Borang Pra-kebenaranPre-Authorisation FormPrivate and Confidential / Sulit dan Persendirian

ZT0008/2/P/G/S/M

2. K.P. (Lama & Baru) / NRIC (Old & New):

4. No. Polisi / No. Ahli / No. Sijil / Pelan / Nama Syarikat Policy No. / Member ID / Certificate No / Plan / Company Name:

5. Tarikh kemasukan hospital: Admission / Planned Admission Date:

6. Nama Hospital Hospital Name:

(b) Butir-butir kemalangan Details of Accident

(b) Doktor-doktor yang dilawati bagi penyakit ini Doctor(s) consulted for this condition

(c) Alamat & Telefon Doktor Doctor’s or Clinic Contact(Address & Telephone)

7. Nama Doktor yang merawat/ Kepakaran: Name of Attending Doctor / Speciality:

3. (a) Tarikh lahir / Date of Birth:

1. Nama Pesakit / Patient Name:

(b) Umur / Age:

8. Kemalangan / Accident

9. Penyakit / Illness

(a) Berlaku pada Tarikh Masa pagi / petang Occurred on: Date _________________________ Time _________ am / pm

(a) Tarikh simptom tersebut bermula: Tarikh Symptoms first appeared on: Date

Sila tanda ( X ) dan jawab soalan yang berkenaanAdmission Reason ( X ) and answer accordingly

Bahagian 1 (Untuk diisi oleh Pesakit / Penuntut)Part 1 (To be completed by Patient / Claimant)

NOTA: MELENGKAPKAN BORANG PERMINTAAN INI TIDAK SEMESTINYA MENJAMIN BAHAWA SURAT JAMINAN AKAN DIKELUARKAN.NOTE: COMPLETION OF THIS PRE AUTHORISATION FORM DOES NOT GUARANTEE THE ISSUANCE OF GUARANTEE LETTER.

(c) Jantina / Sex:

Pengisytiharan dan pemberikuasa / Declaration and authorization

Saya mengisytiharkan bahawa jawapan yang diberikan di atas adalah benar dan lengkap setakat pengetahuan dan kepercayaan saya.

Saya memahami bahawa penyerahan borang ini, tidak sama sekali boleh dianggap sebagai pengakuan liabiliti Zurich General Takaful Malaysia Berhad ini ke atas tuntutan saya/Assured dan saya bersetuju bahawa bayaran kepada hospital oleh Zurich General Takaful Malaysia Berhad atau wakilnya tidak akan ditafsirkan sebagai pengakuan muktamad liabiliti Zurich General Takaful Malaysia Berhad dan Zurich General Takaful Malaysia Berhad berhak menjalankan penilaian sewajarnya berhubung tuntutan ini atau apa-apa tuntutan yang timbul selanjutnya.

Saya memahami sepenuhnya had-had insurans perubatan saya di bawah Polisi yang tersebut di atas. Saya dengan ini berjanji akan menyelesaikan sebarang amaun yang melebihi had kelayakan saya, yang tidak dilindungi oleh insurans berkenaan.

Saya yang bertandatangan di bawah, dengan ini membenarkan pada setiap masa, mana-mana organisasi, institusi atau individu yang mempunyai apa-apa rekod atau pengetahuan tentang kesihatan dan latar belakang atau rawatan atau nasihat perubatan saya/Assured/Insured, yang telah atau mungkin kemudian dari ini dirujuk untuk mendedahkan kepada Zurich General Takaful Malaysia Berhad atau wakilnya segala maklumat tersebut. Saya bersetuju membenarkan Zurich General Takaful Malaysia Berhad atau wakilnya untuk mengguna dan mendedahkan apa-apa maklumat yang dikumpul atau dipegang kepada pihak ketiga (di dalam atau di luar Malaysia, termasuk syarikat induk, anak syarikat atau syarikat berkait dalam Zurich General Takaful Malaysia Berhad, reinsurer, pemeriksa perubatan, penyiasat tuntutan dan pertubuhan/persekutuan industri dan lain-lain.) berkaitan dengan tuntutan ini. Pengesahan ini hendaklah mengikat waris-waris dan penama saya/Assured/insured dan kekal sah meskipun setelah kematian saya/Assured/insured setakat yang dibenarkan di sisi undang-undang. Salinan pengesahan ini adalah sah. Saya bersetuju sekiranya saya membuat pengakuan palsu atau tidak mendedahkan maklumat yang berkaitan, Zurich General Takaful Malaysia Berhad berhak membatalkan tuntutan saya dan menarik balik sebarang tuntutan awal yang telah dibayar.

