death claim form / borang tuntutan kematian.../ laporan bedah siasat dan borang tuntutan manfaat...

DEATH CLAIM FORM / BORANG TUNTUTAN KEMATIAN

Type of Policy / Jenis Polisi:

This form is to be completed by the person legally entitled to policy monies. / Borang ini perlu dilengkapkan oleh pihak yang berhak secara sah ke atas wang tuntutan.

Life / Individu Group / Berkelompok

DECEASED’S DETAILS / BUTIR-BUTIR SIMATI1. Policy No(s) /

No. Polisi.

2. Name of Deceased* / Nama penuh Si Mati*

5. Last address of the Deceased* / Alamat terakhir SiMati*

7. Cause of Death / Sebab Kematian

8. Was the Deceased a Muslim at death? / Adakah Si Mati seorang Muslim pada tarikh kematian?

Note: Nominee of a Muslim Deceased shall distribute the policy moneys in accordance with Islamic law / Nota: Penama kepada Si Mati yang beragama Islam haruslah mengagihkan wang tuntutan menurut undang-undang Syariah.9. Was the Deceased married at the time of death? / Adakah Si Mati berkahwin pada masa kematian?

Note: Proof of relationship is required for non-Muslims claiming in the capacity as a spouse, child or parent nominee under a “trust policy and for ALL CLAIMANTS claiming on a policy without NOMINATION. / Nota: Bukti hubungan diperlukan untuk tuntutan bukan Islam yang menuntut sebagai suami/isteri, anak/ibubapa untuk polisi amanah dan SEMUA TUNTUTAN untuk polisi tanpa PENAMA.10. What family has the Deceased left / Keluarga yang ditinggalkan Si Mati:

11. Has the Deceased have any other insurance with other insurers? / Adakah Si Mati mempunyai polisi dengan syarikat insurans yang lain?

Policy Number / Nombor Polisi Company / Syarikat

a) d)

b) e)

c) f)

3. Age / Umur 4. Gender / Jantina: Male / Lelaki Female / Perempuan

6. Date of Death / Tarikh Kematian / / 2

Tick this box if cause of death is unknown. / Tandakan kotak ini jika sebab kematian tidak diketahui

Yes / Ya No / Tidak

Spouse / Suami/isteri Child / Anak Others. Please Specify / Lain-lain. Sila Nyatakan:

Yes / Ya No / Tidak

* Obligatory / wajib

Yes / Ya No / Tidak

DECEASED’S EMPLOYMENT DETAILS / BUTIR-BUTIR PEKERJAAN SIMATI12. a) Occupation / Pekerjaan: b) Address of employer/business / Alamat majikan/perniagaan:

c) Nature of employment/business/work / Jenis pekerjaan/perniagaan/tugasan:

AmL/Claims/Death/0315

AmMetLife Insurance Berhad (15743-P)(Formerly known as AmLife Insurance Berhad) Licensed Insurer Level 19, Menara AmMetLife, No. 1, Jalan Lumut, 50400 Kuala Lumpur 1300 88 8800 +603 2171 3000 [email protected] Type AML<space>message send to 33911 ammetlife.com

DEATH DUE TO ILLNESS/NATURAL DEATH / KEMATIAN KERANA SAKIT/KEMATIAN BIASABilakah Si Mati mula mengadu atau menunjukkan

sebarang petanda penyakitnya yang terakhir?

Bilakah Si Mati mula-mula berjumpa doktor untuk penyakitnya yang terakhir?

c) Please state the names and addresses of the doctors who attended to the Deceased during his/her last illness? / Sila berikan nama dan alamat doktor-doktor yang merawat Si Mati semasa sakit terakhirnya?

d) Smoking / Perokok?

14. Names & addresses of all doctors/hospitals who attended to the Deceased during the last two years prior to death? / Nama & Alamat kesemua doktor/hospital yang merawat Si Mati dua tahun sebelum kematiannya:

15. Is there any other medical information or comment which you wish to provide to us. / Sila berikan maklumat kesihatan tambahan Si Mati jika ada.

No Name & Address / Nama & Alamat Date(s) of Consultation / Tarikh Rawatan Diagnosis / Diagnosis

1.

2.

3.

4.

DEATH DUE TO ACCIDENT (Only required to be completed if cause of death was due to an accident) / KEMATIAN AKIBAT KEMALANGAN (Hanya perlu dilengkapkan jika sebab kematian adalah akibat kemalangan).16. a) Date & Time of accident / Tarikh & Masa kemalangan

b) Place of accident / Tempat Kemalangan

c) What was the Deceased doing just before the accident? / Apakah yang dilakukan oleh Si Mati ketika kemalangan?

d) Describe in detail how the accident happened / Terangkan secara terperinci bagaimana kemalangan berlaku?

e) Was the accident reported to the Police? / Adakah kemalangan dilaporkan kepada polis?

f) Were there witnesses? If yes, please provide name & contact details. /

If Yes, please provide a certified copy of the report. / Jika Ya, sila berikan salinan laporan yang disahkan

Jika ada saksi, sila berikan nama & no. telefon

g) Was the accident published in the newspaper? / Adakah kemalangan dilaporkan di akhbar?

h) Was there a Post-Mortem carried out? / Adakah bedah siasat dilakukan?

