LONPAC INSURANCE BHD (307414-T) Head Office : LG, 6th, 7th, 21st to 26th Floor, Bangunan Public Bank, 6, Jalan Sultan Sulaiman, 50000 Kuala Lumpur, Malaysia. P.O. Box 10708, 50722 Kuala Lumpur, Malaysia. Tel: (03) 2262 8688, 2723 7888 Fax: (03) 2715 1332, 2034 2654, 2715 0722, 2072 3385, 2715 0696, 2723 7886 Website: www.lonpac.com DMS/16/SKHPPA/P/003/June FOREIGN WORKER HOSPITALISATION AND SURGICAL SCHEME PROPOSAL FO (SKHPPA) BORANG CADANGAN SKIM KEMASUKAN HOSPITAL DAN PEMBEDAHAN PEKERJA ASING (SKHPPA) IMPORTANT NOTICE / NOTIS PENTING Consumer Insurance Contract Pursuant to Paragraph 5 of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance wholly for yourself/family/dependants, you have a duty to take reasonable care not to make a misrepresentation in answering the questions in this Proposal Form. You must answer the questions in this Proposal Form fully and accurately. Failure to take reasonable care in answering the questions may result in avoidance of your contract of insurance, refusal or reduction of your claim(s), change of terms or termination of your contract of insurance. The above duty of disclosure shall continue until the time your contract of insurance is entered into, varied or renewed with us. In addition to answering the questions in this Proposal Form, you are required to disclose any other matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied. You also have a duty to tell us immediately if at any time after your contract of insurance has been entered into, varied or renewed with us any of the information given in this Proposal Form is inaccurate or has changed. Kontrak Insurans Pengguna Menurut Perenggan 5 daripada Jadual 9 Akta Perkhidmatan Kewangan 2013, jika anda memohon Insurans ini sepenuhnya untuk diri sendiri/keluarga/ tanggungan, anda mempunyai kewajipan untuk mengambil langkah yang munasabah untuk tidak salah nyata dalam menjawab soalan-soalan dalam Borang Cadangan ini. Anda dikehendaki menjawab soalan-soalan dalam Borang Cadangan ini dengan lengkap dan tepat. Kegagalan untuk mengambil langkah yang munasabah dalam menjawab soalan-soalan, mungkin mengakibatkan pembatalan kontrak insurans anda, keengganan atau pengurangan gantirugi, perubahan terma atau penamatan kontrak insurans anda. Kewajipan pendedahan di atas hendaklah diteruskan sehingga kontrak insurans anda dimeterai, diubah atau diperbaharui dengan kami. Sebagai tambahan kepada soalan-soalan dalam Borang Cadangan ini, anda dikehendaki untuk mendedahkan apa-apa perkara lain yang anda tahu akan mempengaruhi keputusan kami dalam menerima risiko dan menentukan kadar dan terma yang dikenakan. Anda juga mempunyai kewajipan untuk memberitahu kami dengan serta-merta jika pada bila-bila masa selepas kontrak insurans anda ditandatangani, diubah atau diperbaharui dengan kami, apa-apa maklumat yang dinyatakan dalam Borang Cadangan ini tidak tepat atau telah berubah. Non-Consumer Insurance Contract Pursuant to Paragraph 4(1) of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance for the purpose of providing insurance benefits to your employees and their family/dependants, you have a duty to disclose any matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied and any matter a reasonable person in the circumstances could be expected to know to be relevant, otherwise it may result in avoidance of your contract of insurance, refusal or reduction of your claim(s), change of terms or termination of your contract of insurance. The above duty of disclosure shall continue until the time your contract of insurance is entered into, varied or renewed with us. You also have a duty to tell us immedaitely if at any time after your contract of insurance has been entered into, varied or renewed with us any of the information given in this Proposal Form is inaccurate or has changed. Kontrak Insurans Komersial Menurut Perenggan 4(1) Jadual 9 Akta Perkhidmatan Kewangan 2013, jika anda memohon Insurans ini untuk memberi manfaat insurans kepada pekerja dan keluarga/tanggungan mereka, anda berkewajipan untuk memdedahkan apa-apa perkara yang anda tahu akan mempengaruhi keputusan kami dalam menerima risiko dan menentukan kadar dan terma yang dikenakan, dan apa-apa perkara yang munasabah yang boleh dijangka, jika tidak ia boleh menyebabkan pembatalan kontrak insurans, keengganan atau pengurangan gantirugi, perubahan terma atau penamatan kontrak insurans anda. Kewajipan pendedahan di atas hendaklah diteruskan sehingga kontrak insurans anda dimeterai, diubah atau diperbaharui dengan kami. Anda juga mempunyai kewajipan untuk memberitahu kami dengan serta-merta jika pada bila-bila masa selepas kontrak insurans anda ditandatangani, diubah atau diperbaharui dengan kami, apa-apa maklumat yang dinyatakan dalam Borang Cadangan ini tidak tepat atau telah berubah.
