TUNE PROTECT TRAVEL - AIRASIA *(For policies underwritten by Tune Protect Malaysia (Tune Insurance Malaysia Berhad K)) CLAIM FORM
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1 TUNE PROTECT TRAVEL - AIRASIA *(For policies underwritten by Tune Protect Malaysia (Tune Insurance Malaysia Berhad K)) IMPORTANT NOTICE: To enable us to process your claim as quickly as possible, it is important to complete this form accurately and provide us with the original documentation requested at your own expense. If the information/documents supplied are insufficient, we shall advise you if further information / documents are required. Upon completing this form, please send the claim form and all supporting documentations to: Tune Protect Malaysia, Non-Motor Claims Department, Level 7, Wisma Tune, No.19, Lorong Dungun, Damansara Heights, Kuala Lumpur, Malaysia. CLAIM FORM Please answer all questions and boxes where appropriate. Leaving a question blank may result in delays in settling your claim. Policy Certificate Number: Policyholder s Name: NRIC:... Passport No:. Contact No: (O) (H). (HP)... Claimant s Name (as per IC / Passport): NRIC:... Passport No:. Contact No: (O)... (H).. (HP)... Address:... Postcode:. Address: CLAIMANT S BANK DETAILS (FOR MALAYSIAN ACCOUNT ONLY) Bank Account No: Bank Name: Please fill in the flight information. Leaving this section blank would result in delays in settling your claims. Airline : AirAsia Flight No :.. Passenger Name Record (PNR) No / Booking No : First Departure Country: MALAYSIA Scheduled First Departure Date (dd/mm/yyyy ) : Scheduled Return Date (dd/mm/yyyy): I am filing a claim in respect of:- (Please the relevant boxes and fill in the blanks) SECTION 1 (A): TYPE OF CLAIM (TUNE PROTECT TRAVEL - AIRASIA) DOMESTIC - ONE WAY INTERNATIONAL - ONE WAY DOMESTIC - RETURN INTERNATIONAL - RETURN 1. PERSONAL ACCIDENT Accidental Death Total Permanent Disablement Disappearance Date of Accident (dd/mm/yyyy):.. Time:. am pm Description of incident/injury:... Nature of Injury:.. Are there any other insurance policies covering you for this incident? If Yes, please specify name of insurer, policy number and amount recoverable. Insurer:... Policy No.:.. Amount: 2. TRAVEL INCONVENIENCE (i) Loss or Damage to Checked-In Baggage (ii) Baggage Delay Baggage Collection Date:.Place:.Time am/pm 1
2 2. TRAVEL INCONVENIENCE (continued) (a) Trip Cancellation (b) AirAsia Flight Delay (c) Trip Curtailment (d) Common Carrier Delay (e) Missed Flight Connection For Trip Cancellation or Curtailment, please state reason: (f) Loss of Personal Money (International Travel Only) (g) Loss of Travel Documents (International Return Trip Only) (h) On-Time Guarantee (i) Travel Re-Route (j) Hijack Distress Allowance 3. MEDICAL AND EVACUATION EXPENSES (a) Medical Expenses (b) Emergency Medical Evacuation & (Excluded for Domestic One way) (C) Compassionate Visit (Hospitalization) (International Travel Only) 4. PERSONAL LIABILITY Mortal Remains Repatriation (Excluded for Domestic One way) Describe incident:.... Date of incident:.. Name of eye witness: Contact No: Law suit filed?: Yes No Please forward a copy of the suit, police report and eye witness report. 5. HOME CARE BENEFIT Describe incident:.... Date of incident:.. Police report lodged? Yes No Please complete Section 2 on Description of Items. 6. TUNE PROTECT TRAVEL SHOP (For customers who purchase Tune Protect Travel Shop Add-On only) (a) Loss of cash and personal valuables due to theft or robbery (b) Monetary loss suffered from credit card fraud (c) Loss of cash withdrawn by means of force (d) (Injury due to snatch theft, robbery or assault) 7. TUNE PROTECT TRAVEL GOLF (For customers who purchase Tune Protect Travel Golf Add-On only) (a) (b) Loss or damage to golf equipment / Personal Effects (Injury due to accident during golfing) (c) Golfing Equipment Hire (d) Liabilities to the Public (during Golfing) 8. TUNE PROTECT TRAVEL WINTER (For customers who purchase Tune Protect Travel Winter Add-On only) (a) (b) Piste Closure (Injury due to accident) (c) Loss, theft or damage to ski equipment (own) (d) Loss, theft or damage to ski equipment (hired) (e) Reimbursement of ski school fees, lift passes and hired ski equipment 2