/ / 2 : AM / Pagi PM / Petang

PARTICULARS OF THE CLAIMANT / BUTIR-BUTIR PIHAK YANG MENUNTUT

17. a) Name of claimant* / Nama Penuntut*

b) What is your relationship with the Deceased? / Apakah hubungan dengan Si Mati?

c) Address* / Alamat*

d) Telephone No. / No. Telefon

e) Email / Emel

-

-

Yes / Ya No / Tidak

Yes / Ya No / Tidak

If Yes, please provide a copy of the newspaper reportage. / Jika Ya, sila sediakan salinan laporan akhbar berkenaanYes / Ya No / Tidak

/ Laporan Bedah Siasat dan Borang Tuntutan Manfaat Kematian Akibat Kemalangan diperlukan sekiranya anda berhak membuat tuntutan faedah kematian untuk polisi ini.

Yes / Ya No / Tidak

Home / Rumah

Mobile / Tel. Bimbit

Pejabat

Fax / Faks

-

-



13. a) When did the Deceased first complain of, or give other indication of his/her last illness? /

b) When did the Deceased first consult a doctor for his/her last illness? /

f) Claimant’s Occupation / Perkerjaan Penuntut

g) Nature of Business / Bidang Pekerjaan

h) Employer’s Name / Nama Majikan

i) Employer’s Address / Alamat Majikan

- -

/ / 2

Old IC/Passport

DECLARATION

Claimant’s Signature

Name*

NRIC no.*

Date



a. I/We represent and declare that the information provided above and in the submitted documents is true, accurate and complete; and the submitted documents are genuine and duly executed. / Saya/ kami mengakui bahawa maklumat yang diberikan di atas dan di dalam dokumen adalah benar, tepat dan lengkap dan dakumen yang dikembarkan adalah tulen dan telah ditandatangani.

b. I/We further understand and agree that AmMetlife shall have the right to use my/our data and personal information for the purpose of the Insurance operational process, which might includetransfer of data and personal information, within or outside Malaysia, to Metlife Group, AmMetlife’s other related companies, subsidiaries and/or its holding companies, outsourcing partners, reinsurers, solicitors, affiliate companies, their outsourcing partners and to any regulatory bodies, or any relevant foreign tax, authority, including any reporting obligations by AmMetlife, its shareholders or its related/affiliated entities under the United States Foreign Account Tax Compliance Act (FATCA). / Saya/Kami memahami dan bersetuju bahawa AmMetLife Insurance Berhad berhak untuk menggunakan data dan maklumat peribadi saya/kami untuk tujuan proses operasi insurans yang mungkin termasuk pemindahan data dan maklumat peribadi, di dalam atau di luar Malaysia, ke Kumpulan MetLife, lain-lain syarikat berkaitan AmMetLife Insurance Berhad, subsidiari dan/atau syarikat pegangan, rakan-rakan khidmat luar, pelindung semula insurans, peguamcara, sebarang badan pengawal selia, atau mana-mana pihak berkuasa cukai asing yang berkaitan termasuk sebarang keperluan laporan oleh AmMetLife Insurance Berhad, pemegang-pemegang saham atau entiti berkaitan/gabungan di bawah Akta Pematuhan Cukai Akaun Asing Amerika Syarikat (FATCA).

c. I/We can withdraw this permission at any time by letting Ammetlife Insurance Berhad know in writing. / Saya/Kami boleh menarik semula kebenaran ini pada bila-bila masa dengan memaklumkan secara bertulis kepada AmMetLife Insurance Berhad.

d. I/We understand that I/We have a right to obtain access to and to request correction of any data and personal information held by AmMetlife Insurance Berhad concerning me/us. Such request can be made via a written request to Ammetlife Insurance Berhad. / Saya/Kami memahami bahawa saya/kami berhak untuk mendapatkan akses dan untuk memohon pembetulan sebarang maklumat peribadi dan data yang dipegang oleh AmMetLife Insurance Berhad berkenaan saya/kami. Permohonon tersebut boleh dilakukan secara bertulis kepada AmMetLife Insurance Berhad.

e. I/We have read and understood the Ammetlife’s Privacy Notice, which is available at AmMetlife’s website and branches. / Saya/Kami telah membaca dan memahami Notis Privasi AmMetLife Insurance Berhad, yang terdapat di laman web dan cawangan-cawangan AmMetLife Insurance Berhad.

f. I/We understand that Ammetlife will deduct any withholding required by FATCA. / Saya/Kami memahami bahawa AmMetLife Insurance Berhad akan memotong sebarang penyekatan yang diperlukan oleh FATCA.

g. I/We understand that it is my duty to inform AmMetlife in the event of any change to my citizenship(s) or any other information relating to US Indicia during the lifetime of the policy issued under this proposal. / Saya/ kami faham bahawa adalah menjadi tanggungjawap kami untuk memaklumkan kepada AmMelife Insurance Berhad sekiranya terdapat apa-apa perubahan kepada kerakyatan saya/kami atau terdapat apa-apa maklumat berkenaan United State Indicia semasa tempoh polisi yang dikeluarkan.

