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CIMB Aviva Takaful Berhad

(689263 - M)

known
as Commerce(689263-M)
Takaful Berhad)
Sun Life Malaysia(formerly
Takaful
Berhad*

LevelAviva
8 338Takaful
Jalan Tuanku
Abdul Rahman 50100 Kua
(formerly known as CIMB
Berhad)
Telephone: (603) 2612 3600 Facsimile: (603) 2698
Level 11, 338 Jalan Tuanku Abdul Rahman, 50100 Kuala Lumpur
Customer Service Line: 1 300 88 5055 Website: w
Telephone (603) 2612 3600 Facsimile (603) 2698 7035
Customer Careline 1300-88-5055 sunlifemalaysia.com

TAKAFUL HOSPITAL & SURGICAL CLAIM FORM


BORANG TUNTUTAN HOSPITAL DAN PEMBEDAHAN TAKAFUL
The issuance and acceptance of this Claim Form is not an admission of liability by Sun Life Malaysia Takaful Berhad (formerly known as CIMB Aviva Takaful Berhad).
You are to disclose on this Claim Form, fully and faithfully all the facts which you know or ought to know otherwise this claim shall be declared null and void. /
Pengeluaran dan penerimaan Borang Tuntutan ini bukan pengakuan bertanggungjawab oleh Sun Life Malaysia Takaful Berhad (dahulunya dikenali sebagai CIMB Aviva
Takaful Berhad). Sekiranya kenyataan dan pengisytiharan palsu dibuat untuk menyokong tuntutan ini, maka tuntutan ini adalah batal dan tidak sah.

SECTION A : PARTICULARS OF PARTICIPANT / SEKSYEN A : BUTIR-BUTIR PESERTA


Certificate No. / No. Sijil
:

Claim No. / No. Tuntutan


:

Participant's Name / Nama Peserta: (If Group Insurance, Name of Company / Jika Berkumpulan, Nama
)
Syarikat )

Name of Claimant / Nama Penuntut


:

Employment Date / Tarikh Mula Bekerja


:

NRIC No. / No. Kad Pengenalan


:
New / Baru

Business Registration No. / No. Pendaftaran Syarikat


:

Old / Lama

Business/Occupation / Perniagaan/Pekerjaan
:

Address (House/Office) / Alamat (Rumah/Pejabat)


:

Postcode / Poskod
Telephone No. / No. Telefon
:
House / Rumah

Commencement Date / Tarikh Mula


:

Office / Pejabat

Expiry Date / Tarikh Tamat


:

Handphone /Telefon Bimbit

SECTION B : OTHER INFORMATION / SEKSYEN B: MAKLUMAT LAIN


Workmen's Compensation? / Pampasan Pekerja?

Yes / Ya

No / Tidak

Social Security Benefits? / Faedah-faedah Sekuriti Sosial?

Yes / Ya

No / Tidak

Any other Insurance/Takaful Policies / Lain-lain Polisi Insurans/Takaful


l

Yes / Ya

No / Tidak

If yes, please state name of Insurance/Takaful Company / Jika ya, sila nyatakan nama Syarikat Insurans/Takaful tersebut
Certificate No. / No. Sijil

Period of Coverage / Tempoh Perlindungan

Version 1.1 August 2013

DECLARATION / PERAKUAN
I/We, the undersigned, declared that the particulars stated on this are true in every aspect. I/We have supplied full information on all particulars relevant to this claim
and the amount claimed herein is lawfully due to me/us under the terms, conditions and exceptions of the above numbered certificate and I/we hereby authorize any
hospital, clinic or physician to release any information required in the course of my/our examination on treatment. / Saya/Kami yang menandatangan di bawah,
mengaku bahawa butiran yang dinyatakan diatas adalah benar dari segi semua aspek. Saya/Kami telah memberikan maklumat sepenuhnya terhadap semua butiran
yang relevan ke atas tuntutan ini dan jumlah yang dituntut disini adalah sah disisi undang-undang yang sewajarnya ke atas Saya/Kami dibawah terma, syarat dan
pengecualian polisi yang bernombor seperti diatas dan Saya/Kami dengan ini membenarkan mana-mana hospital, klinik atau pakar perubatan menyalurkan maklumat
yang diperlukan tentang perubatan dan pemeriksaan ke atas diri Saya/Kami.
l/We agree that any of my/our personal information collected or held by Sun Life Malaysia Takaful Berhad (formerly known as CIMB Aviva Takaful Berhad) [you] in
this document is provided with my/our consent for it to be held, used, and disclosed by you to individuals or organizations associated with you or any selected third
party (within or outside of Malaysia, including reinsuranceand claims investigation companies and industry associations/federations) to process my/our application as
stated in this document, and to communicate with me/us for - purposes of processing such application. I/We understand that I/we am/are entitled to obtain access
to and to request correction of any personal information held by you and that such request can be made to the your Customer Careline at 1300-88-5055. / Saya/Kami
bersetuju bahawa sebarang maklumat peribadi saya/kami yang diperolehi atau disimpan oleh Sun Life Malaysia Takaful Berhad (dahulunya dikenali sebagai CIMB Aviva
Takaful Berhad) [anda] di dalam dokumen ini, adalah boleh diberikan atau disimpan, digunakan dan didedahkan oleh anda kepada individu atau organisasi yang
berkaitan dengan anda atau mana-mana pihak ketiga yang terpilih (di dalam atau di luar Malaysia termasuk syarikat-syarikat insurans/takaful semula dan siasatan
tuntutan serta persatuan/persekutuan industri) untuk memproses permohonan.
Signature of Participant/Claimant / Tandatangan Peserta/Penuntut
(Parent of a Minor/lbubapa Kanak-kanak)
* A joint venture between Sun Life Assurance Company of Canada and Renggis Ventures Sdn Bhd.

