29th Floor, Menara Dion, 27 Jalan Sultan Ismail, 50250 Kuala Lumpur, Malaysia.Hotline: 1300-88-8833 F : (03) 2070 9088 tokiomarine.com

Tokio Marine Insurans (Malaysia) Berhad (149520-U)

Signature of Insured/Claimant

Name:

NRIC: Date:

Company Stamp (if applicable)

Designation:

Claim Form

Personal Accident

Name:

Claim No.: Policy No.:

NRIC/Passport/ID No.

Occupation:

Mobile No.:

Name of Insured/Employer:

Address:

Gender: □ Male □ Female

1. (a) Date of Accident (b) Time of Accident

(c) Place where accident occurred

2. Please describe in detail how the accident occurred and what were you doing at that time.

3. Please state briefly the injuries you sustained / Final Diagnosis.

4. Have you ever made a claim in respect of any injury during the last 5 years from any insurance company? If so, please give details.

5. Have you made a claim in respect of accident injury from any insurance/source(s)? If yes, please give details.

6. Were you/Insured Person the driver or passenger / pillion rider?

7. If you/Insured Person was the driver/main rider, state class of valid licence and expiry date (Please attach a copy of the licence)

Licence No. Expiry Date

D D M M Y Y Y Y M M H H

D D M M Y Y Y Y

I hereby declare that the above information are true and correct in every aspect and agree that if I have made any false or untrue statement, any concealment, suppression, mis-statement or omission of material fact or if the claim is exaggerated in any manner, my right to the compensation shall be absolutely forfeited.

I hereby authorize any physician, medical practitioner, hospital or clinic by whom or where I have been observed or treated, to give full particulars about my health including my whole medical history to Tokio Marine Insurans (Malaysia) Berhad.

I further authorize any insurance company and its authorized representatives to release all information and documents pertaining to my policies including all previous and current claim details to Tokio Marine Insurans (Malaysia) Berhad.

A photocopy of this authorization shall have the full effect of the original authorization.

Claimant or Policyholders Statement

Additional Information for Motor Vehicle Accident:

Authorization To Physician, Hospital Or Clinic To Release Information

CF/PA/160331

□ The Driver □ Passenger / Pillion

□ Class B □ I have no valid licence□ Class D □ Class E

Age:

Address:

It is important to complete answer to every question. If insufficient space is provided for your answer, please continue on a separate sheet.

Below is a list of documents required to proceed with your claim. In certain circumstances, more information may be required to substantiate the claim.

Documents Required

Basic Documents

Medical Expenses

Weekly Benefit

Daily Hospital Income

Accidental Death

Permanent Disablement

□ Duly completed claim form□ Medical Certification (not required for claims below RM500.00)□ Copy of police report and valid driving licence at the time of accident (applicable for motor vehicle accident only)

□ Original Medical Bills and Receipts (inclusive deposit receipt)□ A copy of the assessment/settlement letter from the other insurer, if claiming for excess amount□ X-ray and/or MRI reports, if any (Claim below RM500, doctor may write the diagnosis on the receipt)

□ Original or Certified True Copy of Medical Sick Leave Certificate

□ Original or Certified True Copy of Medical Bill or Discharge Summary

□ Specialist Report confirming the permanent disablement□ Photographs depicting the amputation of the affected limb(s)□ X-ray and/or MRI reports, if any

□ Detailed Post-Mortem Report□ Toxicology Report, where applicable□ Death Certificate□ Police Report□ Newspaper cutting of the incident, where applicable□ Burial or Cremation Permit□ Copy of Deceased's Identity Card □ Copy of Named Nominee(s)/Claimant's Identity Card□ Copy of Marriage/Birth Certificate, where applicable□ Letter of Administration/Distribution Order/Sijil Faraid - when there is no nomination□ Any other available medical reports or documents to substantiate the claim□ Copy of Deceased's employment letter and last three months salary slip (applicable for Group PA only)

CF/PA/160331

Type of Incident Documents Required (Please tick against the documents you have submitted)

Personal Details

Documents To Be Attached Herewith This Form

Declaration

Authorized Signature

Name:

Position: Date:Company Stamp(Compulsory for Group Policy)

Registration Form

E-Payment

Policy Holder

Beneficiary Name:

Business Registration No (non-individual):

NRIC No (individual):

Address:

Telephone No: Handphone No:

Email:

Email:

Bank Code Bank Account Number (please ignore all dashes: ‘-’)

Contact Person 1:

Contact Person 2:

Banker (Please select from Appendix A)

RepairerAgentLawyer

BrokerFinancial Institution

ReinsurerService Provider

AdjusterOthers(Please specify) __________________

Please complete the details herein this Form with capital letters and cross (X) the appropriate box.