I declare that the answers given above are true and complete to the best of my knowledge and belief.

I understand the delivery of this form is in no way an admission of Zurich General Takaful Malaysia Berhad’s liability and payment to the hospital by Zurich General Takaful Malaysia Berhad or its representative shall not be construed as final admission of Zurich General Takaful Malaysia Berhad’s liability and for this and any further claims arising, Zurich General Takaful Malaysia Berhad reserves all rights for evaluation as appropriate.

I am fully aware of the limits as to my/Assured medical insurance under the above-mentioned policy. I hereby undertake to settle/reimburse any medical expenses exceeding my entitlement under the said policy contract, or that is not covered by the same.

I hereby irrevocably authorize any organisation, institution, or individual that has any record or knowledge of my health and medical history or treatment or advice that has been or may hereafter be consulted, other personal information or details of related accident/injury, to disclose to Zurich General Takaful Malaysia Berhad or its representative such information. I agree that Zurich General Takaful Malaysia Berhad or its representative may use or disclose any of the information collected or held to third parties (within or outside Malaysia, including Zurich General Takaful Malaysia Berhad’s parent company, subsidiaries or any other associated companies within Zurich General Takaful Malaysia Berhad’s Group, reinsurers, medical examiners, claims investigators and industry associations/federations etc.) in relation to this claim. This authorization shall bind my/the Assured’s/Insured’s successors and assigns and remain valid notwithstanding my/Assured’s/Insured’s incapacity in so far as legally possible. A photocopy of this authorization shall be valid as the original. I agree that in the event I make, or have in the past made, any false or untrue statement and/or suppressed and/or concealed any material facts in respect of my/the insured’s condition, Zurich General Takaful Malaysia Berhad shall absolutely forfeit my/the Insured’s/Assured’s right to compensation and further reserves the right to recover any amounts paid earlier as a result thereof.

Nama Penuh/Full Name:

No K/P. / I/C No.:

No Telefon/Contact No:

Email Address: Tarikh/Date:

Tandatangan Pesakit / Signature of Patient

Tarikh/Date:

Nama Penuh/Full Name:

Nama Penuh/Full Name:

Tandatangan Saksi / Signature of Witness

Tandatangan Pemilik Polisi /Penuntut /Signature of Assured/ Claimant

Tarikh/Date:

No Telefon/Contact No:

No Telefon/Contact No:

Hubungan dengan PesakitRelationship to Patient:

No K/P. / I/C No.:

No K/P. / I/C No.:

(b) NRIC (Old & New):

2. Policy No. / Member ID/ Certificate No/ Plan/ Company Name:

7. (a) Any previous consultation / treatment / hospitalization for this symptom / illness or related conditions, or other disorders whether in this hospital or any other facilities?

(d) Can the condition be managed under the Outpatient basis: If no please provide reasons of admission:

6. (a) Symptoms / Conditions requiring admission:

3. Admission No. / MRN and Hospital Name/ Hospital Contact and Fax No:

(b) Was this patient referred? If Yes, please provide details below:

(c) If this condition existed before symptoms became apparent to the patient, please indicate in your professional opinion how long has the condition existed:

Date

Disease / Disorder

Details of Treatment / Hospitalization

Doctor / Hospital/ Clinic

(b) How long is patient aware of the condition:

4. Admission Date and Time:

(c) Patient’s BP / Temp / Pulse:

5. Expected days of stay / Discharge Date:

(d) Date symptoms first appeared:

(e) Date first consulted:

1. (a) Patient name:

(c) Age:

Yes No

Yes No

(d) Sex:

Part 2 ADMISSION SECTION ( To be completed upon admission by Doctor )

Male Female

Doctor / Hospital Stamp Name & Signature of Attending Doctor DR’s Contact no and Email addresss:

Tarikh/Date :

13. Any other medical/surgical conditions present? details below:

(a)

since ______/_____/_____

(b)

since / /

14. Was the patient pregnant at the time of hospitalization? (For Female Only) months

(e) Any possibility of relapse?

