**PERMOHONAN HENDAKLAH DIPOSKAN MENGIKUT ALAMAT KAMI DI BANGSAR DAN PERMOHONAN INI TIDAK BOLEH DIFAKSKAN KEPADA KAMI**
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- Frank Randall
- 6 years ago
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1 KEPADA: TUAN/PUAN TUNTUTAN KEMATIAN SKIM INSURANS BERKELOMPOK - GS : 2926 Merujuk Kepada Perkara Diatas. Bersama-Sama Ini Dikemukakan Borang Tuntutan Khas Kematian Sepertimana Makluman Tuan/Puan. Untuk Membolehkan Kami Menilai Tuntutan Kematian, Kami Sangat Menghargai Jika Tuan Dapat Menghantar Maklumat Seperti Berikut :- 1) DEATH CLAIM FORM :- Diisi Oleh Waris 2) DEATH CLAIM - DOCTOR'S STATEMENT:- Polisi kurang 5 tahun sahaja 3) ACCIDENTAL DEATH BENEFITS CLAIM :- POLIS / DOKTOR 4) LETTER OF AUTHORISATION/CONSENT :- Diisi Oleh Waris 5) SALINAN SIJIL KEMATIAN 6) SALINAN KAD PENGENALAN SI MATI 7) SALINAN KAD PENGENALAN PASANGAN DAN ANAK-ANAK 8) SALINAN SIJIL NIKAH 9) SALINAN POST MORTEM REPORT 10) LAPORAN POLIS 11) LAPORAN TOXICOLOGY 12) SALINAN KERATAN AKHBAR ( JIKA ADA ) 13) LAPORAN PENYIASATAN POLIS ( JIKA ADA ) 14) LESEN MEMANDU SIMATI (JIKA ADA ) **PERHATIAN : SEMUA DOKUMEN HENDAKLAH DIAKUI SAH OLEH DOKTOR ATAU KETUA UNION **PERMOHONAN HENDAKLAH DIPOSKAN MENGIKUT ALAMAT KAMI DI BANGSAR DAN PERMOHONAN INI TIDAK BOLEH DIFAKSKAN KEPADA KAMI** Sekian, Terima Kasih. Yang Ikhlas, AMIRA NIK NUR AMIRA IZZATY BT NIK GHAZALI BAHAGIAN PENTADBIRAN CUEPACS LIVING CARE AGENSI PEMASARAN & PERKHIDMATAN PELANGGAN CUEPACS LIVING CARE D/A JAMES D.RAVI & ASSOCIATES LEVEL 3, BANGUNAN PSM, NO: 17B, JALAN BANGSAR, KUALA LUMPUR. TEL: , Fax:
2 DEATH CLAIM FORM - CLAIMANT'S STATEMENT BORANG TUNTUTAN KEMATIAN - KENYATAAN PENUNTUT SECTION A. PARTICULARS OF DECEASED BUTIR-BUTIR SI MATI Policy.. Polisi Policy.. Polisi Policy.. Polisi Policy.. Polisi New NRIC.. KP Baru Old NRIC/Birth Certificate/ Passport.. KP Lama/ Sijil Kelahiran/Pasport Name Nama a) Last Correspondence Address Alamat Terakhir Postcode Poskod Country Negara Town Bandar 2. a) Marital Status at point of death Status perkahwinan semasa kejadian mati b) Religion Agama Single Married Divorced Widow / Widower Bujang Berkahwin Bercerai Duda / Janda Muslim Islam n-muslim Bukan Islam **minee of Muslim deceased shall distribute the policy moneys in accordance with Islamic laws. **Penama kepada pemegang polisi yang beragama Islam haruslah mengagihkan wang tuntutan menurut Undang-Undang Syariah. c) Deceased's surviving family member (s) Ahli keluarga Si Mati Spouse Father Mother Child(ren) Anak-anak : Suami / Isteri Bapa Ibu Others. Please specify : Lain-lain. Sila nyatakan : person (s) orang 3. Any other insurance policy with other company? Adakah Si Mati mempunyai polisi dengan syarikat yang lain? Ya Tidak If "", please provide details. Jika "Ya", sila nyatakan butir-butir tersebut. Company Syarikat Policy Number. Polisi SECTION B. FOR GROUP EMPLOYEE BENEFITS ONLY UNTUK MANFAAT PEKERJA BERKELOMPOK SAHAJA 1. Name of Policyholder Nama Pemegang Polisi 2. Deceased's occupation at point of death Pekerjaan Si Mati semasa kematian 3. Date employed Tarikh mula bekerja (hh/bb/tttt) 4. Last date of work Tarikh terakhir aktif bekerja 5. Last drawn salary Gaji terakhir 6. Salary last adjusted Tarikh terakhir penyelarasan gaji R M (hh/bb/tttt) (hh/bb/tttt) 7. Sum Assured Jumlah Asurans R M CLM-DTHCF-V GREAT EASTERN LIFE ASSURANCE (MALAYSIA) BERHAD (93745-A) Menara Great Eastern 303 Jalan Ampang Kuala Lumpur Customer Service Careline: Fax: wecare-my@greateasternlife.com Website: greateasternlife.com Page 1 of