3 9. TUNE PROTECT TRAVEL ADVENTURE (For customers who purchase Tune Protect Travel Adventure Add-On only) (a) (b) Loss, theft or damage to equipment (own) (Injury due to accident) (c) Loss, theft or damage to equipment (hired) (d) Liabilities to the Public (during adventure) SECTION 2: DESCRIPTION OF ITEMS AND AMOUNTS CLAIMED Details of amount claimed (please enclose original purchase receipts or other proof of purchase) Item Description /Model Type When And Where Purchased Original Cost Price Amount Claimed Notice: If you have more items, please attach separate sheet Total Amount: Are you or will you be a registered person under the Malaysian Goods and Services Tax (GST) at the commencement date of this policy If yes, please provide the following:- (i) GST Identification No (ii) Date of registration Is the above policy for:- (i) Personal (including sole proprietorship) (ii) Business Is the input tax incurred by you on the medical or personal accident policy premium blocked from claims under Regulation 36 of the GST Regulations 2014? (Applicable for Medical and Personal Accident only) : : YES I/we acknowledge that I/we have accessed and/or read the Privacy Notice of TIMB (available at all TIMB branch customer service counters and/or TIMB website) and agree to the processing of my/our personal data in the manner specified therein. I/we also consent to the collection, further processing and disclosure of my/our sensitive details herein for the purpose of processing claims and making the related payments. DECLARATION I/We hereby declare that the above statements and particulars are correct and complete in every respect and I/We have not concealed, misrepresented or misstated any material fact. I/We agree that if such statements and particulars are written by any other person, such person shall be deemed to have my/our Agent for the purpose of filling in this form and his statement shall be binding upon me/us I/We hereby acknowledge and understood the contents of the Personal Data Protection Act 2010 and agree to give my fullest co-operation to Tune Protect Malaysia or its representative in relation to this claim.... Name Signature Date:.. /. /.. 3
4 SECTION 3: CHECKLIST ON THE REQUIRED SUPPORTING DOCUMENTS BY TYPE OF CLAIM The following checklist will help you assemble the documents required to support your claim Please note: i) Dependent upon the circumstances, we may require other evidence to support your claim; in which case we will contact you. ii) Failure to provide the supporting documents may result in a delay of your claim. iii) Please provide translation if the supporting document is not in English, at your own expense. COMPULSORY FOR ALL TYPES OF CLAIM Duly completed Claim Form Original Flight Itinerary PERSONAL ACCIDENT BENEFIT (Death and TPD) Original medical report /Bills Copy of medical Specialist report where required Photograph of injury Original or certified true copy of police report of the accident. Copy of Death Certificate, burial permit and post mortem report where applicable TRIP CANCELLATION Travel agency/airline/hotel confirmation on the cost of non-refundable prepaid travelling expenses Medical report or Death Certificate of the insured person of the immediate family member Proof of relationship between insured person / deceased and the immediate family member. Confirmation of date and time, the duration and reasons of delay form relevant public transportation authorities. / vehicle workshop receipt where applicable PERSONAL ACCIDENT BENEFIT (Disappearance) Court Order presuming insured s death in the event of disappearance Undertaking Letter stating that Claimant shall refund paid sum to the Company if the Insured Person is subsequently found to be living TRIP CURTAILMENT Medical report or copy of Death Certificate of the insured person or the immediate family member Proof of the relationship between insured person and the immediate family member. Travel agency/airline/hotel confirmation on the cost of non-refundable prepaid travelling expenses Proof of hospitalization for own self. ON-TIME GUARANTEE FLIGHT DELAY MISSED FLIGHT CONNECTION Letter from airline confirming the actual time of arrival