h. I/We further understand that AmMetlife Insurance Berhad reserves the right, within its sole discretion, to terminate this arrangement in the event that appropriate documentation of my/our US or non-US status for purposes of FATCA is not timely provided to AmMetlife Insurance Berhad. In particular, in and no waiver of such local law is obtained, AmMetlife reserves the right to close the account. / Saya/Kami juga memahami bahawa AmMetLife Insurance Berhad berhak,bergantung pada budi bicara, untuk membatalkan permohonan ini sekiranya dokumen-dokumen daripada saya/kami yang diperlukan berkenaan dengan status AS2 atau bukan AS2 untuk tujuan FATCA tidak diserahkan dalam masa yang ditetapkan kepada AmMetLife Insurance Berhad. Khususnya, sekiranya undang-undang atau peraturan-peraturan Malaysia yang berkaitan akan menghalang sekatan pembayaran kepada polisi atau menghalang laporan kepada polisi tersebut dan tiada perlepasan yang diterima daripada undang-undang tempatan tersebut, AmMetLife Insurance Berhad berhak untuk menutup polisi tersebut.

Item Claimant 1 Claimant 2 Claimant 3 Claimant 4 Claimant 5

Name

NRIC

Telephone

Address

Occupation

Country of Birth

Are you a citizen of the United States of America?

List other countries of citizenship (if applicable)

Industry

Employer’s Name

Employer’s Address

DIRECT CREDITING (To be completed by claimant)

Please complete the rest of the boxes if more than 1 claimant.

Yes No Yes No Yes No Yes No Yes No

* Obligatory / WajibAmL/Claims/Death/0315

Note / Nota-notaMetLife is a multinational organization and as such, MetLife and AmMetlife as its associates are subject to the restrictions imposed by economic andtrade sanctions programs in the United States as well as other countries where MetLife conducts business. Therefore, MetLife may not engage in anytransactions, or pay claims that would violate any applicable trade or economic sanctions. AmMetLife shall not be deemed to provide coverage andAmMetLife shall not be liable to pay any claim or provide any Benefit to the extent that the provision of such Benefit would expose AmMetLife to anysanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union,United Kingdom or United States of America or any applicable laws. This policy will be deemed null and void should a party be subject to any forementioned sanction or restriction at policy issuance. / MetLife merupakan sebuah organisasi multinasional, oleh itu MetLife dan AmMetLife sebagai sekutunya tertakluk kepada sekatan yang dikenakan oleh program sekatan ekonomi dan perdagangan di Amerika Syarikat dan negara-ne-gara lain di mana MetLife menjalankan perniagaan. Oleh itu, MetLife tidak boleh terlibat dalam sebarang transaksi, atau membayar tuntutan yang akan melanggar sebarang sekatan perdagangan atau ekonomi yang berkaitan. AmMetLife tidak akan tertakluk untuk memberi perlindungan dan AmMetLife tidak akan bertanggungjawab untuk membayar sebarang tuntutan atau memberikan sebarang faedah sekiranya peruntukan faedah itu akan mendedahkan AmMetLife kepada sebarang sekatan, larangan atau sekatan di bawah resolusi Bangsa-Bangsa Bersatu atau sekatan perdagan-gan atau ekonomi,undang-undang atau peraturan-peraturan Kesatuan Eropah, United Kingdom atau Amerika Syarikat atau sebarang undang-un-dang yang berkenaan. Polisi ini akan dianggap terbatal dan tidak sah sekiranya sesuatu pihak tertakluk kepada sebarang sekatan-sekatan yang disebutkan atau sekatan ketika pengeluaran polisi.

Do you have a USaddress?

If Yes, pleaseprovided /

Country ofIncorporation (if policy owner isa company)


Purpose of policy? Personal

Business

Personal

Business

Personal

Business

Personal

Business

Personal

Business

FOR CUSTOMER SERVICE/BRANCH USE ONLY / UNTUK KEGUNAAN KHIDMAT PELANGGAN/CAWANGAN SAHAJA

Checklist of documents received / Senarai dokumen-dokumen yang disertakan:

Application Through / Permohonan melalui:

Walk-in Claimant / Penuntut Hadir Agent / Ejen Post / Pos

Signature of Staff / Tandatangan Kakitangan:

Name / Nama :

Date / Tarikh :

Death Claim Form / Borang Tuntutan Kematian

Statement by Physician / Pernyataan Doktor

Authorisation for Release of Medical Report / Kebenaran untuk mengeluarkan laporan perubatan

Post Mortem Report / Laporan Bedah Siasat

Hospital/Clinic Appointment Card / Kad Temujanji Hospital/KlinikName & Address of Usual Attending Physician / Nama & Alamat Doktor biasa yang merawat

Copy of NRIC of the Deceased / Salinan Kad Pengenalan Si Mati

No. Kad Pengenalan Penama yang dinamakan/Penuntut - Disahkan

Sijil Kematian - Disahkan

Sijil Perkahwinan - Disahkan

Copy / Sijil Kelahiran - DisahkanOriginal Policy Document/Statutory Declaration for Lost of Policy / Dokument Asal Polisi/Borang Pengesahan Kehilangan Polisi


Bank NamePlease enclose

page of your bank passbook (saving account/joint account) or account statement (for current account).