3 SECTION C. NATURE OF CLAIM AND RELATED DETAILS JENIS TUNTUTAN DAN BUTIR-BUTIR BERKENAAN I. CLAIM RELATED DETAILS BUTIR-BUTIR TUNTUTAN BERKENAAN 1. Date of Death Tarikh Kematian (hh/bb/tttt) 2. Cause of Death Sebab Kematian Accident Illness Others, please specify Kemalangan Penyakit Lain-lain, sila nyatakan 3. What complaint(s)/ailment(s) did the Deceased have before death? Apakah tanda-tanda penyakit Si Mati sebelum kematian? 4. When did the complaint(s)/ ailment(s) first appear? Bilakah tanda-tanda penyakit bermula? (hh/bb/tttt) 5. First visit to doctor for the complaint(s)/ailment(s) Lawatan pertama ke doktor untuk tanda-tanda penyakit tersebut (hh/bb/tttt) 6. Post mortem done? Bedah siasat dibuat? Ya Tidak 7. Was there any other illness before the death event? Adakah Si Mati mengalami penyakit lain sebelum kematian? Ya Tidak If "", please state the other illnesses or conditions. Jika "Ya", sila nyatakan penyakit atau keadaan lain tersebut. Name of Illness Nama Penyakit Name of Doctor or Specialist Nama Doktor atau Pakar Name & Address of Hospital or Clinic Nama dan Alamat Hospital atau Klinik Date of Visit Tarikh Rawatan II. FOR DEATH DUE TO ACCIDENT UNTUK KEMATIAN AKIBAT KEMALANGAN 1. Date & Time of accident Tarikh dan waktu kemalangan (hh/bb/tttt) a.m. / p.m. pagi / petang 2. Exact location of accident Lokasi sebenar kemalangan House Workplace Road/Others, please specify & state the address : Rumah Tempat Kerja Jalan raya/ Lain-lain, sila tentukan & nyatakan alamat : 3. How did the accident happen? Bagaimana kemalangan berlaku? Fall Industrial Accident Road Traffic Accident Others. Please specify : Jatuh Kemalangan Industri Kemalangan Jalan Lain-lain. Sila tentukan : Raya 4. Accident reported to : Kemalangan dilaporkan kepada : (i) the police polis (ii) newspaper surat khabar Ya Ya Tidak Tidak Page 2 of
4 SECTION D. DECLARATION & AUTHORISATION BY THE LIFE ASSURED / ASSURED (POLICY OWNER) / CLAIMANT FOR ALL APPLICABLE POLICIES PENGISYTIHARAN & KEBENARAN OLEH HAYAT YANG DIASURANSKAN / ASURED (PEMILIK POLISI) / PIHAK YANG MENUNTUT BAGI SEMUA POLISI BERKAITAN I declare the above answers are true and correct and I agree that If I have made, or shall make any untrue statement, or suppressed or concealed any material fact; my/the Life Assured's right to be compensated shall be absolutely forfeited. I, the Life Assured / Assured (Policy owner) / Claimant hereby authorise and give my consent to any doctor, medical practitioner, physician, hospital, laboratory, surgeon, nurse, medical staff, clinic, insurance company, credit reporting agency, organization, institutions or persons that may have any records or knowledge of my/life Assured's health or medical history ("Information Provider"), to provide such information to GREAT EASTERN LIFE ASSURANCE (MALAYSIA) BERHAD (93745-A) ("The Company") and its authorised service provider and/or its employee about my personal data, employment and credit information (as defined in Credit Reporting Agencies Act 2010) in order to process my insurance claim. I authorise the Company and its representative to give and release any such information to any party in relation to my application or transaction with the Company for the following purposes (but not limited to): verifying information given pursuant to this claim,background screening, credit evaluation, scoring solutions, administration, analysis or monitoring of policy with the Company or processing of claim. I, the Life Assured / Assured (Policy owner) / Claimant, expressly waive on behalf of myself or any other person who shall have any claim or interest in any policy hereunder, all provision of law or professional ethics forbidding any Information Provider from disclosing any information acquired while attending to me in a