at the airport of transit and actual departure time of the connecting flight Flight Itinerary for onward connecting flight COMMON CARRIER DELAY Confirmation of date and time, the duration and reasons of delay from relevant public transportation authorities. EMERGENCY MEDICAL EVACUATION / REPATRIATION (in the event of accident injury or death) Original bill and receipts by ambulance operator/hospital. Copy of medical report from the treating doctor This section is Not Applicable If Asia Assistance Network (M) Sdn Bhd had provided the services in regard to Medical Evacuation or Repatriation. PERSONAL LIABILITY Demand letter from Third Party claimant Eye Witness report / statement Correspondences (if any) between Insured and Third party Claimant Original or certified true copy of police report where applicable LOSS OF PERSONAL MONEY / TRAVEL DOCUMENTS Copy of the report filed with the Airlines / Airport or Police at place of loss within 24 hours Original receipts and proof of payment for all emergency expenses. Receipt of expenses paid to get replacement travel documents MEDICAL EXPENSES REIMBURSEMENT / HOSPITAL ALLOWANCE Original medical Bills/Invoices Original receipts issued by the clinic/hospital Copy of medical report from the attending doctor Discharge Note/Summary from Hospital COMPASSIONATE VISIT Recommendation Letter from the attending doctor to confirm that the Insured should be accompanied by another person during his/her admission in hospital. Receipt of expenses incurred ie. hotel accommodation. Boarding pass of the person accompanying the Insured. LOSS OR DAMAGE TO BAGGAGE AND / OR PERSONAL EFFECTS Property Irregularity report from the Airline Authority (Airline) confirmation letter stating compensation amount Photographs of damaged items Original or certified true copy of policy report where applicable Note: Please do not admit liability or negotiate with the third party without written consent from the Insurer. BAGGAGE DELAY Written confirmation of length of delay from Airline (Property Irregularity Report). TRAVEL RE-ROUTE Letter from AirAsia confirming the length, destination and reason for the flight re-route 4
5 SECTION 3: (CONTINUED) HIJACK DISTRESS ALLOWANCE Original certification from AirAsia regarding hijack incident and duration of hijacking HOME CARE BENEFITS Police report on the break-in or robbery Receipts / Purchase invoice of the stolen / missing items Photograph of the damaged property due to the break-in / robbery Receipt for repair / replacement cost of the damaged property TUNE PROTECT SHOP-SAFE Loss of cash and personal valuables due to theft or robbery obtained at the place of loss & official translation of the report Currency exchange slip Purchase receipt / Invoice of the missing valuables Monetary loss suffered from credit card fraud Dispute Form from the Credit Card company Credit Card Statement Loss of cash withdrawn by means of force Dispute Form from the Bank Bank Statement ATM withdrawal slip TUNE PROTECT WINTER-SHIELD Piste Closure Receipt /bill incurred from the transport company Written confirmation from the resort/hotel on the closure Loss, theft or damage to ski equipment (own/hired) List of items claimed Reimbursement of ski school fees, lift passes and hired ski equipment Bill/receipt paid for the ski school fees TUNE PROTECT GOLF-PRO Incident report issued by the Golf Course official/authority Loss or damage to golf equipment / Personal Effects Internal Incident report issued by the Golf Course official / Authority or Police report List of item claimed Golfing Equipment Hire Copy of rental slip / Receipt Incident report Liabilities to the Public (during Golfing) Demand letter from third party Eye witness report / statement Police report or Internal Incident report issued by the Golf Course official / Authority TUNE PROTECT ADVENTURE-EZ Loss, theft or damage to equipment (own/hired) List of items claimed Liabilities to the Public (during Adventure) Demand letter from third party Eye witness report / statement Police report Note: Please do not admit liability or negotiate with the third party without written consent from the Insurer. 5
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