10. Admission requires:

12. Medical treatment, Investigations and Surgical procedure to be performed, if any (please supply copy of all investigation results):

15. (a) If hospitalization was due to injury, please describe circumstances and cause of injury:

(b) Please indicate date/time of accident: (dd/mm/yy) / / (hrs) am / pm

(a) Pregnancy / Childbirth / Infertility / Caesarean section / miscarriage Or any complications arising therefrom.(b) Congenital / Hereditary diseases(c) Influence of Drugs / Alcohol(d) Nervous / Mental / Emotional / Sleeping Disorder(e) Cosmetic reason / Dental care / refractive errors correction(f) AIDS / STD / VD / HIV (g) Self-inflicted injuries / Violation of laws / Strike / Riots(h) None of the above

(a) Admitting Diagnosis: (c) Diagnosis confirmed on or Advised patient on (b) Provisional Diagnosis:

9. Estimated Total Costs : RM

(d) Cause and pathology underlying the present diagnosis:

Yes No

Yes No

Yes No

Hospitalisation Day Care On Patient’s Request

11. Is the illness / condition related to: (please tick (X) if YES). Please provide details:

16. I hereby certify that I have personally examined and treated the Patient for his/her injuries/illness described above and that the facts as stated above represent my medical opinion of his/her condition.

8.

21. (a) Surgical procedures performed:

MMA code / PHFSR code:

(b) In the case of DEATH, please advise Date/ Time and Cause of death :

18. Date of Discharge:

(b) Cause and pathology of the diagnosis:

20. Treatment given / Investigation done: ( Please supply copy of all investigation results ).

17. Undertaking Letter Ref No:( If available )

(b) Date of surgery / procedure:

22. (a) Recovery complication that arose (if any):

19. (a) Final Diagnosis:

ICD code:

DISCHARGE SECTION (To Be Completed Upon Discharge by Doctor)

Doctor / Hospital Stamp Name & Signature of Attending Doctor

Tarikh/Date :

23. I hereby certify that I have personally examined and treated the Patient for his/her injuries/illness described above and that the facts as stated above represent my medical opinion of his/her condition.

Zurich General Takaful Malaysia Berhad (1260157-U)

11th Floor, Menara Zurich, No.12, Jalan Dewan Bahasa,50460, Kuala Lumpur, MalaysiaTel: 03-2146 8000 Fax: 03-2144 0352www.zurich.com.my

Borang Pra-kebenaranPre-Authorisation FormPrivate and Confidential / Sulit dan Persendirian

ZT0008/1/P/G/S/M

4. No. Polisi / No. Ahli / No. Sijil / Pelan / Nama Syarikat Policy No. / Member ID / Certificate No / Plan / Company Name:

5. Tarikh kemasukan hospital: Admission / Planned Admission Date:

6. Nama Hospital Hospital Name:

(b) Butir-butir kemalangan Details of Accident

(b) Doktor-doktor yang dilawati bagi penyakit ini Doctor(s) consulted for this condition

(c) Alamat & Telefon Doktor Doctor’s or Clinic Contact(Address & Telephone)

7. Nama Doktor yang merawat/ Kepakaran: Name of Attending Doctor / Speciality:

1. Nama Pesakit / Patient Name:

2. K.P. (Lama & Baru) / NRIC (Old & New):

3. (a) Tarikh lahir / Date of Birth:

(b) Umur / Age:

(c) Jantina / Sex:

8. Kemalangan / Accident

9. Penyakit / Illness

(a) Berlaku pada Tarikh Masa pagi / petang Occurred on: Date _________________________ Time _________ am / pm

(a) Tarikh simptom tersebut bermula: Tarikh Symptoms first appeared on: Date

Sila tanda ( X ) dan jawab soalan yang berkenaanAdmission Reason ( X ) and answer accordingly

Bahagian 1 (Untuk diisi oleh Pesakit / Penuntut)Part 1 (To be completed by Patient / Claimant)

NOTA: MELENGKAPKAN BORANG PERMINTAAN INI TIDAK SEMESTINYA MENJAMIN BAHAWA SURAT JAMINAN AKAN DIKELUARKAN.NOTE: COMPLETION OF THIS PRE AUTHORISATION FORM DOES NOT GUARANTEE THE ISSUANCE OF GUARANTEE LETTER.

