Personal Accident/Snatch Theft Claim Form Borong Tuntutan Kemalangan Diri/Ragut

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1 Personal Accident/Snatch Theft Claim Form Borong Tuntutan Kemalangan Diri/Ragut 1. This form is sent to You on a without admission of liability basis. / Borang ini dihantar kepada anda atas dasar tanpa pengakuan liabiliti. 2. The medical certificate in Section 2 of the form must be completed by a registered medical practitioner at the Insured Person s own expenses. No claim will be admitted unless the medical certificate is completed or agreed to be waived by the Insurer. / Sijil perubatan di Seksyen 2 hendaklah dilengkapkan oleh Pengamal Perubatan Berdaftar dengan perbelanjaan ditanggung oleh pihak yang diinsuranskan. Tuntutan tidak akan diterima melainkan Sijil Perubatan adalah lengkap atau mendapat pengecualian dari pihak insurans. 3. Please enclose a copy of police report if you are involved in a motor accident or a victim of snatch theft. / Sila lampirkan salinan laporan polis sekiranya anda terlibat di dalam kemalangan jalan raya atau diragut. 4. In the event of a fatal claim, please obtain the Death Certificate, Burial Certificate, Post-mortem Report and the Letter of Administration/Probate. / Sekiranya melibatkan tuntutan kematian, sila lampirkan Sijil Kematian, Sijil Pengebumian, Laporan Bedah Siasat dan Surat Kuasa Mentadbir/Probet. 5. It is necessary that complete particulars are given. Please attach a separate sheet if the space provided in the form is insufficient. / Adalah penting butir-butir terperinci dikemukakan. Sila lampirkan salinan berasingan sekiranya ruang yang disediakan di dalam borang ini tidak mencukupi. SECTION 1 / SEKSYEN 1 NOTIFICATION OF CLAIM / PEMBERITAHUAN TUNTUTAN A. Particulars of Insured Person / Butir-butir Orang Tertanggung Name of Insured Person / Nama Orang Tertanggung Occupation / Nature of Business / Pekerjaan / Jenis Perniagaan Address / Alamat Postcode / Poskod / Emel Tel. No. / No.Tel. Fax. No. / No. Faks. Handphone No. No. Telefon Bimbit Policy No. / No. Polisi B. Particulars of Accident/Snatch Theft and Injuries / Butir-butir Kemalangan/Ragut dan Kecederaan Date of Incident / Tarikh Kejadian Time of Incident / Waktu Kejadian : AM / PM Place / Tempat Please state circumstances of incident / Sila nyatakan bagaimana kejadian berlaku. Describe the injuries sustained indicating the part of the body injured and the type of injury. Example: Fracture of the left lower leg. / Sila nyatakan kecederaan yang dialami dengan menunjukkan bahagian badan yang tercedera dan jenis kecederaan. Contoh: Patah bahagian bawah kaki kiri. ACE Jerneh Insurance Berhad (formerly known as Jerneh Insurance Berhad) (9827-A) Level 26 Menara Weld 76 Jalan Raja Chulan Kuala Lumpur Malaysia Tel Fax Claims Helpline

2 Have you made or intend to make a claim for compensation from any other insurance company in respect of the same incident? If so, please state the name of the company and policy number. / Adakah anda pernah membuat atau akan membuat tuntutan pampasan dari mana-mana syarikat insurans lain berkaitan kejadian tersebut? Jika ya, sila nyatakan nama syarikat dan nombor polisi. Give name, address and contact number of doctor who attended to you/the Insured Person. / Berikan nama, alamat, dan nombor telefon doctor yang merawat anda/pihak yang diinsuranskan. If known, please give name, address and contact number of witness who saw the incident. / Jika ada berikan nama, alamat, dan nombor telefon saksi yang menyaksikan kejadian tersebut. C. Declaration / Pengakuan I/We warrant that the above statement and particulars are correct. I hereby authorise any hospital, doctor or any other person who has attended to me to furnish ACE Jerneh Insurance Berhad or its representative any and all information with respect to any sickness or injury, medical history, consultation prescription or treatment and copies of