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TOKIO MARINE INSURANS (MALAYSIA) BERHAD

29th Floor, Menara Dion, 27, Jalan Sultan Ismail, 50250 Kuala Lumpur.
Telephone : 03-20269808/27838383

E-PAYMENT REGISTRATION FORM


Please complete the details herein this Form with capital letters and cross (X) the appropriate box.
Policy Holder
Agent
Broker
Reinsurer
Repairer

Lawyer

Financial Institution

Adjuster

Service Provider

Others
(Please specify)

Section A: PERSONAL DETAILS


Beneficiary Name :

Business Registration No (non-individual) :


NRIC No (individual) :
Address :

Telephone No:

Handphone No.

Contact Person 1:

Email:

Contact Person 2:

Email:

Banker (Please select from drop down list or Appendix A)

Bank Code

Bank Account Number (please ignore all dashes:'-')

Section B: DOCUMENTS TO BE ATTACHED HEREWITH THIS FORM


For verification purpose, kindly attach the following supporting document that confirm the said account belongs to you/your company
Photocopy of top portion of the bank statement of Current Account, OR
Front page of the Savings Account Passbook, OR
Confirmation letter from bank
Section C:DECLARATION
I/We hereby authorize Tokio Marine Insurans (Malaysia) Berhad (TMIM) to credit all monies due to me/us to my/our bank account indicated above by way of Giro Fund
Transfer/Rentas and confirm that:
1

I/We hereby declare that the above is my personal account/our company account, NOT joint account and the information given is true and accurate to the best of
my/our knowledge and record.

I/We shall indemnify TMIM for any loss, damage or claims incurred as consequence of acting on such reliance.

I hereby give my consent to TMIM to disclose my Personal Data provided in this E Payment Registration Form to TMIM, TMIM's service providers and bankers and
such service providers and bankers have my consent to process my Personal Data for the purpose of effecting and administrating the electronic payments to me
(including without limitation, my name, personal identification number, contact details and any other personal data obtained hereafter collectively known as
Personal Data).

I understand that I have the right, upon payment of a prescribed fee, to request access to my Personal Data that is being processed by TMIM and to request
correction of my Personal Data. Such request shall be submitted to the Head of Finance, TMIM; and

I understand that the supply of my Personal Data herein is voluntary and it is necessary for TMIM to process my Personal Data for effecting and administrating the
electronic payments to me.

Authorised Signatory
Name
Position
Date

Company/Agency Stamp

PLEASE RETURN ORIGINAL SIGNED FORM TO TMIM


FOR OFFICE USE ONLY :
To be completed by relevant department:
Department/branch
Agent Name
Client Code
Verified by
To be completed by Finance department:
Date received
Data Entry by Finance
Verified by Finance

MO Code
Agent Code
Signature/Date

Signature/Date
Signature/Date

APPENDIX A
LIST OF BANKERS
Bank Account Number (please ignore all dashes:'-')

Banker
.

Bank Code

AFFIN BANK BERHAD

PHBM

AGRO Bank ( Bank Pertanian M'sia Bhd )

AGOB

ALLIANCE BANK MALAYSIA BERHAD

MFBB

AL-RAJHI BANKING & INVESTMENT CORPORATION (MSIA) BHD

RJHI

AMBANK BERHAD

ARBK

BANK ISLAM MALAYSIA BERHAD

BIMB

BANK KERJASAMA RAKYAT BERHAD

BKRM

BANK MUAMALAT BERHAD

BMMB

BANK OF AMERICA

10

BANK OF TOKYO-MITSUBISHI UFG (MALAYSIA) BERHAD

BOFA
BOTK

11

BANK SIMPANAN NASIONAL

BSNA

12

CIMB BANK BERHAD

CIBB

13

CITIBANK BERHAD

CITI

(10)

14

DEUSTCHE BANK

DEUT

(10)

15

HONG LEONG BANK BERHAD

HLBB

16

HSBC BANK MALAYSIA BERHAD

HBMB

17

J.P. MORGAN CHASE BANK BERHAD

CHAS

18

KUWAIT FINANCE HOUSE (M) BERHAD

KFHO

19

MALAYAN BANKING BERHAD

MBBE

20

OCBC BANK (M) BERHAD

OCBC

(10)

21

PUBLIC BANK BERHAD

PBBE

(10)

22

RHB BANK BERHAD

RHBB

23

ROYAL BANK OF SCOTLAND BHD

ABNA

24

STANDARD CHARTERED BANK MSIA BHD

SCBL

25

SUMITOMO MITSUI BANKING CORPORATION MALAYSIA BERHAD

SMBC

26

UNITED OVERSEAS BANK

UOVB

(12)
(17)
(15)
(15)
(13)
(14)
(12)
(14)
(12)
(6)
(16)
(14)

(11)
(12)
(10)
(12)
(12)

(14)
(7 to 9)
(12)
(8)
(11)