Account Type (Please tick one)

Bank Account Number

Policy No. 1

Policy No. 2

Policy No. 3

Declaration

Signature of Claimant

Email

Date

Savings

Current

Savings

Current

Savings

Current

Savings

Current

Joint Joint Joint Joint

Savings

Current

Joint

a.I/We hereby authorise AmMetLife Insurance Berhad to credit claim payment or refund premium of policy referred to herein into my/our bank account as stated above and hereby irrevocably and unconditionally agree to fully indemnify AmMetLife Insurance Berhad and keep AmMetLife Insurance Berhad fully indemnified against all costs, losses, damages or expenses whatsoever that AmMetLife Insurance Berhad may incur or suffer from and against all actions, proceedings, claims and demands taken or made against AmMetLife Insurance Berhad as a result of the credit claim payment or refund premium of policy referred to herein.

b.I/We hereby agree to indemnify and keep the Company indemnified against any claims, loss, damage cost and expenses which the Company may suffer or incur due to my authorisation to direct credit payment into the Third Party Account accord-ing to the details stated in this form and I/we shall accept full responsibility for this authorisation and shall keep the Company indemnified against all claims, expenses etc arising from this authorisation and I/we hereby give AmMetLife Insurance Berhad a valid discharge from all/any liability for the above said matter

GST RegistrationNo.

Do you claim theInput Tax Credit onthe GST paid onthe policy


* Obligatory / Wajib

Yes No

Yes No

Yes No

Assessment (For office use only) A. Officer’s Review of the Account – In Scope for FATCA 1. Is the applicant’s product in scope for FATCA? (refer to the In-Scope FATCA Product Listing)

2. Does the Cash Value of the account exceed USD 50,000? (Conversion of MYR to USD must be based on exchange rate as at date of review)

Is the Account In Scope for FATCA? (Answer ‘Yes’ if ‘Yes’ to both of the above)

B. Officer’s Declaration and Acknowledge I declare that the required assessment has been performed for the customer(s) listed above; and that the information provided is true correct and

updated.

Officer Signature Date Officer Name :

Officer ID :


Sila kemukakan invois terperinci, resit asal mencatatkan perbelanjaan rawatan hospital dan Nota Keluar hospital.

1. *Policy No. / *No. Polisi

2. Life Assured’s details / Butir Diri yang DiInsuranskan

i) *Name of Life Assured / *Nama Diri yang DiInsuranskan

ii) *NRIC No. / *No. K/P

iii) Correspondence address / Alamat surat menyurat

iv) Nationality / Warganegara

v) Date of birth / Tarikh Lahir

vi) Occupation / Pekerjaan

vii) Name of Employer / Nama Majikan

viii) Nature of Business / Jenis Perniagaan

viii) Employer’s Address / Alamat Majikan

ix) Telephone No. / No. Telefon

Residence / Rumah :

Pejabat:

Mobile No. / Telefon Bimbit:

3. Policy Owner’s Details (if other than Life Assured) / Butir Pemilik Polisi (jika selain daripada Diri yang DiInsuranskan)

i) *Name of Policy Owner / *Nama Pemegang Polisi

ii) *NRIC No. / *No. K/P

iii) Correspondence address / Alamat surat menyurat








Residence / Rumah:

Pejabat:


4. If hospitalisation was due to accident, please provide details of accident / Jika kemasukan ke hospital disebabkan kemalangan, sila beri butir kejadian kemalangani. When did it occur? / Bilakah kemalangan tersebut berlaku?

ii. Where did it occur? / Dimanakah kemalangan tersebut berlaku?

iii. How did it occur? / Bagaimanakah kemalangan tersebut berlaku?

iv. Nature and extent of injury / Jenis dan tahap kecederaan yang dialami

HOSPITALISATION & SURGICAL CLAIM FORM / BORANG TUNTUTAN HOSPITAL & PEMBEDAHAN

Faedah Hospital (HB) AmFamily Scheme / Skim AmFamily

Health Management Rider (HMR) / Faedah Pengurusan Hospital Special Medicare / Medicare Khas

Part I – CLAIMANT’S STATEMENT / Bahagian I – KENYATAAN PENUNTUT



AmL/Claims/H&S/0315

5. If hospitalisation was due to illness / Jika kemasukan ke hospital disebabkan penyakit

a) Nature of illness or symptom? / Jenis penyakit atau simptom

Berapa lamakah anda/Diri Yang DiInsuranskan menghadapi symptom sebelum pertama kali dimasukkan ke hospital?

c) What was the diagnosis? / Apakah diagnosis ketika itu?

6. Name and address of doctors who treated you/the Life Assured for this illness or injury / Nama dan alamat doktor yang merawat anda/Diri Yang DiInsuranskan bagi penyakit atau kecederaan ini

i.

ii.

Date of Consultation / Tarikh rawatan Date of Admission (if any) / Tarikh masuk hospital (jika ada)

7. Please provide name and address of your/the Life Assured’s regular attending doctor other than the above / Sila nyatakan nama dan alamat doktor yang biasa merawat anda/Diri Yang DiInsuranskan selain daripada yang di atas.

Name of Company/Program Scheme Policy/membership no. Nama Syarikat/Skim Program No. polisi/No. keahliani.

ii.