all hospital and medical records. I agree that a copy of this authorisation shall be as effective and valid as the original. I further confirm that my employer may be approached for verification of my claim and I hereby authorised them to disclose any such information required. Saya/Kami memberi jaminan bahawa kenyataan dan keterangan di atas adalah benar. Dengan ini saya memberi kebenaran mana-mana hospital, doctor atau sesiapa yang pernah merawat saya untuk mengemukakan kepada ACE Jerneh Insurance Berhad atau wakil-wakil mereka sebarang dan semua maklumat berkaitan sebarang penyakit, sejarah perubatan, preskripsi perundingan atau rawatan dan salinan semua rekod hospital dan perubatan. Saya bersetuju supaya salinan kebenaran ini akan mempunyai kesan yang sama dan sah seperti salinan asal. Saya juga mengesahkan majikan saya boleh dihubungi untuk mendapatkan pengesahan tuntutan saya dan dengan ini membenarkan mereka mendedahkan sebarang maklumat yang diperlukan. Signature of Policy Holder / Tandatangan Pemegang Polisi Signature of Insured Person / Tandatangan Pihak Diinsuranskan SECTION 2 / SEKSYEN 2 MEDICAL CERTIFICATE / SIJIL PERUBATAN (The fee for this certificate is to be paid by the claimant / Yuran bagi sijil ini ditanggung oleh pihak yang menuntut) Name of Patient / Nama Pesakit Date first attended to patient / Tarikh pertama kali merawat pesakit Nature of Incident / Jenis Kejadian What injuries did the patient suffer? / Apakah kecederaan yang dialami oleh pesakit? Please state whether the injuries are consistent with the circumstances of the states incident. Please explain if not consistent. / Sila nyatakan sama ada kecederaan yang dialami selaras dengan kejadian tersebut? Tolong terangkan kalau tidak selaras. Yes / Ya No / Tidak Keterangan / Explanation Has any pre-existing conditions contributed to the injuries? Please explain if Yes. / Adakah keadaan sedia yang menyumbang kepada kecederaan? Tolong terangkan kalau Ya. Yes / Ya No / Tidak Keterangan / Explanation

3 In your professional opinion, to what extend have the injuries disabled the patient? / Berdasarkan pendapat professional anda dan dengan mengambil kira pekerjaan pesakit, setakat manakah kecederaan telah menidakupayakan pesakit? Permanent Total Disablement / Ketidakupayaan Kekal Penuh (Means disablement which, having lasted for at least 12 consecutive months, will, in all probability, entirely prevent the patient from engaging in gainful employment of any and every kind for the remainder of his/her life. / Erti ketidakmampuan yang berlangsung sekurang-kurangnya selama 12 bulan berturut-turut yang mana ianya menghalang pesakit daripada melakukan sebarang pekerjaan semasa hayatnya.) Permanent Partial Disablement / Ketidakupayaan Kekal Separa (Means dismemberment or loss of sight. / Erti kehilangan anggota atau penglihatan.) If the patient is suffering from any permanent disablement please describe in full: / Jikalau pesakit mengalami sebarang keilatan kekal sila terangkan keadaan dengan penuh: Have you any reason to suspect the patient was under the influence of intoxicants at the time of the accident? (If it was a motor vehicle accident) / Adakah anda mempunyai sebarang sebab untuk mengesyaki pesakit berada di bawah pengaruh bahan yang memabukkan pada masa kejadian? (Kalau kemalangan kereta). SECTION 3 / SEKSYEN 3 - ATTENDING DOCTOR S STATEMENT / KETERANGAN DOKTOR YANG MERAWAT I / Saya of / dari have examined the patient abovementioned name and the facts set out are true to the best of my knowledge. / mengesahkan bahawa saya sendiri telah memeriksa pesakit yang disebutkan di atas dan fakta-fakta yang dinyatakan di atas adalah benar sepanjang pengetahuan saya. Signature / Tandatangan Qualification / Kelayakan Address / Alamat Telephone No. / No. Telefon Postcode / Poskod Date / Tarikh Notice / Notis: For all intents and purpose where there is a conflict or ambiguity as to the meaning in the Bahasa Malaysia provisions, it is hereby agreed that the English version shall prevail. Bagi setiap tujuan dan maksud sekiranya terdapat konflik atau kekaburan berkenaan makna di dalam peruntukan Bahasa Malaysia, adalah dipersetujui bahawa versi Bahasa Inggeris akan digunakan. 11/11/V2