professional capacity. I, the Life Assured / Assured(Policy owner) / Claimant, hereby authorise and give consent, to the deduction of monies due to the Company from the claim proceeds payable pursuant to any policy hereunder, including but not limited to any Automatic Premium Loan, Cash Loan, overdue interests, premium due, advance benefit paid, erroneous and/or payment made in excess of any claim amount. I, the Life Assured/Assured (policy owner) / Claimant, hereby authorise and give consent to the Company to amend my addresses as provided in this claim form. This authorisation shall irrevocably bind my successors and assignees and shall remain valid not withstanding my death or incapacity, and a copy of this form shall be effective and valid as the original. Saya mengisytiharkan bahawa jawapan di atas adalah betul dan benar serta saya bersetuju jika saya membuat atau akan membuat sebarang kenyataan yang tidak tepat atau menahan atau menyembunyikan sebarang fakta material; hak saya/hayat yang Diasuranskan untuk menerima pampasan akan dilucutkan dengan mutlak. Saya, Hayat yang Diasuranskan / Asured (Pemilik Polisi) / Pihak yang Menuntut dengan ini membenarkan dan memberi kebenaran kepada mana-mana doktor, pengamal perubatan, pakar perubatan, hospital, makmal, pakar bedah, jururawat, kakitangan perubatan, klinik, syarikat insurans, agensi pelaporan kredit, organisasi, institusi atau individu yang mungkin mempunyai sebarang rekod atau pengetahuan berkenaan kesihatan atau sejarah kesihatan saya / Hayat yang Diasuranskan ( Pemberi Maklumat ) bagi menyediakan maklumat tersebut kepada GREAT EASTERN LIFE ASSURANCE (MALAYSIA) BERHAD (93745-A) ("Syarikat") dan penyedia perkhidmatan berdaftar dan/atau pekerjanya mengenai maklumat peribadi saya, pekerjaan dan maklumat kredit (seperti yang ditakrifkan dalam Akta Agensi Pelaporan Kredit 2010) bagi memproses tuntutan insurans saya. Saya memberi kebenaran kepada Syarikat dan wakilnya untuk memberi dan mengeluarkan sebarang maklumat kepada mana-mana pihak mengenai permohonan atau transaksi dengan Syarikat untuk tujuan berikutnya (tetapi tidak terhad kepada) : pengesahan maklumat yang diberikan menurut tuntutan ini, pemeriksaan latar belakang,penilaian kredit, penyelesaian skor, pentadbiran, analisis atau pemantapan polisi dengan Syarikat atau proses tuntutan. Saya, Hayat yang Diasuranskan / Asured (Pemilik Polisi) / Pihak yang Menuntut, bagi pihak saya atau mana-mana individu yang mempunyai sebarang tuntutan atau kepentingan dalam mana-mana polisi di bawah ini, mengetepikan semua peruntukan undang-undang atau etika profesional yang melarang mana-mana Pemberi Maklumat daripada mendedahkan sebarang maklumat yang diperlukan semasa memberi perkhidmatan kepada saya dalam kapasiti sebagai seorang profesional. Saya, Hayat yang Diasuranskan / Asured (Pemilik Polisi) / Pihak yang Menuntut, dengan ini memberi kebenaran dan keizinan untuk menolak wang yang perlu dibayar kepada Syarikat daripada jumlah tuntutan yang boleh dibayar menurut sebarang polisi di bawah ini, termasuk tetapi tidak terhad kepada sebarang Pinjaman Premium Automatik, Pinjaman Tunai, tunggakan faedah, premium yang perlu dibayar, manfaat yang telah didahulukan dan/atau pembayaran salah yang dibuat melebihi sebarang amaun tuntutan. Saya, Hayat yang Diasuranskan / Asured (Pemilik Polisi) / Pihak yang Menuntut, memberi kebenaran dan keizinan kepada Syarikat untuk membuat pindaan maklumat terhadap alamat-alamat saya yang dinyatakan dalam borang tuntutan ini. Kebenaran ini akan terikat kepada pengganti hak milik dan penerima serah hak tanpa boleh ditarik balik serta kekal sah walaupun selepas saya meninggal dunia atau