AmL/Claims/H&S/0315

8. Are you presently insured for Hospitalisation & Surgical benefits under any government law/program, employee benefit, any health benefit scheme or any other insurance policy? If so, please provide details / Adakah anda, ketika ini dibawah perlindungan insurans faedah Hospital & Pembedahan, dibawah sebarang program/undang-undang kerajaan, kemudahan pekerja, sebarang skim faedah kesihatan atau sebarang polisi insurans lain? Jika ada, sila beri butir

Declaration

Perisytiharan

Saya dengan ini mengisytiharkan bahawa maklumat yang diberi dalam borang tuntutan ini adalah benar dan bahawanya saya tidak menghidap sebarang penyakit ketika polisi ini dikuatkuasakan. Saya seterusnya mengisytiharkan bahawa kemasukan ke hospital kali ini bukan disebabkan keadaan yang dinyatakan dalam Fasal Pengecualian polisi.Saya bersetuju bahwanya jika saya membuat atau pernah membuat sebarang kenyataan palsu atau tidak benar dan/atau menghalang dan/atau menyembunyikan sebarang fakta berkaitan dengan kesihatan dengan kesihatan dan keadaan saya, pihak syarikat akan secara mutlak berhak menarik balik hak saya untuk mendapat pampasan dan seterusnya mendapat hak untuk menuntut semula sebarang jumlah yang telah dibayar sebelum ini.

Signature of Life Assured / Tandatangan Diri Yang DiInsuranskan

Name / Nama :

Date / Tarikh :

AmL/Claims/H&S/0315

DECLARATIONa. I/We represent and declare that the information provided above and in the submitted documents is true, accurate and complete; and the submitted

documents are genuine and duly executed. / Saya/ kami mengakui bahawa maklumat yang diberikan di atas dan di dalam dokumen adalah benar, tepat dan lengkap dan dakumen yang dikembarkan adalah tulen dan telah ditandatangani.








I hereby declare that the information given in this claim form are true and that I did not suffer from any of the pre-existing conditions at the time of this policy was taken up, I further declare that the current confinement to the hospital is not due to any causes which are stipulated in the Exclusion Clause of the Policy. I agree that in the event that I make, or have in the past made, any false or untrue statement and/or supressed and/or concealed any materials facts inrespect of my health and condition, the company shall absolutely forfeit my right to compensation and futher reserves the right to recover any amounts paid earlier as a result thereof.

- -

/ / 2

Old IC/Passport


Name*

NRIC no.*

Date


Name

NRIC

Telephone

Address

Occupation

Country of Birth



Industry

Employer’s Name

DIRECT CREDITING (To be completed by claimant)Please complete the rest of the boxes if more than 1 claimant.


* Obligatory / WajibAmL/Claims/H&S/0315






Savings

Current

Savings

Current

Savings

Current

Savings

Current


Savings

Current

Joint




Bank Account Number

Policy No. 1

Policy No. 2

Policy No. 3

Declaration


Email

Date



b.I/We hereby agree to indemnify and keep the Company indemnified against any claims, loss, damage cost and expenses which the Company may suffer or incur due to my authorisation to direct credit payment into the Third Party Account according to the details stated in this form and I/we shall accept full responsibility for this authorisation and shall keep the Company indemnified against all claims, expenses etc arising from this authorisation and I/we hereby give AmMetLife Insurance Berhad a valid discharge from all/any liability for the above said matter

AmL/Claims/H&S/0315

Purpose of policy?

GST RegistrationNo.


Personal

Business

Personal

Business

Personal

Business

Personal

Business

Personal

Business


Yes No

Yes No

Yes No





updated.


Officer ID :

Please enclose the following documents / Sila kemukakan dokumen berikut:

Salinan Sijil Kelahiranii) To be eligible to claim for maternity bonus up to maximum RM1,000.00, kindly submit original invoice from the hospital where delivery took

place. / Untuk layak menuntut bonus bersalin sehingga maksima RM1,000.00, sila lampirkan invois asal hospital tempat bersalin.

1. Policy No. / No. Polisi: ______________________________

2. Details of Life Assured / Butir-butir Diri yang Diinsuranskan

i) Name of Life Assured* / Nama Diri Yang DiInsuranskan*

ii) NRIC No.* / No. Kad Pengenalan Baru*

iii) Correspondence Address* / Alamat surat-menyurat*








Residence / Rumah :


Details of Policy Owner / Butir-butir Pemilik Polisi

i) Name of Life Assured* / Nama Diri Yang DiInsuranskan*

ii) NRIC No.* / No. Kad Pengenalan Baru*

iii) Correspondence Address* / Alamat surat-menyurat*








Residence / Rumah :


3. Date of giving birth / Tarikh Bersalin: __________________________

Signature of Life Assured/Policy OwnerTandatangan Diri Yang DiInsuranskan/

Pemilik Polisi

MATERNITY CLAIMS FORM / BORANG TUNTUTAN BERSALIN(To be completed by the Life Assured/Policy Owner) / (Perlu dilengkapkan oleh Diri yang Diinsuranskan/Pemegang Polisi)

*Obligatory / Wajib

Date / Tarikh


AmL/Claims/Maternity/0315

Office / Pejabat: Office / Pejabat:

i) Copy of the Birth Certificate. /

Declaration

Perisytiharan

Saya dengan ini mengisytiharkan bahawa maklumat yang diberi dalam borang tuntutan ini adalah benar dan bahawanya saya tidak menghidap sebarang penyakit ketika polisi ini dikuatkuasakan. Saya seterusnya mengisytiharkan bahawa kemasukan ke hospital kali ini bukan disebabkan keadaan yang dinyatakan dalam Fasal Pengecualian polisi.Saya bersetuju bahwanya jika saya membuat atau pernah membuat sebarang kenyataan palsu atau tidak benar dan/atau menghalang dan/atau menyembunyikan sebarang fakta berkaitan dengan kesihatan dengan kesihatan dan keadaan saya, pihak syarikat akan secara mutlak berhak menarik balik hak saya untuk mendapat pampasan dan seterusnya mendapat hak untuk menuntut semula sebarang jumlah yang telah dibayar sebelum ini.