Signature of Employer / Tandatangan Majikan


Company Chop / Cop Syarikat
1/2

TO BE COMPLETED BY ATTENDING DOCTOR (IN BLOCK LETTERS) /


UNTUK DIISI OLEH DOKTOR RAWATAN (DALAM HURUF BESAR)

MRN NO:

d AddressName
/ Nama
Hospital dan
: / Nama Hospital dan Alamat
of Hospital
andAlamat
Address
:

Nama Pesakit
: of Patient / Nama Pesakit
Name
:

NRIC No. / No. KP :

NRIC No. / No. KP:

octor andName
Address
Nama dan
Alamat
Doktor
Rujukan
:
of/ Referring
Doctor
and
Address
/ Nama
dan Alamat Doktor Rujukan
:

Doktor Kemasukan
Attending
rawatan
:
Specialty
/ :Keistimewaan :
Admitting: Doctor / Doktor Kemasukan
: Doctors / Doktor-doktor
Attending
Doctors
/ Doktor-doktor
rawatan

ding /

Specialty / Keistimewaan
:

Diagonsis/CD
Coding
1a. Diagnosis/CD
Coding / Diagonsis/CD Coding

ogy (if applicable)


the above
diagnosis
/ Sebabofdan
bersesuaian)
untuk
diagnosis
atas bersesuaian) untuk diagnosis di atas
1b. Causeofand
Pathology
(if applicable)
thePatologi
above (jika
diagnosis
/ Sebab
dan
Patologidi(jika

first consult
for this
2a. you
When
did condition?
patient first consult you for this condition?
dapat rundingan
dengan
Perubatan
untukdengan
k
eadaan
ini? Perubatan untuk keadaan ini
Tarikh
mulaPegawai
mendapat
rundingan
Pegawai

previously2b.
treated
this
condition?
Yes /for
Yathis condition?
No / Tidak
Wasfor
the
patient
previously treated
t mendapatkanPernahkah
rawatan bagipesakit
keadaanmendapatkan
ini?
rawatan bagi keadaan ini?

Yes / Ya

No / Tidak

ils and when /Please


Sila nyatakan
butiran
bila /Sila nyatakan butiran dan bila
give details
anddan
when

professional
opinion
hasin
the
condition
ex
isted?
2c. How
long
your
professional
opinion has the conditionisted?
ex
etahuan dan kepercayaan
anda berapa lamakah
keada
ananda
ini wujud?
Sepanjang pengetahuan
dan kepercayaan
berapa lamakah keadaan ini wujud?

elapse? 3. Any possibility of relapse?


kemungkinan
ia akansebarang
berulang? kemungkinan ia akan berulang?
Adakah

re of Treatment
and Investigation
/ of Treatment
Sila nyatakanand
Jenis
Rawatan dan Siasatan
:
4a. Please
state Nature
Investigation
/ Sila nyatakan
Jenis Rawatan dan Siasatan
:
give details / OTHERS,
LAIN-LAIN,
sila nyatakan
butiran/
PEMBEDAHANOPERATION / PEMBEDAHAN
BLOOD TESTS / UJIAN DARAH
please
give details
BLOOD TESTSOTHERS,
/ UJIANplease
DARAH

S/

UBATAN

X-RAY / X-RAY

MEDICATIONS / UBATAN

LAIN-LAIN, sila nyatakan butiran

X-RAY / X-RAY

PHYSIOTHERAPY
/
FISIOTERAPI
KAUNSELING
PEMAKANAN / KAUNSELING
PHYSIOTHERAPY / FISIOTERAPI
DIETARY COUNSELING
PEMAKANAN

UNSELING /

procedures
involved,
of
Procedures
/ Jika
lebih
satu prosedur,
sila /nyatakan
Jenis
Prosedursatu prosedur,
yang dijalankan
:
4b.
If moreplease
thanstate
one Type
procedures
involved,performed
please state
Type
of daripada
Procedures
performed
Jika lebih
daripada
sila nyatakan
Jenis Prosedur yang
: dijalankan
DATE / TARIKH
NAME OF DOCTOR / NAMANAME
DOKTOR
TYPE / JENIS
DATE / TARIKH
OF DOCTOR / NAMA DOKTOR
I.
II.
III.

