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SECTION A
Every question must be fully answered and the Company reserves the right to require further information should it deem necessary.
Submission of this Claim Form does not guarantee admission of liability.
Contract No:
Agents Name :
1. Participants Details
Name of Participant : ..
NRIC No. : ..
BC / Old IC No. :
Age : ..
Sex :
Date of Birth : ..
Marital Status :
Male
Female
Old IC No. :
Fax No. : ..
E-mail Address :
3.
Hospitalisations Details
................................................................................................................................................,,
6. Please give details of other doctors that have been consulted in connection with this injury / illness :
Date of Visit
Hospitalisation
Actual Diagnosis
i. ..................
Yes / No
..
ii. ......................
Yes / No
..
iii. ...................
Yes / No
..
7. Name(s) of all medical practitioner(s) and clinic(s) / hospital(s) which the Participant has, sought or received medical treatment,
advice, consultation and/or check-up within the past three (3) years.
Date of Consultation or Treatment
etc.
8.
Name, address and contact no. of the Participants regular doctor other than above :
................................................................................
................................................................................
9.
Are there other contracts in force on the Participants life taken with other companies ?
If yes, please furnish the following details :
Yes
No
Contract No.
Type of Coverage
Amount of
Compensation (RM)
..
Name of Company
10. IMPORTANT :
Please state your (the Claimant) Maybank account details in order for us to credit the payment directly into your bank
account.
Maybank branch :
Account No:
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_____________________________________________
Signature / Thumb print of Participant
_________________________________________________
Signature / Thumb print of Claimant (if other than the Participant)
Date : _______________________________________
Date : ____________________________________________
Full name : ________________________________________
Contact No. : _______________________________________
Designation & Official stamp is required for Company :
____________________________________________________
____________________________________________
Signature of Witness
Date
: __________________________________
: __________________________________
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Name of Participant : .
IC No. : (New )
..(Old)
I expressly waived all provisions of law or professional ethics forbidding the information Provider(s) from disclosing any such information
acquired on myself in a professional and/or client capacity and I further release the information Provider(s) and its agent/staff from any
liability whatsoever that may arise, in supplying such information requested by the Company.
This authorization/consent is irrevocable and a copy of it will have the same effect and validity as the original.
Name: ..
Date:
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