Assurance Malaysia Berhad (107655-U) Level 17 Menara Prudential, 10 Jalan Sultan Ismail, 50250 Kuala Lumpur, Malaysia. P.O.Box 10025, 50700
Kuala Lumpur. Tel (603) 2031 8228 Fax (603) 2032 3939 www.prudential.com.my Part of Prudential plc (United Kingdom)
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RAISE PMAR template version 2.0_Sept09
3b) Have any of the aforementioned conditions left any sequelae? (If so, please give details)
3c) Is any treatment by drugs or otherwise being given at present? (If so, please give details)
4a) Please give details of any urine test, X-rays, ECG's or other investigations done.
Date Nature of Investigation Result and Diagnosis
4b) Please give details of any blood pressure readings for the past 3 years
(If no treatment, please indicate any pre-treatment levels).
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
Date
B/P
Reading
5) To the best of your knowledge, has the life proposed ever received medical attention from any other
medical advisers? If yes, please give the following particulars.
Name and Address of Medical Adviser Nature of Conditions
6) Additional Information (not applicable for General Health Condition) :
Dr to please comment on the following :
a) What is the exact diagnosis and underlying cause?
b) Any treatment or medication? What is the response? Please provide details

3. Prudential Assurance Malaysia Berhad (107655-U) Level 17 Menara Prudential, 10 Jalan Sultan Ismail, 50250 Kuala Lumpur, Malaysia. P.O.Box 10025, 50700
Kuala Lumpur. Tel (603) 2031 8228 Fax (603) 2032 3939 www.prudential.com.my Part of Prudential plc (United Kingdom)
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RAISE PMAR template version 2.0_Sept09
c) What are the investigations being done? If yes, what are the results?
d) Any follow up? When was the last follow up? What was the finding of last follow up?
e) Any complications? If yes, kindly provide full details.
f) Prognosis?
g) Any future management contemplated?
h) What is the current condition? Fully recovered?
i) Any recurrence? When and what are the symptomatic condition? Please provide details.
Dr to please provide a copy of all investigations done, if any, and kindly complete the attached
Questionnaires (if any).
………………………………………….
Signature of Doctor
……………………………………………………. ……………………………………………………..
Date Name & Hospital Address (in block capital)
[10201003 ]

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RAISE PMAR template version 2.0 Sept09
CONSENT & AUTHORISATION LETTER
SURAT PERSETUJUAN DAN KEBENARAN
Proposal Number /Nombor Cadangan : ______________________________
Name of Life Proposed / Nama Pencadang : ______________________________
Dear Sir / Madam,
Tuan/Puan,
I, the undersigned, consent to Prudential Assurance Malaysia Berhad (the Company) seeking medical information
from any doctor who at any time attended to me or the child and for the doctor to release the results to the Company.
I authorize the giving of such information.
The information stated in Personal Medical Attendant’s report (PMAR) shall be treated as Confidential and not be
disclosed to any third party. The completed PMAR should return to the Company in sealed envelope.
Saya, yang bertanda tangan di bawah,mengizinkan Prudential Assurance Malaysia Berhad (Syarikat)mendapatkan
keterangan perubatan daripada mana-mana doctor yang pernah merawat saya atau anak yang berkenaan dan
doctor melepaskan keputusan –keputusan ujian kepada pihak Syarikat. Saya member keizinan ke atas pemberian
keterangan tersebut.
Keterangan – keterangan dicatatkan di borang PMAR akan dikendalikan secara sulit dan tidak akan didedahkan
kepada mana-mana pihak yang tidak berkenaan. Borang PMAR yang telah dilengkapi hendaklah dihantar kepada
Syarikat menerusi sampul surat tertutup.
Signature of Life Proposed : _________________________
Tandatangan Hayat yang Dicadangkan
Name of Life Proposed : _________________________
Nama Hayat yang Dicadangkan
Identity Card / Passport No. : _________________________
Nombor K/P / Nombor Pasport
Date/ Tarikh : __________________________
This consent form is used for Private Clinic / Hospital only.