hilang upaya serta salinan borang ini adalah berkuat kuasa dan sah seperti asal. Authorisation for Claim Matters Kebenaran untuk Perkara-Perkara Tuntutan I, the Life Assured/Assured (Policy owner)/claimant hereby give consent to GREAT EASTERN LIFE ASSURANCE (MALAYSIA) BERHAD (93745-A) ("GELM") Agent or Authorised Person,, Agent Code or New NRIC. to assist in matters pertaining to this claim and cheque collection, if any. I hereby agree to release and discharge GELM from all losses, claims, allegations, suits, proceedings, demands, damages, costs and expenses arising from or in connection to the said collection. I further agree to indemnify GELM and to keep GELM fully indemnified from and against any and all such losses, claims, allegations, suits, proceedings, demands, damages, costs and expenses arising from or in connection to the said collection. For Group Policies, please refer to respective Union/Servicing Agent/ Employer in relations to cheque collection. Saya, Hayat yang Diasuranskan/Asured (Pemilik Polisi) / Pihak yang Menuntut, dengan ini memberi kebenaran kepada Ejen GREAT EASTERN LIFE ASSURANCE (MALAYSIA) BERHAD (93745-A) ("GELM") atau Pihak yang diberi kuasa, Kod Ejen atau. KP Baru untuk membantu dalam perkara-perkara berhubungan dengan tuntutan ini dan pengambilan cek, jika ada. Saya dengan ini bersetuju untuk melepaskan GELM dari segala kerugian, tuntutan dan guaman, prosiding, permintaan, ganti rugi, kos dan perbelanjaan yang timbul dari atau berkaitan dengan penerimaan perkara tersebut. Saya selanjutnya bersetuju untuk menanggung kerugian GELM serta memelihara GELM dengan indemniti sepenuhnya dari dan terhadap sebarang dan segala kerugian, tuntutan, tuduhan, guaman, prosiding, permintaan, ganti rugi, kos dan perbelanjaan yang berbangkit dari atau berkaitan dengan penerimaan perkara tersebut.sila rujuk kepada Kesatuan/Ejen Insurans Berkelompok/Majikan tersebut berhubung dengan pengambilan cek bagi polisi berkelompok. Page 3 of
5 SECTION D. DECLARATION & AUTHORISATION BY THE LIFE ASSURED / ASSURED (POLICY OWNER) / CLAIMANT FOR ALL APPLICABLE POLICIES PENGISYTIHARAN & KEBENARAN OLEH HAYAT YANG DIASURANSKAN / ASURED (PEMILIK POLISI) / PIHAK YANG MENUNTUT BAGI SEMUA POLISI BERKAITAN te : If Claimant is unable to sign, the thumbprint has to be witnessed by the attending doctor or our authorised officers at any nearest office ta : Sekiranya Pihak yang Menuntut tidak dapat menandatangani, cap jari perlu disaksikan oleh doktor atau pihak yang diberi kuasa di mana-mana cawangan berdekatan. Are you the beneficiary of the policies? Adakah anda benefisiari kepada polisi ini? Ya Tidak Name : Nama NRIC :. KP Baru - - Signature of Claimant Tandatangan Penuntut Relationship with the Deceased : Hubungan dengan Si Mati Spouse Suami/Isteri Sibling Adik-Beradik Others, please specify Lain-lain, sila nyatakan Parent Ibu/Bapa Child(ren) Anak-anak Date Tarikh : (hh/bb/tttt) Contact. :. Tel. Address Alamat : Name : Nama Signature of Witness Tandatangan Saksi NRIC :. KP Baru Date Tarikh : - - (hh/bb/tttt) Contact. :. Tel. Address Alamat : Page 4 of
6 SECTION E. DOCUMENTS TO BE SUBMITTED WITH THIS CLAIM DOKUMEN UNTUK DISERTAKAN BERSAMA TUNTUTAN INI te i. Photocopy of documents MUST be duly certified by authorised parties, i.e. Claims Officer or Customer Service Officer or Public tary or Advocate & Solicitor or Justice of Peace or Ketua Balai Polis or District Officer or Medical Officer or Group Sales Manager or Unit Sales Manager. In addition, for claims incurred outside Malaysia (except Singapore), the confirmation of claim event and all other related documents issued by the Foreign Authority must be certified