DIISI OLEH PESAKIT/ PENUNTUT

JOANNA JOSEPH

880917-43-6897

17.09.1988

30

FEMALE

23/04/2018

CURE & CARE MEDICAL CENTRE

DR STEVEN LAU/ CONSULTANT PHYSICIAN

20/04/2018

DR SITI,KLINIK FA'IE

0333249091

20/04/2018

MOTOR VEHICLE ACCIDENT

6AM

TIDAK PERLU DIISI

Pengisytiharan dan pemberikuasa / Declaration and authorization

Saya mengisytiharkan bahawa jawapan yang diberikan di atas adalah benar dan lengkap setakat pengetahuan dan kepercayaan saya.

Saya memahami bahawa penyerahan borang ini, tidak sama sekali boleh dianggap sebagai pengakuan liabiliti Zurich Takaful Malaysia Berhad ini ke atas tuntutan saya/Assured dan saya bersetuju bahawa bayaran kepada hospital oleh Zurich Takaful Malaysia Berhad atau wakilnya tidak akan ditafsirkan sebagai pengakuan muktamad liabiliti Zurich Takaful Malaysia Berhad dan Zurich Takaful Insurance Malaysia Berhad berhak menjalankan penilaian sewajarnya berhubung tuntutan ini atau apa-apa tuntutan yang timbul selanjutnya.

Saya memahami sepenuhnya had-had insurans perubatan saya di bawah Polisi yang tersebut di atas. Saya dengan ini berjanji akan menyelesaikan sebarang amaun yang melebihi had kelayakan saya, yang tidak dilindungi oleh insurans berkenaan.

Saya yang bertandatangan di bawah, dengan ini membenarkan pada setiap masa, mana-mana organisasi, institusi atau individu yang mempunyai apa-apa rekod atau pengetahuan tentang kesihatan dan latar belakang atau rawatan atau nasihat perubatan saya/Assured/Insured, yang telah atau mungkin kemudian dari ini dirujuk untuk mendedahkan kepada Zurich Takaful Malaysia Berhad atau wakilnya segala maklumat tersebut. Saya bersetuju membenarkan Zurich Takaful Malaysia Berhad atau wakilnya untuk mengguna dan mendedahkan apa-apa maklumat yang dikumpul atau dipegang kepada pihak ketiga (di dalam atau di luar Malaysia, termasuk syarikat induk, anak syarikat atau syarikat berkait dalam Zurich Takaful Malaysia Berhad, reinsurer, pemeriksa perubatan, penyiasat tuntutan dan pertubuhan/persekutuan industri dan lain-lain.) berkaitan dengan tuntutan ini. Pengesahan ini hendaklah mengikat waris-waris dan penama saya/Assured/insured dan kekal sah meskipun setelah kematian saya/Assured/insured setakat yang dibenarkan di sisi undang-undang. Salinan pengesahan ini adalah sah. Saya bersetuju sekiranya saya membuat pengakuan palsu atau tidak mendedahkan maklumat yang berkaitan, Zurich Takaful Malaysia Berhad berhak membatalkan tuntutan saya dan menarik balik sebarang tuntutan awal yang telah dibayar.

I declare that the answers given above are true and complete to the best of my knowledge and belief.

I understand the delivery of this form is in no way an admission of Zurich Takaful Malaysia Berhad’s liability and payment to the hospital by Zurich Takaful Malaysia Berhad or its representative shall not be construed as final admission of Zurich Takaful Malaysia Berhad’s liability and for this and any further claims arising, Zurich Takaful Malaysia Berhad reserves all rights for evaluation as appropriate.

I am fully aware of the limits as to my/Assured medical insurance under the above-mentioned policy. I hereby undertake to settle/reimburse any medical expenses exceeding my entitlement under the said policy contract, or that is not covered by the same.

I hereby irrevocably authorize any organisation, institution, or individual that has any record or knowledge of my health and medical history or treatment or advice that has been or may hereafter be consulted, other personal information or details of related accident/injury, to disclose to Zurich Takaful Malaysia Berhad or its representative such information. I agree that Zurich Takaful Malaysia Berhad or its representative may use or disclose any of the information collected or held to third parties (within or outside Malaysia, including Zurich Takaful Malaysia Berhad’s parent company, subsidiaries or any other associated companies within Zurich Takaful Malaysia Berhad’s Group, reinsurers, medical examiners, claims investigators and industry associations/federations etc.) in relation to this claim. This authorization shall bind my/the Assured’s/Insured’s successors and assigns and remain valid notwithstanding my/Assured’s/Insured’s incapacity in so far as legally possible. A photocopy of this authorization shall be valid as the original. I agree that in the event I make, or have in the past made, any false or untrue statement and/or suppressed and/or concealed any material facts in respect of my/the insured’s condition, Zurich Takaful Malaysia Berhad shall absolutely forfeit my/the Insured’s/Assured’s right to compensation and further reserves the right to recover any amounts paid earlier as a result thereof.