Notice: To ensure payment is made via e-payment, kindly complete the e-payment registration form.

For verificaton purpose, kindly attach the following supporting document that confirm the said account belongs to you/your companyPhotocopy of top portion of the bank statement of Current Account, ORFront page of the Savings Account Passbook, ORConfirmation letter from bank

I/We hereby authorize Tokio Marine Insurans (Malaysia) Berhad (TMIM) to credit all monies due to me/us to my/our bank account indicated above by way of Giro Fund Transfer/Rentas and confirm that:1 I/We hereby declare that the above is my personal account/our company account, NOT joint account and the information given is true

and accurate to the best of my knowledge and record.2 I/We shall indemnify TMIM for any loss, damage or claims incurred as consequence of acting on such reliance.3 I hereby give my consent to TMIM to disclose my Personal Data provided in this E Payment Registration Form to TMIM, TMIM’s service

providers and bankers and such service providers and bankers have my consent to process my Personal Data for the purpose of effecting and administrating the electronic payments to me (including without limitation, my name, personal identification number, contact details and any other personal data obtained hereafter collectively known as “Personal Data”).

4 I understand that I have the right, upon payment of a prescribed fee, to request access to my Personal Data that is being processed by TMIM and to request correction of my Personal Data. Such request shall be submitted to the Head of Finance, TMIM; and

5 I understand that the supply of my Personal Data herein is voluntary and it is necessary for TMIM to process my Personal Data for effecting and administrating the electronic payments to me.

Please Return Original Signed Form To TMIM

To be completed by Finance department:

Date received:

Data Entry by Finance:

Signature/Date:

Verified by Finance:

Signature/Date:

To be completed by relevant department:

Department/branch:

MO Code:

Agent Name:

Client Code:

Agent Code:

Verified by:

Signature/Date:

FOR OFFICE USE ONLY:

Appendix A

List of Bankers - for E-Payment Registration Form

Banker Bank Code Bank Account Number (Please ignore all dashes: “-”)

1. AFFIN BANK BERHAD PHBM

2. AGRO Bank (Bank Pertanian M’sia Bhd) AGOB

3. ALLIANCE BANK MALAYSIA BERHAD MFBB

4. AL-RAJHI BANKING & INVESTMENT CORPORATION (MSIA) BHD RJHI

5. AMBANK BERHAD ARBK

6. BANK ISLAM MALAYSIA BERHAD BIMB

7. BANK KERJASAMA RAKYAT BERHAD BRKM

8. BANK MUAMALAT BERHAD BMMB

9. BANK OF AMERICA BOFA

10. BANK OF TOKYO-MITSUBISHI UFG (MALAYSIA) BERHAD BOTK

11. BANK SIMPANAN NASIONAL BSNA

12. CIMB BANK BERHAD CIBB

13. CITIBANK BERHAD CITI

14. DEUSTCHE BANK DEUT

15. HONG LEONG BANK BERHAD HLBB

16. HSBC BANK MALAYSIA BERHAD HBMB

17. J.P. MORGAN CHASE BANK BERHAD CHAS

18. KUWAIT FINANCE HOUSE (M) BERHAD KFHO

19. MALAYAN BANKING BERHAD MBBE

20. OCBC BANK (M) BERHAD OCBC

21. PUBLIC BANK BERHAD PBBE

22. RHB BANK BERHAD RHBB

23. ROYAL BANK OF SCOTLAND BHD ABNA

24. STANDARD CHARTERED BANK MSIA BHD SCBL

25. SUMITOMO MITSUI BANK CORPORATION MALAYSIA BERHAD SMBC

26. UNITED OVERSEAS BANK UOVB

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