Operational Hub - InsuFlow Hub

1Policy

2Claim Type

3Person

4Incident

5Doctors

6E-Banking

7Sign

Particulars of Policy

Date submitted (DD/MM/YYYY)

Agent is also the Witness

Agent Name Agent Contact Agency Name

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

NIRC/Passport No.

Mobile No. Email

Current Correspondence Address

Current Occupation

Exaxt Duties Performed

Name of Current Employer

Address of Employer

Particulars of Policyowner

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

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)

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

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

Date signed (DD/MM/YYYY)

Tap to Sign (Policyowner / Assignee)

Signature of Witness

Name of Witness

NIRC Mobile No.

Date signed (DD/MM/YYYY)

Tap to Sign (Witness)

Signature of Trustee(s)/Nominee(s)

Name of Trustee/Assignee

New IC/Old IC/Passport No.

Tap to Sign (Trustee/Nominee)

Secured Session Active: This platform operates on a static, local-injection framework. We do not store, log, or track any personal details or financial credentials on external servers.