by Malaysian Embassy or Public tary at the incident country. If you have returned to Malaysia, the documents can be certified by relevant country's Embassy in Malaysia. Dokumen Salinan perlu diakui sah oleh pihak yang diberi kuasa, iaitu, Pegawai Tuntutan atau Pegawai Khidmat Pelanggan di cawangan atau Ibu Pejabat atau tari Awam atau Peguambela dan Peguamcara atau Jaksa Pendamai atau Ketua Balai Polis atau Pegawai Daerah atau Pegawai Perubatan atau Group Sales Manager atau Unit Sales Manager. Bagi tuntutan yang berlaku di luar Malaysia (kecuali Singapura), pengesahan peristiwa tuntutan dan segala dokumen berkaitan yang dikeluarkan oleh Pihak Berkuasa Di Luar Negara perlu diakui sah oleh Kedutaan Besar Malaysia atau tari Awam di negara kejadian tersebut. Jika anda telah pulang ke Malaysia, dokumen-dokumen tersebut perlu diakui sah oleh Kedutaan Negara berkenaan di Malaysia. ii. This list is not exhaustive. The Company may request further document(s) for the purpose of this claim. Senarai ini tidak muktamad. Pihak Syarikat berkemungkinan meminta dokumen lain bagi tujuan tuntutan ini. iii. For "Great Senior" policies, the Death Claim Doctor's Statement is waived. However, if death is due to accident, the Accidental Death Benefit form and post morterm report are required. "Death Claim Doctor's Statement" adalah diketepikan bagi polisi "Great Senior". Akan tetapi, sekiranya kematian adalah disebabkan oleh kemalangan, Borang Tuntutan Faedah Kemalangan Maut dan Laporan Bedah Siasat perlu dilampirkan. Please tick ( )the documents submitted. Sila tandakan dokumen yang disertakan. *CTC = Certified true copy Salinan diakui sah 1. Direct Credit Facility Form (if not submitted before) Borang Kemudahan Kredit Terus (jika tidak pernah disertakan) 2. Death Claim Tuntutan Kematian a) Death Claim Form- Claimant's Statement Borang Tuntutan Kematian- Kenyataan Penuntut b) CTC of Death Certificate Salinan diakui sah Sijil Kematian c) CTC of Deceased's NRIC Salinan diakui sah Kad Pengenalan Si Mati d) CTC of Claimant's NRIC Salinan diakui sah Kad Pengenalan Pihak yang Menuntut e) Letter of Authorisation/Consent Surat Pemberikuasa/Kebenaran f) Death Claim Doctor's Statement "Death Claim Doctor's Statement'' g) Grant of Probate/Letter of Administration, for policy without nomination Geran Probet/Surat Kuasa Mentadbir untuk polisi tanpa penamaan h) CTC of Detailed Post Mortem Report Salinan diakui sah Laporan Bedah Siasat Terperinci te : If the Deceased is non-malaysian or if the death event occurred outside Malaysia (except Singapore), please attach :- Sekiranya Si Mati bukan warganegara Malaysia atau kematian berlaku di Luar Malaysia (kecuali Singapura), sila sertakan :- a) CTC of Deceased's Full Passport Book/ Citizenship Certificate Salinan diakui sah Buku Pasport Lengkap/ Sijil Kewarganegaraan b) Confirmation letter from National Registration Department (for death outside of Malaysia) Surat Pengesahan dari Jabatan Pendaftaran Negara (untuk kematian di luar Malaysia) Additional Requirements for Death Due to Accident Dokumen Tambahan untuk Kematian Disebabkan oleh Kemalangan a) Accidental Death Benefit Claim Form Borang Tuntutan Faedah Kemalangan Maut b) CTC of Police Report Salinan diakui sah Laporan Polis c) CTC of Toxicology report Salinan diakui sah Laporan Toksikologi d) Copy of Newspaper Cutting, if any Salinan Keratan Akhbar, jika ada e) CTC of Police Investigation Report, if any Salinan diakui sah Laporan Siasatan Polis, jika ada f) CTC of Deceased's Driving License Salinan diakui sah Lesen Memandu Page 5 of