LONPAC INSURANCE BHD (307414-T) Head Office : LG, 6th, 7th, 21st to 26th Floor, Bangunan Public Bank, 6, Jalan Sultan Sulaiman, 50000 Kuala Lumpur, Malaysia. P.O. Box 10708, 50722 Kuala Lumpur, Malaysia. Tel: (03) 2262 8688, 2723 7888 Fax: (03) 2715 1332, 2034 2654, 2715 0722, 2072 3385, 2715 0696, 2723 7886 Website: www.lonpac.com FOREIGN WORKER HOSPITALISATION AND SURGICAL SCHEME PROPOSAL FO (SKHPPA) BORANG CADANGAN SKIM KEMASUKAN HOSPITAL DAN PEMBEDAHAN PEKERJA ASING (SKHPPA) Account No. No. Akaun Type of Proposal : Jenis Cadangan New Baru Take-over Ambil alih Reference No. No. Rujukan EMPLOYER S PARTICULARS / BUTIR-BUTIR MAJIKAN 1. Business Registration No./NRIC : No. Pendaftaran Syarikat/KP 2. Name of Proposer / Employer : Nama Pencadang / Majikan (Business Registration Document/NRIC verified by: Signature & Name of Agent/Staff) 3. Address of Employer : Alamat Majikan 4. Telephone No. : No. Telefon 5. E-mail Address : Alamat E-Mel 6. Business/Occupation : Perniagaan/Pekerjaan Postcode: Poskod Office Pejabat State Negeri Mobile - Bimbit - PERIOD OF INSURANCE COVERAGE / TEMPOH PERLINDUNGAN INSURANS 7. Period of Coverage : Tempoh Perlindungan 8. Date of Coverage : Tarikh Perlindungan From Dari Months Bulan To Hingga 9. No. of worker(s) to be insured / Bilangan pekerja yang akan diinsuranskan (if more than one (1) worker, please complete the Workers Particulars Form) (jika lebih dari seorang (1) pekerja, sila lengkapkan Borang Butir-Butir Pekerja yang disertakan dalam lampiran ini) 10. Sector (Please tick 3) : Sektor (Sila tanda 3) Construction Pembinaan Plantation Perladangan Domestic Maids Pembantu Rumah Hunting Memburu Factory Perkilangan Manufacture Pembuatan Fishery Perikanan Forestry Perhutanan Services Perkhidmatan Farming Pertanian Livestock Binatang Ternakan Others, Please Specify Lain-lain, Sila Memperinci 11. Who will be paying the premium : for this insurance policy? Siapakah yang akan membayar premium untuk polisi insuran ini? Employer Majikan Foreign worker themselves Pekerja asing sendiri PLACE OF EMPLOYMENT / TEMPAT PEKERJAAN 12. To be filled up only if Place of Employment Address is not the same as the Address of Employer above :- Hanya perlu diisi sekiranya Alamat Tempat Pekerjaan berlainan dengan Alamat Majikan di atas :- a) Business Registration No./ : NRIC/Passport/Construction Site No./ Project Reference No. No. Pendaftaran Syarikat/KP/Pasport/ Rujukan Tapak Pembinaan/Rujukan Projek
