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Medical and Accident Claims
1
Policy
2
Claim Type
3
Person
4
Incident
5
Doctors
6
E-Banking
7
Sign
8
Generate
Particulars of Policy
Date submitted
(DD/MM/YYYY)
Today
Agent is also the Witness
Agent Name
Agent Contact
NRIC
Agency Name
+ Add Another Policy
Up to 4 Policies
Type of Claim
Hospitalisation/Day Surgery Medical Expenses
Pre or Post Hospitalisation Treatment
Outpatient Emergency Accidental Injury Treatment
Outpatient Kidney Dialysis/Outpatient Cancer Treatment
Outpatient Dengue Fever Treatment
Home Nursing Care
Hospitalization Benefit/Allowance only
Accident Indemnity
Others
Total Claim Amount (Medical Expenses Only): (RM)
Particulars of Insured Person
Ensure your email and mobile number are updated in order to receive claim notifications on a timely manner.
Name
NRIC/Passport No.
Mobile No.
Email
Current Correspondence Address
Current Occupation
Exaxt Duties Performed
Name of Current Employer
Address of Employer
Particulars of Policyowner
(Tick if) Insured and Policyowner is DIFFERENT PERSON
Name
New IC/Old IC/Passport No.
Mobile No.
Email
Current Correspondence Address
Particulars of Illness/Accident
This is due to:
Ilness
Accident
Nature of Illness Disability
Date of diagnosis
(DD/MM/YYYY)
Presenting sign and symptoms
Onset date
(DD/MM/YYYY)
Date of accident
(DD/MM/YYYY)
Time of accident
:
--
AM
PM
Place of accident
How did the accident happen?
Nature and extend of injury
Date first absent from work due to accident
(DD/MM/YYYY)
Date returned to work
(DD/MM/YYYY)
Particulars of Doctors Consulted
First doctor consulted for this illness/disability
First consultation date
(DD/MM/YYYY)
Name and Address of Doctor(s)
All other doctors consulted for this illness/disability
First consultation date
(DD/MM/YYYY)
Name and Address of Doctor(s)
Regular doctors/ gynaecologist/ obstetrician
First consultation date
(DD/MM/YYYY)
Name and Address of Doctor(s)
All other doctors consulted in the past five (5) years
First consultation date
(DD/MM/YYYY)
Name and Address of Doctor(s)
Particulars of Other Coverage/Scheme/Policy(ies)
+ Add Other Coverage
Up to 4 policies
Particulars of Bank Account for Claim Payment
Account Holder Name
New IC/Old IC/Passport No/Co. Registration No. (as per bank’s records)
Bank Account No.
Name of Bank
-- Select Bank --
Maybank
CIMB Bank
Public Bank
RHB Bank
Hong Leong Bank
AmBank
UOB Bank
OCBC Bank
HSBC Bank
Standard Chartered
Alliance Bank
Affin Bank
Citibank
Bank Rakyat
Bank Islam
Bank Muamalat
Bank Account Type
Conventional
Islamic
Signature of Insured Person/Policyowner/Claimant
Name of Insured Person/Policyowner/Claimant
New IC/Old IC/Passport No.
Mobile No.
Relationship with Insured Person
-- Select Relationship --
Self
Spouse
Child
Parent
Sibling
Employee
Employer
Legal Guardian
Trustee
Assignee
Other
Date signed
(DD/MM/YYYY)
Today
Tap to Sign (Insured Person/Policyowner/Claimant)
Clear Signature
Signature of Witness
Name of Witness
NRIC
Mobile No.
Date signed
(DD/MM/YYYY)
Today
Tap to Sign (Witness)
Clear Signature
Generate PDF / Reset Form
Medical and Accident Claim – Claimant’s Statement
LF5191 · 4 Pages (upload to
Claims Easy
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