dical conditions?
/ present
Keadaanmedical
perubatan
lain yang terkini?
4c. Other
conditions?
/ Keadaan perubatan lain yang terkini?
since
since
since
semenjak
semenjak
semenjak

since
semenjak

Mental// Khuatira
Mentaln
Nervous

Adakah
Congenital
/ Kongenital
5. keadaan
Was theitucondition / Adakah
keadaan
itu

Nervous
/ Khuatira n
Congenital
/ Kongenital

females
6. Was the patient pregnant at rthe
timeonly)
of hospitalisation? (fr
only)
Yesfemales
/ Ya
No / Tidak
mil ketika dimasukkan
ke hospital?
(untuk
perdimasukkan
empuan sahaja)
Adakah pesakit
hamil
ketika
ke hospital? (untuk perempuan sahaja)

Yes / Ya

since
semenjak
Mental / Mental

No / /Tidak
months
bulan

months / bulan

was due to
accident,
please indicate
of accident
Jika kemasukkan
ke hospital
adalah /akibat
akan
tarikh/masa
n sila nyatakan akan tarikh
7. If
the hospilisation
wasd due ate/time
to accident,
please/ indicate
date/time
of accident
Jika kemalangan,
kemasukkansilakenyat
hospital
adalah
akibatkemalanga
kemalangan,

/masa kemalangan

time / masa

date / tarikh

Up Instructions /

time / masa

Keluaran/Arahan Tindakan Susulan

8. Discharge/Follow Up Instructions / Keluaran/Arahan Tindakan Susulan

Date / Tarikh

Name and Signature of Attending Doctor /


Tandatangan
danNama
Nama
Doktor
Rawatan
Tandatangan dan
Doktor
Rawatan

Date / Tarikh

Hospital Stamp / Cop Hospital


Cop Hospital

BASIC DOCUMENTS REQUIRED FOR CLAIMS / DOKUMEN-DOKUMEN YANG DIPERLUKAN UNTUK TUNTUTAN

Fatal / Kemalangan Maut


angan Bukan
Fatal / Kemalangan Maut
NonMaut
Fatal / Kemalangan Bukan Maut
TuntutanClaim
Yang Lengkap
orm / Borang
TuntutanClaim
Yang Lengkap
Completed
Form / Borang Tuntutan Yang Lengkap
Completed
Form / Borang Tuntutan Yang Lengkap Completed Claim Form / Borang
Police Report / Laporan Polis
ent / Surat
Perlantikan
Police Report / Laporan Polis
Letter
of Appointment / Surat Perlantikan
Letter of Appointment / Surat
Perlantikan
d Pengenalan
Letter
of Appointment / Surat Perlantikan
Identity Card / Kad Pengenalan
Identity Card / Kad Pengenalan
n workers)
Pasport(for
(untuk
pekerja
asing) / Pasport (untuk pekerja asing)
Identity Card / Kad Pengenalan
/Passport
foreign
workers)
Passport (for foreign worker)/ Passport
Pasport (for
(untuk
pekerjaworker)
asing) / Pasport (untuk pekerja asing)
ls/Receipt / Original
Bil-bil/Resit
Perubatan
Asal
foreign
Medical
Bills/Receipt
/ Bil-bil/Resit Perubatan Asal
Post Mortem Report / Laporan
Bedah
SiasatReport / Laporan Bedah Siasat
ave / Sijil
Cuti SakitMedical
Asal
Post
Mortem
Original
Leave / Sijil Cuti Sakit Asal
Death Certificate and Burial Certificate
/
Sijil Kematian
dan Sijil
Pengkebumian
eport / Laporan
Perubatan
Asal
Death Certificate
and Burial
Certificate
/ Sijil Kematian dan Sijil Pengkebumian
Original
Medical
Report / Laporan Perubatan Asal

2/2

SUN LIFE MALAYSIA ASSURANCE BERHAD

E-PAYMENT FORM

NOTIFICATION ON BANK ACCOUNT DETAILS FOR E-PAYMENT PURPOSE


TO

FROM
:
(Name & Address)

SUN LIFE MALAYSIA ASSURANCE BERHAD


LEVEL 8, NO 338, JALAN TUANKU ABDUL RAHMAN
50100 KUALA LUMPUR
Attn: _____________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Telephone No

_________________________________________________________________

E-mail
:
_________________________________________________________________
(For notification of payment)
I/We hereby agree with your Companys arrangement to make payment directly into my/our bank account.
Details of my/our bank account as follows:

Account Holder Name


Co. Registration No.
Bank Name
Bank Account Number*
I /We hereby declare that the information given is true and accurate to the best of my/our knowledge and
record. I/We shall indemnify SUN LIFE MALAYSIA ASSURANCE BERHAD for any loss arising from the reliance on
above information. In the event of a change in bank account, I/We shall inform you in writing no later than 7
days after the change.
Thank you.

Yours faithfully,

_________________________
(Authorised Signature)
Name :
Date
:

_________________________
(Company Stamp)

*please attach top portion of the bank statement of current account/Front page of the Savings Account
Passbook/Confirmation letter from bank

SUN LIFE MALAYSIA ASSURANCE BERHAD

E-PAYMENT FORM

APPENDIX A

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