Nama Penuh/Full Name:

No K/P. / I/C No.:

No Telefon/Contact No:

Email Address: Tarikh/Date:

Tandatangan Pesakit / Signature of Patient

DIISI OLEH PESAKIT/ PENUNTUT

25/05/2018

JOANNA JOSEPH

880917-43-6897

016-3198675

joannajoseph@hotmail.my

Tarikh/Date:

Nama Penuh/Full Name:

Nama Penuh/Full Name:

Tandatangan Saksi / Signature of Witness

Tandatangan Pemilik Polisi /Penuntut /Signature of Assured/ Claimant

Tarikh/Date:

No Telefon/Contact No:

No Telefon/Contact No:

Hubungan dengan PesakitRelationship to Patient:

No K/P. / I/C No.:

No K/P. / I/C No.:

(b) NRIC (Old & New):

2. Policy No. / Member ID/ Certificate No/ Plan/ Company Name:

7. (a) Any previous consultation / treatment / hospitalization for this symptom / illness or related conditions, or other disorders whether in this hospital or any other facilities?

(d) Can the condition be managed under the Outpatient basis:If no please provide reasons of admission:

6. (a) Symptoms / Conditions requiring admission:

3. Admission No. / MRN and Hospital Name/ Hospital Contact and Fax No:

(b) Was this patient referred? If Yes, please provide details below:

(c) If this condition existed before symptoms became apparent to the patient, please indicate in yourprofessional opinion how long has the condition existed:

Date

Disease / Disorder

Details of Treatment / Hospitalization

Doctor / Hospital/ Clinic

(b) How long is patient aware of the condition:

4. Admission Date and Time:

(c) Patient’s BP / Temp / Pulse:

5. Expected days of stay / Discharge Date:

(d) Date symptoms first appeared:

(e) Date first consulted:

1. (a) Patient name:

(c) Age:

Yes No

Yes No

(d) Sex:

Part 2 ADMISSION SECTION ( To be completed upon admission by Doctor )

Male Female

WAJIB DIISI OLEH SESIAPA SELAINPESAKIT & PEMEGANG POLISI

DIISI OLEH DOKTOR YANG MERAWAT

KESHAV RAO A/L MAHENDRAN

860716-43-5639

016-5054075

SPOUSE

SURI JOSEPH

870112-10-6798

012-3130975

75025/CURE&CARE MEDICAL CENTRE/ 03-33183000/FAX:03-33182500

23/04/2018

3 DAYS / 26/04/2018

FEVER,LETHARGY,MUSCLE SPASM

4 DAYS

120/80,38 DEGREE CELSIUS,80 BPM

20/04/2018

23/04/2018

20/04/2018

VIRAL FEVER

OUTPATIENT TREATMENT IN KLINIK FA'IE

DR SITI,KLINIK FA'IE

YES,REFERRED FROM KLINIK FA'IE

JOANNA JOSEPH

880917-43-6897

30

25/05/2018

25/05/2018

Doctor / Hospital Stamp Name & Signature of Attending Doctor DR’s Contact no and Email addresss:

Tarikh/Date :

13. Any other medical/surgical conditions present? details below:

(a)

since ______/_____/_____

(b)

since / /

14. Was the patient pregnant at the time of hospitalization? (For Female Only) months

(e) Any possibility of relapse?

10. Admission requires:

12. Medical treatment, Investigations and Surgical procedure to be performed, if any (please supply copy of all investigation results):

15. (a) If hospitalization was due to injury, please describe circumstances and cause of injury:

(b) Please indicate date/time of accident: (dd/mm/yy) / / (hrs) am / pm

(a) Pregnancy / Childbirth / Infertility / Caesarean section / miscarriage Or any complications arising therefrom.(b) Congenital / Hereditary diseases(c) Influence of Drugs / Alcohol(d) Nervous / Mental / Emotional / Sleeping Disorder(e) Cosmetic reason / Dental care / refractive errors correction(f) AIDS / STD / VD / HIV (g) Self-inflicted injuries / Violation of laws / Strike / Riots(h) None of the above

(a) Admitting Diagnosis: (c) Diagnosis confirmed on or Advised patient on (b) Provisional Diagnosis:

9. Estimated Total Costs : RM

(d) Cause and pathology underlying the present diagnosis:

Yes No

Yes No

Yes No

Hospitalisation Day Care On Patient’s Request

11. Is the illness / condition related to: (please tick (X) if YES). Please provide details:

16. I hereby certify that I have personally examined and treated the Patient for his/her injuries/illness described above and that the facts as stated above represent my medical opinion of his/her condition.