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8 LETTER OF AUTHORISATION/CONSENT - To Obtain Further Information for Death SURAT PEMBERIKUASA/KEBENARAN - Untuk Mendapatkan Maklumat Lanjut untuk Kematian Policy.. Polisi Policy.. Polisi Policy.. Polisi Policy.. Polisi New NRIC.. KP Baru Old NRIC/Birth Certificate/ Passport.. KP Lama/Sijil Kelahiran/Paspot Name of Deceased Nama Si Mati - - To Whom It May Concern Kepada Sesiapa Yang Berkenaan Dear Sir/Madam, Tuan/Puan, I hereby authorise and give my consent to any medical practitioner, physician, surgeon, clinic, hospital, medical centre, insurance company or other organization, institution or individual concerned ("the Information Provider(s),") that may have any records or knowledge of the employment, financial, health or medical history of ("the Assured") and to provide such information to GREAT EASTERN LIFE ASSURANCE (MALAYSIA) BERHAD (93745-A)("the Company) or its authorised agents and/or employees. I expressly waive on behalf of myself and/or as a next-of-kin of the Assured and for his/her estate all provision of law or professional ethics forbidding the Information Provider(s) from disclosing any such information acquired on the Assured in a professional and/or client capacity and I further release the Information Provider(s) and its agent/staff from any liability whatsoever that may arise, in supplying such information requested by the Company. This authorisation/consent is irrevocable and a copy of it will have the same effect and validity as the original. Saya dengan ini memberi kuasa dan mengizinkan mana-mana pegawai perubatan, doktor, pakar bedah, klinik, hospital, pusat perubatan, syarikat insurans atau organisasi, institut atau orang perorangan ("Pemberi Maklumat") yang mungkin mempunyai apa-apa rekod atau mengetahui tentang pekerjaan, kewangan, kesihatan atau sejarah perubatan ("Pemegang Polisi") untuk memberi maklumat kepada Great Eastern Life Assurance (Malaysia) Berhad ('Syarikat") atau mana-mana ejen/kakitangannya yang diberi kuasa. Saya juga tidak ragu-ragu untuk mengetepikan bagi pihak saya dan/atau sebagai waris terdekat Pemegang Polisi dan untuk harta pusakanya segala peruntukan undang-undang atau etika profesional yang menghalang Pemberi Maklumat daripada memberi maklumat berkenaan mengenai Pemegang Polisi dalam bidang kuasa sebagai profesional dan/atau pelanggan dan saya juga memberi pelepasan kepada Pemberi Maklumat dan ejen/kakitangannya daripada apa-apa liabiliti kerana memberi maklumat tersebut kepada syarikat. Surat pemberikuasa/kebenaran ini adalah muktamad dan salinannya juga memberi hak dan pengesahan yang sama dengan yang asal. Signature of Claimant Tandatangan Penuntut Name: Nama NRIC.:. KP Relationship with the Deceased: Hubungan dengan Si Mati Address: Alamat Date: Tarikh CLM-AUTHO-V GREAT EASTERN LIFE ASSURANCE (MALAYSIA) BERHAD (93745-A) Menara Great Eastern 303 Jalan Ampang Kuala Lumpur Customer Service Careline: Fax: wecare-my@greateasternlife.com Website: greateasternlife.com Page 1 of CLA029
9 ACCIDENTAL DEATH BENEFITS CLAIM CLAIMS DEPARTMENT 303, JALAN AMPANG KUALA LUMPUR. 1. This form may be completed by the Police (if a report has been made or the accident is investigated) or by the hospital/ doctor who attended to the emergency as a result of the accident. 2. A Post Mortem or Autopsy report is required to be submitted with this claim. 3. Any costs incurred in completing this form is borne by the claimant. Please complete this form as fully as possible. Your kind assistance will expedite the claim processing. 1. Name of Deceased NRIC. 2. Date & Time of Accident 3. Nature of Accident (please tick only one) :- Road Traffic Accident Fall from Height/ Building Drowning Industrial/ Accident at Work Fire Air/ Rail/ Ship Disaster Explosion Sports Related Other: please describe 4. How did the accident happen? 