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RAISE PMAR template version 2.0 Sept09
LAPORAN PERUBATAN :
BORANG PERMOHONAN
LAPORAN PERUBATAN / POST MORTEM / INSURAN
NAMA :
ALAMAT SURAT MENYURAT :
POSKOD : TEL :
KEPADA :
TUAN,
Laporan Perubatan/Post Mortem/Insurans (Biasa/Pakar)
Adalah saya dengan ini ingin memohon satu laporan berkenaan ke atas perkara berikut :
Nama :
No. K/P (lama) : Baru :
* sebagai pesakit dalam : No Daftar : Wad :
Tarikh masuk wad : Tarikh keluar wad :
* sebagai pesakit luar pada : Di klinik :
Rawatan diterima untuk penyakit :
Tarikh mati (bagi laporan Post mortem) : (disertakan salinan sijil mati)
Tujuan laporan ini ialah untuk tuntutan :
Bersama-sama ini saya sertakan borang berikut :-
1. Borang Insuran (5 salinan) [ ]
2. Borang Buruh 90 (5 salinan) [ ]
3. Borang Perkeso (PKS 8) (5 salinan) [ ]
dan satu salinan kad rawatan, satu salinan cuti sakit.
Bersama-sama ini juga saya sertakan (cek/tunai) sebanyak RM bagi laporan tersebut.
Yang Benar.
Tandatangan Tarikh
KENYATAN KEIZINAN DARI PESAKIT
Saya dengan ini memberi keizinan
kepada pihak Hospital untuk mengeluarkan kesemua/sebahagian atau mana-mana
bahagian maklumat ke atas penyakit dan rawatan yang saya alami di
seperti yang tercatit di atas kepada
Terima kasih.
Tandatangan Tarikh
[ 12301006 ]
This consent form is used for Government Hospital only.

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RAISE PMAR template version 2.0 Sept09
SURAT PERMOHONAN LAPORAN / SURAT PERAKUAN PERUBATAN
Saya, (nama pesakit) ______________
No. Kad Pengenalan : No. Pendaftaran : _____________________
dengan ini memohon daripada Pusat Perubatan ________________________________________________
ke atas * diri saya / ____________________________.
[ ] laporan perubatan
[ ] surat perakuan perubatan
[ ] yang akan digunakan untuk maksud tuntutan insuran
[ ] permohonan perlindungan
[ ] tuntutan gantirugi insuran nyawa melalui peguam saya
Saya telah alami * penyakit / kecederaan yang dimaksudkan dalam permohonan ini pada
dan telah dirawati :-
[ ] di wad dari sehingga
[ ] di klinik dari sehingga
Dalam tempoh rawatan ini saya telah diberi cuti sakit dari sehingga
* Potong mana yang tidak dikehendaki
_____________________________________________________________________________________________
KEIZINAN UNTUK MENGELUARKAN MAKLUMAT
Dengan permohonan ini, saya memberi kuasa kepada pihak Pusat Perubatan _____________________________
dan kakitangannya untuk mengeluarkan sebahagian daripada atau kesemua maklumat yang terkandung dalam rekod
perubatan saya sendiri / rekod perubatan waris saya yang tersebut di atas kepada
(nama dan alamat perseorangan atau pertubuhan)
dan dengan ini melepaskan pihak Pusat Perubatan ____________________________ dan kakitangannya daripada
sebarang tanggungjawab dan tanggungan undang-undang yang mungkin berbangkit daripada keizinan ini.
Tarikh : Tandatangan atau Cap ibujari :
PERHATIAN :
Borang ini hendaklah ditandatangani oleh waris / penjaga, jika ianya di bawah umur 18 tahun atau sekiranya pesakit
ini dapat melakukannya dengan baik dari segi fizikal atau mental, bagi mengizinkan untuk mengeluarkan maklumat.
[12301007]
This consent form is used for University Hospital only.