8.

DIISI OLEH DOKTOR YANG MERAWAT*UNTUK KES KEMALANGAN SAHAJA*

23/04/201823/04/2018

VIRAL FEVER

4000

IV FLUIDS,IV ANALGESICS,PCM,ANTIHISTAMINE,FBC,DENGUE SEROLOGY,BUSE,CRP

HYPERTENSION

MOTOR VEHICLE ACCIDENT

012-3456789

stevelau@gmail.com

DR STEVEN LAUCONSULTANT PHYSICIANCURE & CARE MEDICAL CENTRE

26/05/2018

20 04 2018

21. (a) Surgical procedures performed:

MMA code / PHFSR code:

(b) In the case of DEATH, please advise Date/ Time and Cause of death :

18. Date of Discharge:

(b) Cause and pathology of the diagnosis:

20. Treatment given / Investigation done: ( Please supply copy of all investigation results ).

17. Undertaking Letter Ref No:( If available )

(b) Date of surgery / procedure:

22. (a) Recovery complication that arose (if any):

19. (a) Final Diagnosis:

ICD code:

DISCHARGE SECTION (To Be Completed Upon Discharge by Doctor)

Doctor / Hospital Stamp Name & Signature of Attending Doctor

Tarikh/Date :

23. I hereby certify that I have personally examined and treated the Patient for his/her injuries/illness described above and that the facts as stated above represent my medical opinion of his/her condition.

DITANDATANGANIOLEH DOKTOR

26/04/2018

ARTHROPOD-BORNE DISEASE

ARTHROPOD-BORNE DISEASE

A90

IV FLUIDS,PCM,FBC,DENGUE SEROLOGY,NS1,CRP

NIL

N/A

NIL

DR STEVEN LAUCONSULTANT PHYSICIANCURE & CARE MEDICAL CENTRE

N/A

DR STEVEN LAUCONSULTANT PHYSICIAN 26/05/2018

Zurich General Takaful Malaysia Berhad (1260157-U)

11th Floor, Menara Zurich, No.12, Jalan Dewan Bahasa,50460, Kuala Lumpur, MalaysiaTel: 03-2146 8000 Fax: 03-2144 0352www.zurich.com.my

New Registration Change of Details

Part I. Beneficiary DetailsName of Applicant/ Company

NRIC No. / Co. Registration No.

Address

Telephone No. Fax No.

Person In-Charge Name 1. 2.

Email Address 1. 2.

Telephone No. 1. 2.

Part II. * Beneficiary Banking DetailsName of Bank

Bank Address

Bank Account No. SWIFT Code

IBAN Code (If applicable)

Part III. DeclarationI/We hereby request that payment(s) due and payable to me/us by Zurich General Takaful Malaysia Berhad be paid to my/our bank

account stated above by way of Inter-bank Giro/RENTAS/TT and confirm that :-

1. I/We consent to Zurich General Takaful Malaysia Berhad releasing the above data to its banker(s). In order to facilitate payment(s)

to me/ us by way of Inter-bank Giro/RENTAS/TT.

2. All information provided herein are correct and accurate.

3. My/Our request herein shall be irrecoverable without the consent of Zurich General Takaful Malaysia Berhad. Zurich General

Takaful Malaysia Berhad may at any time in its absolute discretion effect payment(s) to me/us by other mode(s).

4. I/We shall keep Zurich General Takaful Malaysia Berhad and its banker(s) indemnified against any loss and/or damage

howsoever arising from any matters in relation to Inter-bank Giro/RENTAS/TT requested by me/us herein including but not limited

to error/misdescription in information furnished, delayed payment(s) and any other circumstances beyond Zurich General

Takaful Malaysia Berhad and its banker(s)’s control.