5. Was the Deceased suspected to be under the influence of any alcohol or drugs? If, was there any sample of urine or blood sent for further test? 6. In your opinion/ investigation, do you think that death resulted from the accident? If, what do you think was the cause of death? Please detail 7. Please provide us with any other additional information about the accident or Deceased that you may think is relevant. Signature & Official Stamp Telephone : Name: Date: Qualification/ Rank: CLM-ABDTH-V GREAT EASTERN LIFE ASSURANCE (MALAYSIA) BERHAD (93745-A) Menara Great Eastern 303 Jalan Ampang Kuala Lumpur Customer Service Careline: Fax: (603) wecare-my@greateasternlife.com Website: Page 1 of CLA008
10 TUNTUTAN FAEDAH KEMALANGAN MAUT JABATAN TUNTUTAN 303, JALAN AMPANG KUALA LUMPUR. 1. Borang ini hendaklah dilengkapkan oleh Polis (Sekiranya laporan polis telah dibuat atau kes kemalangan sedang dalam penyiasatan) atau oleh pihak hospital/ doktor yang memberi rawatan kecemasan semasa kemalangan. 2. Laporan Bedah Siasat atau Autopsi perlu disertakan bersama borang tuntutan ini. 3. Sebarang kos yang timbul untuk melengkapkan borang ini akan ditanggung oleh penuntut. Sila lengkapkan borang ini sebaik mungkin. Kerjasama anda akan menpercepatkan process tuntutan. 1. Nama Si Mati. Kad Pengenalan 2. Tarikh & Masa Kemalangan 3. Bentuk Kemalangan (SIla tandakan satu sahaja) Kemalangan Trafik Jalan Raya Jatuh dari tempat tinggi/ bangunan Mati Lemas Kemalangan Industri/ Di tempat kerja Kebakaran Kemalangan Udara/ Keretapi/ Kapal Letupan Semasa Bersukan Lain-lain: SIla nyatakan 4. Bagaimana kemalangan berlaku? 5. Adakah anda mengesyaki Si Mati meminum alkohol atau mengambil dadah? Sekiranya "Ya", adakah contoh air kencing atau darah dihantar untuk ujian lanjut? 6. Pada pendapat/ dari penyiasat anda, adakah Kematian Si Mati berpunca dari kemalangan? Sekiranya "Tidak", pada pendapat anda, apakah yang menyebabkan kematian ini? SIla nyatakan secara terperinci Ya Tidak Ya Tidak Ya Tidak 7. Sila berikan kami lain-lain maklumat berkenaan kemalangan atau Si Mati yang pada pendapat anda ada kaitan dengan kemalangan ini. Tandatangan & Cop Rasmi. Telefon: Nama: Tarikh: Kelayakan/ Pangkat: CLM-ABDTH-V GREAT EASTERN LIFE ASSURANCE (MALAYSIA) BERHAD (93745-A) Menara Great Eastern 303 Jalan Ampang Kuala Lumpur Customer Service Careline: Fax: (603) Website: Page 2 of CLA008
11 DEATH CLAIM DOCTOR'S STATEMENT Policy. Policy. Policy. Policy. New NRIC. - - Old NRIC/Birth Certificate/ Passport. Name of Deceased The above name is insured with GREAT EASTERN LIFE ASSURANCE (MALAYSIA) BERHAD against the happening of certain contingent events associated with his / her health. A claim has been submitted for Death benefit and to enable us to assess the claim, kindly complete this confidential report. (For any fee incurred in completing this form, it will be borne by claimant) SECTION I: DECEASED'S MEDICAL RECORD 1. Date of Death 2. Height / Weight 3. Are you the Deceased's regular / family doctor? If "YES", since what date? 4. Has the Deceased previously suffered from or been detected to have hypertension, diabetes, angina, hyperlipidaemia, cardiovascular disease, transient ischaemic attack, neurological disorders, renal disease, hepatitis B or C, autoimmune disorder, pre-malignant condition, cancer or any other significant illnesses? If "YES", please provide the following: (cm) (kg) Medical Condition Date of Diagnosis Medication / Treatment Name of Treating Doctor Name of Clinic / Hospital and Address 5. Did you attend to the Deceased's last