Personal Accident Claim Form
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- Mervin Newman
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1 Personal Accident Claim Form AGENCY NO. CLAIM NO. Notes: The issue of this form is not an admission of liability by the Company. If the Claimant is unable to fill up this form personally it may be filled up on behalf of the Claimant. This form must be completed giving full particulars of any event in respect of which a claim is to be made and return to the Company at the office of the Company at which the Policy is issued as soon as possible, but in any case within fourteen days after the occurence of the accident. 1. Name of Claimant in Full NRIC No (New) (Old) Address Tel No: Name of Policyholder Date of Birth Relationship (if different claimant) Policy No. Period of Insurance From To 2. Name of Employer Address Tel No: 3. Date of Accident Time AM/PM Place of Accident 4. a) Please state in detail how the accident occured and what were you doing at the time. b) If accident involved other person(s) or motor vehicle(s), please state the name and address of the person(s) and/or the Registration Number of the vehicle. 5. Please state precisely the injuries that you have sustained. 6. Please give name and address of any persons who witnessed the accident. 1836/4/P/G/S/M
2 7. a) Please give name and address of Medical Practitioner who attended to you after the accident. b) Is he your usual Medical Attendant? If not, please state reason why he was consulted. 8. Please state whether you are entitled to compensation from any other source in respect of this accident. If so, please state the name of the company and the amount. 9. a) Have you ever met with any accident? If so, please give particulars. b) Have you ever made a claim for compensation in respect of accidental injury from any Insurer? If so, please state the name of Insurer and the amount of compensation. I hereby declare that I have complied in every respect with the terms and conditions of the policy and that I have not abstained from my usual occupation, either entirely or partially, longer than absolutely necessary in consequence of the said accident, and that such accident is the sole cause of my disablement. I do hereby warrant the truth of the foregoing statements and particulars in every respect, and I agree that if I have made, or in any further declaration the officers of the Company may require of me in respect of the said claim shall make, any false or fraudulent statement or any concealment of material fact, the Policy shall be void as against the Company and my right to compensation absolutely forefeited, and I am willing, whenever required by the officers of the Company, to make a statutory declaration of the truth of all the foregoing statements, and of such other particulars as may be required by the officers of the Company. Date Authorisation to Medical Practitioner, Hospital or Clinic Signature of Policyholder/Claimant/ Employee & Company Stamp I hereby authorise any physician, practitioner, hospital or clinic by whom or where I have been examined or treated for any reason, to give full particulars thereof including prior medical history to Zurich General Insurance Malaysia Berhad. A photostat copy of this authorisation shall be deemed valid as the original. I/We hereby give my/our unconditional and unequivocal consent to you and all your related companies to process my/our personal data revealed hereto. You are at liberty to process the data and share the information revealed thereto with any of your service providers and your other related companies provided that the revelation of my/our personal data strictly for the purposes in relation to the insurance which I/We have applied hereto. The consent given hereto is in line with the requirement set forth in the Personal Data Protection Act Date Signature of Policyholder/Claimant/Patient/Employee N.B - Please have your medical attendant complete the Medical Certificate attached to this form Zurich General Insurance Malaysia Berhad ( V) 11th Floor, Menara Zurich, No.12, Jalan Dewan Bahasa, Kuala Lumpur, Malaysia Tel: Fax: Call Centre:
3 Medical Certificate Accident Claim AGENCY NO. CLAIM NO. Notes: The Company does not admit liability by the issue of this form. No Claim will be recognized unless this Medical Certificate is completed by a duly registered Medical Practitioner and forwarded to the Company as soon as possible. This Medical Certificate must be obtained at the Insured s own expense. 1. Name of Patient NRIC No (New) Date of Birth (Old) Sex Business/Occupation 2. a) Date of Accident Time AM/PM b) Cause of Injuries c) Please state explicity of the injuries sustained by the patient: d) Please state details of treatment given to patient e) Is the patient hospitalized? If so, please state the duration 3. a) Are you the patient s regular medical attendant? If so, how long have you known the patient and for what ailments or injuries have you treated him? b) Are the injuries sustained consistent with the circumstances of the accident as described to you by the patient? c) Was the patient suffering from any disease or physical infirmity at the time of accident? d) Is there any previous medical history of disablement which may have contributed directly on indirectly to the accident or which may likely retard the patient s recovery? 1836/4/P/G/S/M
4 e) Have you any reason to suspect that the patient was under the influence of intoxicants or drugs at the time of accident? 4. a) What is the present condition of the injuries? If recovered, please give date of recovery. b) Please give dates of your visits to the patient and/or the patient s visit to you as from the date of accident. 5. Keeping in view of his/her occupation as a, what do you feel the disability indicated below should be in: (i) Temporary Total Disability (TTD), was from until (Day) (Month) (Year) (Day) (Month) (Year) (ii) Temporary Partial Disability (TPD), was from until (Day) (Month) (Year) (Day) (Month) (Year) I HEREBY CERTIFY HAVING EXAMINED THE ABOVE NAMED AND THAT MY FOREGOING STATEMENT ARE CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF Signature and stamp of Attending Physician/Surgeon Address Date Qualification Zurich General Insurance Malaysia Berhad ( V) 11th Floor, Menara Zurich, No.12, Jalan Dewan Bahasa, Kuala Lumpur, Malaysia Tel: Fax: Call Centre:
5 Borang Tuntutan Kemalangan Peribadi NO. AGENSI NO TUNTUTAN Perhatian: Pengeluaran borang ini bukan pengakuan liabiliti oleh syarikat. Jika Pihak yang Membuat Tuntutan tidak dapat mengisi borang ini sendiri, ia boleh diisi bagi pihaknya. Borang ini mesti diisi dengan memberikan butiran penuh sebarang kejadian berkaitan dengan tuntutan yang akan dibuat dan dipulangkan kepada Syarikat di pejabat Syarikat di mana Polisi dikeluarkan secepat mungkin, tetapi dalam apa jua keadaan dalam masa empat belas hari selepas berlaku kemalangan. 1. Nama Penuh Pihak yang Membuat Tuntutan No KP (Baru) (Lama) Alamat No Tel: Nama Pemegang Polisi Tarikh Lahir Hubungan (jika pihak yang membuat tuntutan berbeza) No. Polisi Tempoh Insurans Dari Hingga 2. Nama Majikan Alamat No. Tel 3. Tarikh Kemalangan Masa PG/PTG Tempat Kemalangan 4. a) Sila nyatakan secara terperinci bagaimana kemalangan berlaku dan apa yang sedang anda lakukan pada waktu itu. b) Jika kemalangan membabitkan orang atau kenderaan bermotor lain, sila nyatakan nama dan alamat orang tersebut dan/ atau Nombor Pendaftaran kenderaan tersebut. 5. Sila nyatakan dengan tepat kecederaan yang anda alami. 6. Sila berikan nama dan alamat sesiapa yang telah menyaksikan kemalangan tersebut. 1836/4/P/G/S/M
6 7. a) Sila berikan nama dan alamat Doktor yang merawat anda selepas kemalangan. b) Adakah beliau Doktor biasa anda? Jika tidak, sila nyatakan sebab anda dirujuk kepada beliau. 8. Sila nyatakan sama ada anda layak menerima pampasan daripada sumber lain bagi kemalangan ini. Jika ya, sila nyatakan nama syarikat dan jumlah. 9. a) HPernahkah anda mengalami kemalangan? Jika ya, sila berikan butirannya. b) Pernahkah anda membuat tuntutan pampasan bagi kecederaan akibat kemalangan daripada mana-mana penanggung insurans? Jika ya, sila nyatakan nama penanggung insurans dan jumlah pampasan. Saya dengan ini mengisytiharkan bahawa saya telah mematuhi terma dan syarat polisi ini dalam segala hal dan saya tidak mengecualikan diri daripada melakukan kerja biasa saya, sama ada sebahagiannya atau sepenuhnya, lebih lama daripada yang benar-benar perlu disebabkan oleh kemalangan tersebut, dan kemalangan tersebut adalah punca tunggal kehilangan upaya saya. Saya dengan ini mengesahkan kebenaran kenyataan dan butiran di atas dalam segala hal, dan saya