b) Place of Employment Address : Alamat Tempat Pekerjaan Postcode Poskod State Negeri FOREIGN WORKER S PARTICULARS [If application is for only one (1) worker, please complete the following particular] :- BUTIR-BUTIR PEKERJA ASING [jika permohonan untuk seorang (1) pekerja, sila lengkapkan butir-butir berikut] : 13. Name of Worker : Nama Pekerja 14. Nationality : Warganegara 15. Passport No. : No. Paspot 16. Date of Birth : Tarikh Lahir 18. Marital Status : Taraf Perkahwinan Single Bujang (DD/MM/YY / HH/BB/TT) Married Kahwin 17. Gender : Jantina Divorced Bercerai Male Lelaki Female Perempuan Widow/Widower Janda/Duda 19. Work Permit No. : No. Permit Kerja 21. Nature of Work : Jenis Pekerja 20. Work Permit Expiry Date : Tarikh Luput Permit Kerja DECLARATION / PENGAKUAN I/We understand that it is my/our duty to take reasonable care not to make a misrepresentation in answering the questions in this Proposal Form and I/we hereby declare that I/we have fully and accurately answered the questions above. Saya/Kami faham bahawa menjadi tanggungjawab saya/kami untuk mengambil langkah yang munasabah untuk tidak salah nyata semasa menjawab soalan-soalan dalam borang cadangan ini dan saya/kami dengan ini mengaku bahawa saya/kami telah menjawab dengan sepenuhnya dan dengan tepat soalan di atas. I/We hereby authorise, any hospital, surgeon, medical practitioner or clinic or other person who attends to me/insured Person for any reason to disclose to the insurance company any and all information with respect to any illnesses or injury and to provide copies of all hospital or medical records/certifications, including any earlier medical history. A photocopy of this authorisation shall be considered as effective and valid as the original. Saya/Kami dengan ini memberi kuasa kepada mana-mana hospital, pakar bedah, pengamal perubatan atau klinik ataupun individu lain yang datang kepada saya/orang yang diinsuranskan untuk apa tujuan sekalipun untuk memberikan syarikat insurans apa-apa dan semua butir-butiran berhubung dengan mana-mana penyakit atau kecederaan dan memberikan semua salinan rekod/sijil hospital atau perubatan, termasuk mana-mana sejarah perubatan. Salinan fotostat pemberikuasaan ini akan diambil kira sebagai berkesanan dan sah sebagai asli. Date Tarikh Signature of Proposer / Company Rubber Stamp Tandatangan Pencadang / Cop Syarikat DETAILS OF PAYMENT / BUTIR-BUTIR BAYARAN FOR OFFICE USE ONLY / UNTUK KEGUNAAN PEJABAT SAHAJA Annual Premium / Premium Tahunan 120.00 (per worker / setiap pekerja) Enclose herewith payment Cash / Cheque No Bersama ini disertakan bayaran Tunai / Cek No Total Premium / Jumlah Premium Goods and Services Tax (6%) Cukai Barang dan Perkhidmatan (6%) Amounting to Berjumlah Stamp Duty / Duti Setem 10.00 TOTAL / JUMLAH All Cheques must be made payable to "LONPAC INSURANCE BHD" Semua Cek hendaklah dibayar atas nama "LONPAC INSURANCE BHD" Date/Time Received Tarikh/Masa Diterima Signature Tandatangan