illness? If "YES", (i) What were the symptoms presented? (i) (ii) Date of symptoms started (iii) What was the diagnosis? (ii) (iii) 6. Was the Deceased hospitalised? If "YES", please state the: (i) Name of hospital admitted (ii) Date of First admission Date of Last admission (iii) Name(s) of attending doctor(s) (i) (ii) (iii) 7. Was other doctor referring the Deceased to you? If "YES", please state the name(s) and address(es) of the attending doctor(s) CLM-DCSCF-V CLA001 GREAT EASTERN LIFE ASSURANCE (MALAYSIA) BERHAD (93745-A) Menara Great Eastern 303 Jalan Ampang Kuala Lumpur Customer Service Careline: Fax: wecare-my@greateasternlife.com Website: greateasternlife.com Page 1 of
12 8. (i) Please state the disease(s) or condition(s) DIRECTLY leading to death with approximate interval between onset and death. Cause of Death Approximate Interval between onset and death Years Months Days Hours (ii) Name of doctor(s) and hospital(s) that made the diagnosis. (iii) Was the Deceased / family been informed of the diagnosis? Information unavailable 9. What is the underlying cause of the illness as per diagnosis above? 10. (a) Was there any predisposing cause(s) of the Deceased's death in relation to his/her habits (use of alcohol, narcotics, etc), family history, occupation? If "YES", please provide details: (b) Was there any predisposing cause(s) of the Deceased's death in relation to his/her previous illness? If "YES", please provide details: 11. Any other information that you feel may be relevant? SECTION II: This section is applicable to ACCIDENTAL DEATH only Please attach certified true copies of ALL the relevant laboratory evidences / tests available Post-mortem or Autopsy report Alcohol / drug test report 1. Date and Time of Accident 2. Nature of Accident (please tick only one) Road Traffic Accident Drowning Fire Explosion Other: Please describe: - (am/pm) Fall from Height / Building Industrial / Accident at Work Air / Rail / Ship Disaster Sports Related 3. Please describe how the accident happen. 4. Was the Deceased suspected to be under the influence of any alcohol or drugs? If "YES", was there any sample of urine or blood sent for further test? 5. In your opinion / investigation, do you think that death was resulted from the accident? If "NO", what do you think was the cause of death? Please elaborate in detail. DECLARATION: TO BE COMPLETED BY THE ATTENDING PHYSICIAN / SPECIALIST I, the undersigned, do hereby declare that I have answered the above questions are true and to the best of my knowledge and belief. Name: Address: Signature and Official Stamp Date: Page 2 of
13 DATE: GREAT EASTERN LIFE ASSURANCE (MALAYSIA) BERHAD MENARA GREAT EASTERN, 303 JALAN AMPANG KUALA LUMPUR. PER: PEMOHONAN PENGECUALIAN SURAT PENTADBIRAN HARTA Saya (, IC NO. ) isteri/suami/waris kepada ( IC NO. ) ingin memohon untuk pengecualian surat pentadbiran harta. Merujuk kepada perkara diatas, untuk mendapatkan surat tersebut akan mengambil masa yang lama dan juga membebankan saya dari segi masa dan kewangan. Untuk maklumat pihak Great Eastern, saya tidak membuat sebarang permohonan pentadbir harta. Saya mohon kepada GREAT EASTERN supaya mempercepatkan proses tersebut kerana saya memerlukan bantuan kewangan tersebut untuk menampung kos harian, hutang dan juga pendidikan anak-anak saya. Dengan pertimbangan tersebut dapat juga mengurangkan bebanan yang ditanggung oleh keluarga saya. Kerjasama dari pihak tuan/puan amat saya hargai. Sekian, terima kasih. Yang benar, ( ) Ic.: Hubungan: *Sila sertakan salinan ic, sijil lahir dan sijil perkahwinan untuk semua waris termasuk anak-anak.
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