Signature of Life Assured / Tandatangan Diri yang DiInsuranskan

Name / Nama :

Date / Tarikh :

DECLARATION



I hereby declare that the information given in this claim form are true and that I did not suffer from any of the pre-existing conditions at the time of this policy was taken up, I further declare that the current confinement to the hospital is not due to any causes which are stipulated in the Exclusion Clause of the Policy.I agree that in the event that I make, or have in the past made, any false or untrue statement and/or supressed and/or concealed any materials facts inrespect of my health and condition, the company shall absolutely forfeit my right to compensation and futher reserves the right to recover any amounts paid earlier as a result thereof.









/ / 2


Name*

NRIC no.*

Date


- - Old IC/Passport



Name

NRIC

Telephone

Address

Occupation

Country of Birth



Industry

Employer’s Name


DIRECT CREDITING (To be completed by claimant)

Please complete the rest of the boxes if more than 1 claimant.











Bank Account Number

Policy No. 1

Policy No. 2

Policy No. 3

Declaration


Email

Date

Savings

Current

Savings

Current

Savings

Current

Savings

Current


Savings

Current

Joint



b.I/We hereby agree to indemnify and keep the Company indemnified against any claims, loss, damage cost and expenses which the Company may suffer or incur due to my authorisation to direct credit payment into the Third Party Account according to the details stated in this form and I/we shall accept full responsibility for this authorisation and shall keep the Company indemnified against all claims, expenses etc arising from this authorisation and I/we hereby give AmMetLife Insurance Berha a valid discharge from all/any liability for the above said matter

a copy of the first

Purpose of policy?

GST RegistrationNo.


Personal

Business

Personal

Business

Personal

Business

Personal

Business

Personal

Business


Yes No

Yes No

Yes No





updated.


Officer ID :

1. Policy Number / Nombor Polisi

2. Name* / Nama*

TOTAL & PERMANENT DISABILITY BENEFITS CLAIM FORM /BORANG TUNTUTAN MANFAAT HILANG UPAYA MENYELURUH & KEKAL

Type of Policy / Jenis Polisi:

To be completed by the Policy Owner / Borang ini perlu dilengkapkan oleh Pemegang PolisiLife / Individu Group / Berkelompok

A) GENERAL DETAILS / BUTIR-BUTIR PERIBADI

a) d)

b) e)

c) f)

3. NRIC number* / No. KP Baru* Old IC/Passport / No. KP Lama/Pasport

4. Age / Umur Date of Birth / Tarikh Lahir D D M M Y Y Y Y 5. Title / Gelaran: Mr/Mrs/Madam/Miss/Dr / Encik/Puan/Cik /Dr

6. Residential Address* / Alamat Kediaman*

* / Alamat Pejabat

7. Telephone No. / No Telefon. - -

- -

Home / Rumah

Mobile / Bimbit

Pejabat

Fax / Faks

Email / E-mel

8. Highest education level / Tahap Pendidikan tertinggi yang diperolehi

Primary school / Sekolah Rendah

Secondary School / Menengah

Diploma /Diploma

Degree /Ijazah

to / Adakah anda kini terlantar di

Sertakan salinan surat tawaran yang disahkan

Bed / Katil House / Rumah Hospital / Hospital

10. Are you entitle for compensation from the insurer or any sources? / Adakah anda berhak untuk menerima pampasan dari syarikat insurans yang lain atau mana-mana sumber? If Yes, please provide details / Jika Ya,berikan butirannya Policy Reference No. / No. Polisi / Rujukan Name of Sources / Nama sumber

Yes / Ya No / Tidak

B) PARTICULARS OF OCCUPATION / BUTIR–BUTIR PEKERJAAN

11. Name of employer / Nama Majikan

Please provide details of your current employment, occupation & exact duties or please attach your current job description. / Sila nyatakan dengan lanjut pekerjaan dan tugasan sekarang atau sertakan salinan huraian tugasan sekarang

* Obligatory / * Wajib

AmL/Claims/TPD/0315


14. Tarikh terakhir anda bekerja

12. Address of business / Alamat Perniagaan

13. Telephone no. / No. Telefon - -

D D M M Y Y Y Y

15. Work Area / Skop Pekerjaan Job Skills / Kemahiran Pekerjaan

Persekitaran tempat kerja anda (pejabat, kilang dan lain-lain) / Kelulusan dan/atau kemahiran yang diperlukan dalam pekerjaan anda

b) Are you in management or supervisory capacity? / Adakah anda menjalankan tugas-tugas pengurusan atau penyeliaan?

e) Any special skills required? / Adakah kemahiran khas diperlukan?

c) Do you operate any machinery or special equipments? / Adakah anda mengendalikan mesin atau alat-alat khas yang lain?

f) What level of practical experience is required? / Apakah tahap pengalaman praktikal yang diperlukan?