4 PRIVACY DECLARATION / DEKLARASI PRIVASI In line with the Personal Data Protection Act 2010 ( PDPA ), I confirm that the personal data I have provided in this form or that is subsequently obtained by you from time to time, including my sensitive personal data such as details about my health or condition, if any ( Personal Data ), may be processed for the purpose of processing my insurance application/proposal, provision of insurance related products or services or any addition, alteration, variation, cancellation, renewal or reinstatement thereof, performing statistical/actuarial research or data study, promoting products and services and other related purposes (collectively, Purpose ). The Personal Data may also be obtained when I fill up other documents; when I liaise with you or your representatives; or when I give it to you or your representatives in person, over the telephone, through websites, or from third parties I have consented to. Although I am not obliged to provide you with my Personal Data, you will not be able to process my application for insurance cover or process my claim if I fail to provide all requested information. I acknowledge and consent that my Personal Data may be disclosed to your related company or any other company carrying on insurance or reinsurance related business, an intermediary, or a claims, investigation or other service provider and to any association, federation or similar organisation of insurance companies that exists or is formed from time to time for the Purpose or to fulfil some legal or regulatory function or is reasonably required in the interest of the insurance industry. In such instances, it will be done in compliance with the PDPA. You may also disclose my Personal Data where such disclosure is required under the law, court orders or pursuant to guidelines issued by regulatory or other relevant authorities, if you reasonably believe that you have a lawful right to disclose my Personal Data to any third party or that you would have had my consent for such disclosure if I had known of the same, and/or if the disclosure is in the public interest. I also allow my Personal Data to be transferred to your related companies and third party providers, which may be located outside Malaysia for the Purpose, if necessary. In the event that you use external service providers, specific security and confidentiality safeguards have been put in place to ensure my privacy rights remain unaffected. In the event the personal data given to you is not my personal data but that of another individual ( Data Subject ), I confirm that I have informed the Data Subject that I am providing the Data Subject's personal data to you, and have gotten the Data Subject's consent to do so. I further confirm that I have explained what is stated here to the Data Subject, and he/she understands, agrees and authorises you to deal with his/her personal data according to what is stated here. I may make inquiries, complaints, request for access to or correction of my Personal Data, or limit the processing of my Personal Data at any time hereafter by submitting such request to you at ACE Jerneh Insurance Berhad (9827-A), Manager, Customer Service Unit, Wisma ACE Jerneh, 38 Jalan Sultan Ismail Kuala Lumpur, Malaysia (Tel: / Inquiries.MY@acegroup.com). Selaras dengan Akta Perlindungan Data Peribadi 2010 ("PDPA"), saya mengesahkan bahawa data peribadi yang saya berikan kepada kamu atau yang selepasnya diperolehi oleh kamu dari semasa ke semasa termasuklah data peribadi sensitif anda seperti butir-butir mengenai kesihatan dan keadaan anda, sekiranya ada ( Data Peribadi ), mungkin diproses untuk tujuan memproses permohonan/cadangan insurans, penyediaan produk atau perkhidmatan berkaitan insurans atau sebarang penambahan, pindaan, perubahan, pembatalan, pembaharuan atau penyambungan, pelaksanaan penyelidikan statistik/aktuari atau kajian data, promosi produk dan perkhidmatan dan untuk tujuan lain yang berkaitan (secara bersama, Tujuan ). Data Peribadi tersebut adalah diperolehi apabila saya mengisi dokumen-dokumen; berhubung dengan kamu atau wakil-wakil kamu; atau memberikan ia kepada kamu atau wakil-wakil kamu secara peribadi, melalui telefon, atau melalui laman-laman web atau daripada pihak-pihak ketiga yang saya telah bersetuju. Walaupun saya tidak diwajibkan untuk memberi kamu Data Peribadi saya, kamu tidak dapat menimbang permohonan saya untuk perlindungan insurans atau memproses tuntutan saya jika saya tidak memberikan semua maklumat yang diminta. Saya mengaku dan bersetuju bahawa Data Peribadi saya mungkin akan didedahkan kepada syarikat berkaitan kamu atau mana-mana syarikat lain yang menjalankan perniagaan berkaitan insurans atau insurans semula, syarikat perantara, atau sesuatu tuntutan, penyiasatan atau penyedia perkhidmatan lain dan kepada mana-mana persatuan, persekutuan atau organisasi syarikat insurans serupa yang wujud atau yang ditubuhkan dari masa ke masa untuk Tujuan tersebut atau untuk memenuhi fungsi perundangan atau peraturan atau diperlukan dengan sewajarnya demi kepentingan industri insurans. Dalam keadaan sedemikian, ia akan dilakukan mengikuti PDPA. Kamu juga mungkin akan mendedahkan Data Peribadi saya apabila pendedahan sedemikian diperlukan di bawah undang-undang, atas arahan-arahan mahkamah atau menurut garis panduan yang dikeluarkan oleh pihak berkuasa kawal selia atau pihak berkuasa lain, jika kamu percaya bahawa kamu mempunyai hak di bawah undang-undang untuk mendedahkan Data Peribadi saya kepada mana-mana pihak ketiga atau mungkin akan mendapatkan persetujuan bagi pendedahan tersebut jika saya mengetahui tentangnya, dan/atau jika pendedahan adalah berasaskan kepentingan umum. Saya juga membenarkan Data Peribadi saya dipindahkan kepada syarikat-syarikat berkaitan kamu dan pembekal-pembekal pihak ketiga yang mungkin terletak di luar Malaysia untuk Tujuan tersebut. Sekiranya kamu menggunakan penyedia perkhidmatan luar, langkah-langkah keselamatan dan kerahsiaan tertentu telah pun diambil untuk memastikan hak kerahsiaan saya tidak terjejas. Sekiranya data peribadi yang diberikan kepada kamu bukan merupakan data peribadi saya tetapi individu lain ("Subjek Data"), saya mengesahkan bahawa saya telah memaklumkan kepada Subjek Data bahawa saya akan memberikan data peribadi Subjek Data kepada kamu, dan telah mendapati persetujuan Subjek Data untuk berbuat sedemikian. Saya selanjutnya mengesahkan bahawa saya telah menjelaskan apa yang telah dinyatakan di sini kepada Subjek Data, dan memastikannya memahami, bersetuju dan membenarkan saya untuk berurusan dengan data peribadinya mengikuti apa yang dinyatakan di sini. Saya boleh membuat pertanyaan, aduan atau permintaan untuk mendapatkan atau membetulkan Data Peribadi saya atau mengehadkan pemprosesan Data Peribadi pada bila-bila masa selepas ini dengan mengemukakan permintaan tersebut menerusi ACE Jerneh Insurance Berhad (9827-A), Pengurus, Unit Khidmat Pelanggan, Wisma ACE Jerneh, 38 Jalan Sultan Ismail Kuala Lumpur, Malaysia (Tel: / Inquiries.MY@acegroup.com).

5 ACKNOWLEDGEMENT AND CONSENT / PERAKUAN DAN PERSETUJUAN I have read and understood the terms of in this Privacy Declaration and consent to the processing of my Personal Data as described above. / Saya telah membaca dan memahami terma dan syarat Deklarasi Privasi ini dan bersetuju membenarkan pemprosesan maklumat Data Peribadi saya seperti yang dinyatakan di atas. Signature / Tandatangan Full Name / Name Penuh Date / Tarikh

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