bersetuju bahawa jika saya membuat, atau dalam sebarang perakuan yang perlu dibuat atas permintaan pegawai Syarikat berkaitan tuntutan tersebut, membuat sebarang kenyataan palsu atau menipu atau melindungi fakta penting, Polisi ini adalah tidak sah terhadap Syarikat dan hak saya untuk menuntut pampasan dibatalkan sepenuhnya, dan saya sanggup, apabila diperlukan oleh pegawai Syarikat, untuk membuat perakuan berkanun tentang kebenaran semua kenyataan di atas, dan butiran lain yang mungkin diperlukan oleh pegawai Syarikat. Tarikh Kebenaran kepada Pengamal Perubatan, Hospital atau Klinik Tandatangan Pemegang Polisi/ Pihak yang Membuat Tuntutan/ Kakitangan & Cop Syarikat Dengan ini saya membenarkan mana-mana doktor, pengamal perubatan, hospital atau klinik yang telah memeriksa atau merawat saya atas sebarang sebab, untuk memberikan butir-butir penuh mengenainya termasuklah sejarah perubatan sebelumnya kepada Zurich General Insurance Malaysia Berhad. Salinan fotostat kebenaran ini hendaklah dianggap sebagai sah seperti yang asal. Saya/Kami dengan ini memberikan kebenaran tanpa syarat dan tanpa keraguan kepada pihak syarikat dan syarikat-syarikat bersekutunya untuk memproses data peribadi saya/kami yang didedahkan di sini. Pihak syarikat adalah berkebebasan untuk memproses data berkenaan dan berkongsi maklumat yang didedahkan di sini kepada mana-mana penyelia perkhidmatan dan mana-mana syarikat bersekutunya dengan syarat bahawa pendedahan maklumat peribadi berkenaan adalah bertujuan dan berkaitan dengan insurans yang saya/kami pohon di sini. Kebenaran ini diberikan selaras dengan peruntukan di bawah Akta Perlindungan Data Peribadi Date Signature of Policyholder/Claimant/Patient/Employee Perhatian Sila minta doktor anda mengisi Sijil Perubatan yang dilampirkan bersama borang ini. Zurich General Insurance Malaysia Berhad ( V) Tingkat 11, Menara Zurich, No.12, Jalan Dewan Bahasa, Kuala Lumpur, Malaysia Tel: Faks: Pusat Panggilan:
7 Tuntutan Kemalangan Sijil Perubatan NO AGENSI NO TUNTUTAN Perhatian : Syarikat tidak akan menanggung liabiliti dengan mengeluarkan borang ini. Tiada tuntutan akan diiktiraf melainkan Sijil Perubatan ini dilengkapkan oleh Doktor yang berdaftar dan dihantar kepada Syarikat secepat mungkin. Sijil Perubatan perlu diperolehi atas perbelanjaan Pemegang Insurans sendiri 1. Nama Pesakit No KP (Baru) Tarikh Lahir (Lama) Jantina Perniagaan/Pekerjaan 2. a) Tarikh Kemalangan Masa PG/PTG b) Punca Kecederaan c) Sila nyatakan dengan terperinci kecederaan yang dialami oleh pesakit d) Sila berikan butiran rawatan yang diberikan kepada pesakit e) Adakah pesakit dimasukkan ke hospital? Jika ya, sila nyatakan tempohnya 3. a) Adakah anda doktor biasa pesakit? Jika ya, berapa lama anda telah mengenali pesakit dan apakah penyakit atau kecederaan beliau yang pernah anda rawat? b) Adakah kecederaan yang dialami konsisten dengan keadaan kemalangan seperti yang diterangkan kepada anda oleh pesakit? c) Adakah pesakit mengalami sebarang penyakit atau kecacatan fizikal semasa kemalangan? d) Adakah terdapat sejarah perubatan atau kehilangan upaya masa lepas yang mungkin menyebabkan kemalangan secara langsung atau tidak langsung atau yang mungkin menjejaskan pemulihan pesakit? 1836/4/P/G/S/M
8 e) Adakah anda mempunyai sebab untuk mengesyaki bahawa pesakit berada di bawah pengaruh bahan yang memabukkan atau dadah pada masa kemalangan? 4. a) Apakah keadaan kecederaan pada masa ini? Jika sudah pulih, sila berikan butiran tentang pemulihan? b) Sila berikan tarikh kunjungan anda untuk merawat pesakit dan/atau kunjungan pesakit untuk mendapat rawatan anda sejak tarikh kemalangan. 5. Mengambil kira pekerjaannya sebagai, pada pendapat anda, kehilangan upaya boleh dianggap sebagai: (i) Kehilangan Upaya Keseluruhan Sementara (TTD) dari hingga (Hari) (Bulan) (Tahun) (Hari) (Bulan) (Tahun) (ii) Kehilangan Upaya Separa Sementara (TPD) dari hingga (Hari) (Bulan) (Tahun) (Hari) (Bulan) (Tahun) SAYA DENGAN INI MENGESAHKAN BAHAWA SAYA TELAH MEMERIKSA PENAMA DI ATAS DAN KENYATAAN SAYA DI ATAS ADALAH BETUL SETAKAT YANG SAYA KETAHUI DAN PERCAYAI Tandatangan dan Cop Doktor/Pakar Bedah yang Merawat Alamat Tarikh Kelayakan Zurich General Insurance Malaysia Berhad ( V) Tingkat 11, Menara Zurich, No.12, Jalan Dewan Bahasa, Kuala Lumpur, Malaysia Tel: Faks: Pusat Panggilan:
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