DESCRIPTION OF BENEFITS / COVERAGE / KETERANGAN FAEDAH/PERLINDUNGAN HOSPITAL & SURGICAL BENEFITS / MANFAAT KEMASUKAN KE HOSPITAL & PEMBEDAHAN Item / Perkara Benefits / Manfaat Amount () / Jumlah () 1 (a) Daily Hospital Room & Board (Maximum up to 30 days) Bilik Hospital & Makan Harian (Maksimum sehingga 30 hari) 1 (b) Intensive Care Unit (Maximum up to 15 days) Unit Rawatan Rapi (Maksimum sehingga 15 hari) 2 Hospital Supplies and Services Bekalan dan Khidmat Hospital 3 Operating Theatre Bilik Bedah 4 Surgical Fees (Excluding organ transplantation) Bayaran Pembedahan (Tidak merangkumi transplant organ) 5 Anaesthetist Fees Bayaran Pakar Bius 6 In-Hospital Physician Visits (Maximum up to 30 days) Lawatan Pakar Perubatan Dalam Hospital (Maksimum sehingga 30 hari) 7 In-Hospital Specialist Consultation Visits (Maximum up to 30 days) Lawatan Rundingan Pakar Dalam Hospital (Maksimum sehingga 30 hari) As charged in accordance to charges consistent with Third (3rd) Class Room & Board to a maximum of 160.00 per day, in a Non-Corporatised Malaysian Government Hospital in conformance to the charges specified under Fees Act 1951, Fees (Medical) Order 1982 and/or its subsequent amendments. Bayaran yang dikenakan mengikut bayaran yang selaras dengan Bilik & Makan Kelas Ketiga (ke-3) sehingga maksimum 160.00 sehari di Hospital Kerajaan Malaysia Bukan Korporat mengikut Akta Fi 1951, Perintah Fi (Perubatan) 1982 dan/atau pindaan berikutnya. 8 Ambulance Fees/Medical Reports Fees Bayaran Ambulans/Bayaran Laporan Perubatan MAXIMUM OVERALL ANNUAL LIMIT (Item 1 to 8) Per Insured Worker HAD TAHUNAN KESELURUHAN MAKSIMUM (Perkara 1 hingga 8) Bagi Setiap Orang Yang Diinsuranskan ANNUAL PREMIUM (Inclusive of GST 6%) PREMIUM TAHUNAN (Termasuk GST 6%) 20,000.00 127.20 (Per Worker / Setiap Pekerja) Important Note: All benefits payable for any number of disabilities in any one given period of insurance is subject to Overall Annual Limit of 20,000.00 per insured worker. Nota Penting: Semua faedah-faedah yang dibayar bagi setiap ketidakupayaan bagi setiap tempoh insurans yang diberi tertakluk kepada Had Tahunan Keseluruhan sebanyak 20,000.00 bagi setiap pekerja yang diinsuranskan. PRIVACY POLICY / POLISI PRIVASI For information on our privacy policy, please visit our website www.lonpac.com/web/my/privacy_policy_my Bagi maklumat mengenai polisi privasi kami, sila lawat laman web kami www.lonpac.com/web/my/privacy_policy_my
FOREIGN WORKER'S PARTICULARS FO / BORANG BUTIR-BUTIR PEKERJA ASING LIST OF WORKERS TO BE COVERED UNDER SKHPPA / SENARAI NAMA PEKERJA YANG DILINDUNGI DI BAWAH SKHPPA Name of Proposer / Employer Nama Pencadang / Majikan Business Registration No./ NRIC / Passport Pendaftaran Syarikat / KP / Pasport Item No. Bil No. Name of Worker Nama Pekerja Nationality Warganegara Passport No. No. Pasport Date of Birth Tarikh Lahir (* Gender) (* Jantina) Work Permit No. No. Permit Kerja Work Permit Expiry Date Tarikh Luput Permit Kerja Reference / Rujukan : * Gender / Jantina : (L) Male / Lelaki; (P) Female / Perempuan