E-Payment Registration Form

Zurich General Takaful Malaysia Berhad (1260157-U)

11th Floor, Menara Zurich, No.12, Jalan Dewan Bahasa, 50460 Kuala Lumpur, MalaysiaTel: 03-2146 8000 Fax: 03-2144 0352www.zurich.com.my

Authorised Signatory (ies) Company Stamp

Name Date

Designation

Part IV. Zurich General Takaful Malaysia Berhad Office Use OnlyDepartment/Branch

Profile Agent Workshop Adjuster Vendor Others, please specify

Agent/Workshop/Adjuster/Vendor Code

Entered by Date

Verified by Date

* Important :1. This facility allows payment to be credited into the above mentioned account only.2. Please attach (i) copy of NRIC or Passport or Business Registration Form whichever is applicable and (ii) 1st page of (a) your bank statement; or (b) your bank saving book showing the account name and account number; or (c) details of your bank account obtained from your bank’s website that has been certified by your bank; or (d) letter from your bank confirming your bank account details.

New Registration Change of Details

Part I. Beneficiary DetailsName of Applicant/ Company

NRIC No. / Co. Registration No.

Address

Telephone No. Fax No.

Person In-Charge Name 1. 2.

Email Address 1. 2.

Telephone No. 1. 2.

Part II. * Beneficiary Banking DetailsName of Bank

Bank Address

Bank Account No. SWIFT Code

IBAN Code (If applicable)

Part III. DeclarationI/We hereby request that payment(s) due and payable to me/us by Zurich General Takaful Malaysia Berhad be paid to my/our bank

account stated above by way of Inter-bank Giro/RENTAS/TT and confirm that :-

1. I/We consent to Zurich General Takaful Malaysia Berhad releasing the above data to its banker(s). In order to facilitate payment(s)

to me/ us by way of Inter-bank Giro/RENTAS/TT.

2. All information provided herein are correct and accurate.

3. My/Our request herein shall be irrecoverable without the consent of Zurich General Takaful Malaysia Berhad. Zurich General

Takaful Malaysia Berhad may at any time in its absolute discretion effect payment(s) to me/us by other mode(s).

4. I/We shall keep Zurich General Takaful Malaysia Berhad and its banker(s) indemnified against any loss and/or damage

howsoever arising from any matters in relation to Inter-bank Giro/RENTAS/TT requested by me/us herein including but not limited

to error/misdescription in information furnished, delayed payment(s) and any other circumstances beyond Zurich General

Takaful Malaysia Berhad and its banker(s)’s control.

E-Payment Registration Form

KESHAV RAO A/L MAHENDRAN

860716-43-5639

NO 45,JALAN MENTARI,TAMAN PALMGROVE

43120 KLANG SELANGOR

016-5054075 NIL

*TIDAK PERLU DIISI *TIDAK PERLU DIISI

keshavrao23@hotmail.my

012-3130975

OBC BANK

OBC BANK,17 JALAN STESEN,KAW 5,41250 KLANG

501123956001 *TIDAK PERLU DIISI

*WAJIB DIISI UNTUK MENERIMA PENYATA BAYARAN

KESHAV RAO A/L MAHENDRAN

POLICY HOLDER

*TIDAK PERLU DIISI

*TIDAK PERLU DIISI

Zurich General Takaful Malaysia Berhad (1260157-U)

11th Floor, Menara Zurich, No.12, Jalan Dewan Bahasa, 50460 Kuala Lumpur, MalaysiaTel: 03-2146 8000 Fax: 03-2144 0352www.zurich.com.my

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Part IV. Zurich General Takaful Malaysia Berhad Office Use OnlyDepartment/Branch

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* Important :1. This facility allows payment to be credited into the above mentioned account only.2. Please attach (i) copy of NRIC or Passport or Business Registration Form whichever is applicable and (ii) 1st page of (a) your bank statement; or (b) your bank saving book showing the account name and account number; or (c) details of your bank account obtained from your bank’s website that has been certified by your bank; or (d) letter from your bank confirming your bank account details.

Cara Pengisian Borang Tuntutan & E-Pembayaran

Sila poskan borang yang lengkap ke alamat:

CUEPACSCARE4U SOLUTIONS SDN BHDB-5-3A, Pusat Perdagangan Intania,Jalan Intan 1/KS1, Persiaran Raja Muda Musa,41200 Klang, Selangor darul Ehsan

Sila sertakan dokumen yang lengkap:

1) Borang Tuntutan & E-Pembayaran yang lengkap2) Sal inan kad pengenalan pemegang pol isi dan sal inan kad pengenalan penuntut3) Resit asal / bi l terperinci4) Sal inan penyata bank atau muka depan buku bank5) Laporan doktor