ACCIDENT CLAIM FORM / BORANG TUNTUTAN KEMALANGAN

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1 AmMetLife Insurance Berhad (15743-P) (Formerly known as AmLife Insurance Berhad) Licensed Insurer Level 19, Menara AmMetLife,. 1, Jalan Lumut, Kuala Lumpur Type AML<space>message send to ammetlife.com ACCIDENT CLAIM FORM / BORANG TUNTUTAN KEMALANGAN NOTE / NOTA This form is issued without admission of liability and must be completed and returned within thirty one (31) days from the date of discharge/life Assured return to work with the following documents: Tuntutan adalah tertakluk kepada terma-terma dan syarat-syarat di dalam kontrak. Ianya mestilah diisi dengan lengkap dan dikembalikan dalam tempoh tiga puluh satu (31) hari dari tarikh keluar hospital/diri Yang DiInsuranskan mula bekerja bersama dokumen yang berikut: 1) The original certificate/certified medical certificate from hospital/clinic Sijil perubatan asal/sijil perubatan yang disahkan dari hospital/klinik. 2) Section B - Certificate of Medical Attendant must be completed and signed by the Medical Attendant at the Life Assured s expense Bahagian B - Sijil Pegawai Perubatan mestilah diisi dengan lengkap dan ditandatangani oleh Pegawai Perubatan dan ditanggung oleh Diri Yang DiInsuranskan 3) Total Temporary Disability (TTD)/Partial Temporary Disability(PTD) benefit is payable based on the Life Assured s job description, injuries sustained and the opinion of Medical Advisor and not based on MC or Light duty certificate given by the treating physician. TTD/PTD adalah dibayar berdasarkan jenis pekerjaan individu, kecederaan yang dialami dan pendapat Penasihat Pakar Perubatan dan bukanlah berdasarkan Sijil Cuti Sakit atau Sijil Kerja Ringan yang diberikan oleh doktor yang memberi rawatan. SECTION A (To be completed by the Life Assured) / BAHAGIAN A (Untuk diisi dengan lengkap oleh Diri Yang DiInsuranskan) I) Information / Maklumat Peribadi Policy. / mbor Polisi: 1. Name of Life Assured* / Nama Diri Yang DiInsuranskan* 2. *Old I/C. / *. K/P Lama 3. *NRIC. / *. K/P Baru 4. Correspondence Address*/ Alamat Surat Menyurat* 6. Residential Address* / Alamat Kediaman* 5. Telephone. /. Telefon Home / Rumah: Office / Pejabat: Mobile. / Telefon Bimbit: 7. Present occupation / Pekerjaan semasa 8. Employer s name, address and telephone no. / Nama, alamat dan no. telefon majikan 9. Exact nature of occupation and duties / Maklumat tepat tentang pekerjaan dan tugas II) Accident Information / Maklumat Kemalangan / Tarikh Time / Masa Location / Tempat Description of accident / Penerangan berhubung kemalangan

2 Police Report (Please enclose a copy - if any) / Laporan Polis (Sila sertakan salinan - jika ada) Police Station / Balai Polis Report no. /. Laporan Report date / Tarikh Laporan III) Please provide information of the Attending Physician who has treated you for the injuries sustained. / Sila berikan maklumat Doktor yang merawat anda bagi kecederaan yang dialami Doctor/Clinic Name / Nama Doktor/Klinik Address / Alamat Telehone. /. Telefon of first Consultation / Tarikh mula dirawat / Sila isikan maklumat berikut jika anda masih diinsuranskan untuk faedah kemalangan dengan syarikat lain. Name of insurance company / Nama syarikat insurans Policy. /. Polisi Jumlah Manfaat Issued / Tarikh dikeluarkan DECLARATION / DEKLARASI I hereby declare that I have suffered the injuries described above, and warrant the truth or foregoing particulars in every respect, and agree that if I have made or I shall make any false or untrue statement, suppression or concealment, my right to compensation shall be absolutely forfeited. / Saya dengan ini mengaku bahawa saya telah mengalami kecederaan seperti yang disebut di atas, dan menjamin kebenarannya atau maklumat sebelum ini dalam setiap hal, dan bersetuju bahawa jika saya telah membuat atau akan membuat apa-apa kenyataan palsu atau tidak benar, penyekatan atau penyembunyian, hak saya untuk mendapat pampasan akan dilucuti secara mutlak. I hereby authorise any hospital, doctor or other person who has attended me to furnish Medical Advisor or its representatives any all information with respect to any injury, medical history, consultation, prescriptions or treatment and hospital or medical records. I agree that a photocopy of this authorisation shall be considered as effective and valid as original. / Saya dengan ini membenarkan mana-mana hospital, doktor atu orang lain yang merawat saya untuk memberikan apa-apa dan semua maklumat kepada penasihat perubatan atau wakilnya berhubung dengan apa-apa rekod kecederaan, sejarah perubatan, perundingan, preskripsi atau rawatan dan hospital atau perubatan. Saya bersetuju bahawa salinan kebenaran ini akan dianggap berkuatkuasa dan sah seperti salinan asal. Signature of witness / Tandatangan saksi Name of witness / Nama saksi NRIC no. /. K/P Baru Telephone no. /. telefon Signature of Life Assured / Tandatangan Diri Yang DiInsuranskan / Tarikh Signature of Policy Owner / Tandatangan Pemilik Polisi / Tarikh I hereby authorise AmMetLife Insurance Berhad to credit claim payment or refund of premium into my 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. Authorised Signature of Policy Owner/Life Assured

3 DECLARATION 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 tice, which is available at AmMetlife s website and branches. / Saya/Kami telah membaca dan memahami tis 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. Claimant s Signature Name* NRIC.* - - Old IC/Passport / / 2 te / ta-nota MetLife 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 any transactions, 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.

4 DIRECT CREDITING (To be completed by claimant) Please complete the rest of the boxes if more than 1 claimant. Name Item Claimant 1 Claimant 2 Claimant 3 Claimant 4 Claimant 5 NRIC Telephone Address Occupation Country of Birth Do you have a US address? If, please provided / Country of Incorporation (if policy owner is a company) Are you a citizen of the United States of America? List other countries of citizenship (if applicable) Industry Employer s Name Employer s Address Purpose of policy? GST Registration. Do you claim the Input Tax Credit on the GST paid on the policy Bank Name Please enclose page of your bank passbook (saving account/joint account) or account statement (for current account).

5 Account Type (Please tick one) Bank Account Number Policy. 1 Policy. 2 Policy. 3 Joint Joint Joint Joint Joint Declaration Signature of Claimant 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 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 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 if 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 Officer Name : Officer ID :

HOSPITALISATION & SURGICAL CLAIM FORM / BORANG TUNTUTAN HOSPITAL & PEMBEDAHAN

HOSPITALISATION & SURGICAL CLAIM FORM / BORANG TUNTUTAN HOSPITAL & PEMBEDAHAN 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 customercare@ammetlife.com