16. Travel & Business hours / Perjalanan ke tempat kerja dan waktu bekerja

a) What is your normal working hours and days? / Apakah waktu dan hari bekerja anda yang normal

b) Are you required to work on / Adakah anda diperlukan bekerja:

c) What is the distance of travel to go to your normal place of work? / Jarak perjalanan ke tempat kerja anda?

d) How do you travel to work? / Bagaimana anda pergi ke tempat kerja?

e) Does your work require you to / Adakah pekerjaan anda memerlukan anda untuk:

Shift / Shif Sunday / Ahad On Call / Dipanggil

Driving a car? / Memandu kereta?

Climbing ladders or heights? / Memanjat tangga atau tempat tinggi?

Lifting heavy loads? / Mengangkat barangan berat?

Driving other vehicles? / Memandu kenderaan lain?

Carrying heavy loads? / Membawa barangan berat?

Crawling or kneeling? / Merangkak atau melutut?

D D M M Y Y Y Y

C) TO BE COMPLETED BY A SELF-EMPLOYED PERSON ONLY / UNTUK DIISI OLEH ORANG YANG BEKERJA SENDIRI SAHAJA

20. Please name your business/company / Berikan nama perniagaan/syarikat anda

21. Nature of business / Jenis perniagaan anda

22. Are there any other proprietors or directors of the business? / Adakah terdapat pemilik atau pengarah yang lain di dalam perniagaan ini?

How many? / Berapa ramai?

23. Please provide your business or company registration number, if incorporated. / Sila berikan no. pendaftaran perniagaan atau syarikat, jika didaftarkan.

Other physical exertions? Please specify /

11.1 Name of employer / Nama Majikan

Travelling away from your normal place of work? / Perjalan luar dari tempat kerja biasa anda?

17. Please list the jobs held in the past 5 years / Senarai pekerjaan anda untuk tempoh 5 tahun yang lepas.

Dates (From-To) / Tarikh (dari-hingga)

Name of Employer / Nama majikan

Address & Telephone No./Alamat & No. Telefon

Job title & exact duties of work /Jawatan & Jenis Kerja Sebenar

Average monthly income (RM) /

Pendapatan Bulanan (RM)

18. State the date when you are expected to resume your work and daily activities? / Nyatakan tarikh anda dijangka kembali bekerja dan menjalankan aktiviti harian anda:

19.Jika perkhidmatan anda telah ditamatkan, sila nyatakan tarikh ianya berkuatkuasa dan sertakan salinan surat tamat perkhidmatan.:

AmL/Claims/TPD/0315

24. When did the accident happen? / Bila kemalangan berikut berlaku?

Date / Tarikh:

Time / Masa:

Place / Tempat:

25. Please provide the police report number and a copy of it and details of any witness (to attach copy of report) / Sila berikan nombor laporan polis dan salinan laporan serta butir-butir mengenai saksi, jika ada:

26. Describe in details how the accident happen. / Nyatakan secara terperinci bagaimana kemalangan berlaku.

27. Describe the extent of the injuries sustained in the accident and treatment given / undergoing including any rehabilitation plan. / Nyatakan tahap kecederaan yang dialami akibat kemalangan dan rawatan yang diterima atau menjalani sebarang rawatan pemulihan.

E) TO BE COMPLETED IF DISABILITY WAS CAUSED BY AN ILLNESS / UNTUK DIISI JIKA HILANG UPAYA DISEBABKAN OLEH PENYAKIT

28. Please fully describe the conditions or the symptoms? / Nyatakan dengan terperinci keadaan atau tanda-tanda penyakit anda?

29. Bilakah tanda-tanda / keadaan itu mula-mula timbul?

30. What are the treatments you are undergoing currently? / Apakah rawatan yang sedang dijalani sekarang?

31. What is the exact diagnosis and when was it made known to you? / Apakah keputusan diagnosis dan bilakah anda diberitahu mengenainya?

32.Apakah ujian atau penyiasatan yang telah dibuat untuk mengesahkan diagnosis itu?

33. Provide the name and address of the doctor who had made the diagnosis? / Berikan nama dan alamat doktor yang telah membuat diagnosis tersebut?

34. Please provide details of what duties of your occupation you are currently unable to perform. / Sila nyatakan secara lengkap tugasan sebenar anda sekarang ini yang anda tidak berupaya lakukan.

35. DETAILS OF DOCTORS YOU HAVE CONSULTED PRIOR TO THE DISABILITY / BUTIR-BUTIR DOKTOR YANG MERAWAT ANDA SEBELUM HILANG UPAYA BERLAKU

Name / Nama Address / Alamat Date of Consultation / Tarikh Rawatan

Reason / Sebab Rawatan

36. DETAILS OF DOCTORS YOU HAVE CONSULTED SINCE THE DISABILITY / BUTIR-BUTIR DOKTOR YANG MERAWAT ANDA SEMENJAK HILANG UPAYA BERLAKU

Name / Nama Address / Alamat Date of Consultation / Tarikh Rawatan

Reason / Sebab Rawatan

D) TO COMPLETED IF DISABILITY WAS CAUSED BY AN ACCIDENT / UNTUK DIISI JIKA HILANG UPAYA DISEBABKAN OLEH KEMALANGAN

D D M M Y Y Y Y

AmL/Claims/TPD/0315

FOR AmMetLife USE ONLY / UNTUK KEGUNAAN AmMetLife SAHAJA

Checklist of Documents received / Senarai dokumen-dokumen yang disertakan:

TPD Claim Form / Borang Tuntutan Faedah Hilang Upaya Menyeluruh & Kekal

Laporan doktor

EPF withdrawal/SOCSO letter / Surat pengesahan daripada SOCSO/Surat pengeluaran KWSP

Original Policy Document / Polisi Asal

Copy of Employer’s Termination Letter / Surat Pemberhentian Kerja daripada majikan (sekiranya ada)

Application Through / Permohonan diterima melalui:

Walk-in Claimant / Penama Agent / Ejen Post / Pos

Signature of Staff / Tandatangan Kakitangan :

Name / Nama : Date / Tarikh:

POLICY OWNER/LIFE ASSURED / PENGAKUAN OLEH PEMEGANG POLISI/DIRI YANG DIINSURANSKAN

I declare the above answers are true and correct. I understand that AmMetLife Insurance berhad will not be deemed to have admitted the liability of the claim by issuing this form and investigating my claim or accepting evidence of my claim. / Saya mengaku bahawa jawapan di atas adalah benar. Saya faham bahawa AmMetLife Insurance Berhad tidak akan dianggap telah menerima liability tuntutan ini dengan cara penyerahan borang ini, menjalankan penyiasatan tuntutan saya atau penerimaan bukti tuntutan.

Signature of Witness / Tandatangan saksiName / Nama :NRIC No. / No. K/P. :Tel. No. / No. Tel. :Address / Alamat :

Signature of the Policy Owner / Tandatangan Pemilik Polisi (if different from the Life Assured / jika lain dari Diri Yang DiInsuranskan)Name / Nama :NRIC No. / No. K/P. :Tel. No. / No. Tel. :Address / Alamat :

Signature of the Life Assured / Tandatangan Diri Yang DiInsuranskanName / Nama :NRIC No. / No. K/P. :

AmL/Claims/TPD/0315

DECLARATION










Name

NRIC

Telephone

Address

Occupation

Country of Birth




DIRECT CREDITING (To be completed by claimant)Please complete the rest of the boxes if more than 1 claimant.

* Obligatory / Wajib AmL/Claims/TPD/0315


- -

/ / 2

Old IC/Passport


Name*

NRIC no.*

Date

Note / Nota-notaMetLife is a multinational organization and as such, MetLife and AmMetlife as its associates are subject to the restrictions imposed by economic and trade sanctions programs in the United States as well as other countries where MetLife conducts business. Therefore, MetLife may not engage in anytransactions, or pay claims that would violate any applicable trade or economic sanctions. AmMetLife shall not be deemed to provide coverage and AmMetLife shall not be liable to pay any claim or provide any Benefit to the extent that the provision of such Benefit would expose AmMetLife to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States of America or any applicable laws. This policy will be deemed null and void should a party be subject to any aforementioned sanction or restriction at policy issuance. / MetLife merupakan sebuah organisasi multinasional, oleh itu MetLife dan AmMetLife sebagai sekutunya tertakluk kepada sekatan yang dikenakan oleh program sekatan ekonomi dan perdagangan di Amerika Syarikat dan negara-negara lain di mana MetLife menjalankan perniagaan. Oleh itu, MetLife tidak boleh terlibat dalam sebarang transaksi, atau membayar tuntutan yang akan melanggar sebarang sekatan perdagangan atau ekonomi yang berkaitan. AmMetLife tidak akan tertakluk untuk memberi perlindungan dan AmMetLife tidak akan bertanggungjawab untuk membayar sebarang tuntutan atau memberikan sebarang faedah sekiranya peruntukan faedah itu akan mendedahkan AmMetLife kepada sebarang sekatan, larangan atau sekatan di bawah resolusi Bangsa-Bangsa Bersatu atau sekatan perdagangan atau ekonomi, undang-undang atau peraturan-peraturan Kesatuan Eropah, United Kingdom atau Amerika Syarikat atau sebarang undang-undang yang berkenaan. Polisi ini akan dianggap terbatal dan tidak sah sekiranya sesuatu pihak tertakluk kepada sebarang sekatan-sekatan yang disebutkan atau sekatan ketika pengeluaran polisi.




Declaration


Email

Date


AmL/Claims/TPD/0315




Bank Account Number

Policy No. 1

Policy No. 2

Policy No. 3

Savings

Current

Savings

Current

Savings

Current

Savings

Current


Savings

Current

Joint

Purpose of policy?

GST RegistrationNo.


Personal

Business


Industry

Employer’s Name



b.I/We hereby agree to indemnify and keep the Company indemnified against any claims, loss, damage cost and expenses which the Company may suffer or incur due to my authorisation to direct credit payment into the Third Party Account according to the details stated in this form and I/we shall accept full responsibility for this authorisation and shall keep the Company indemnified against all claims, expenses etc arising from this authorisation and I/we hereby give AmMetLife Insurance Berhad a valid discharge from all/any liability for the above said matter

Personal

Business

Personal

Business

Personal

Business

Personal

Business


AmL/Claims/TPD/0315

Yes No

Yes No

Yes No





updated.


Officer ID :