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IB002
9
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Floor, Bangunan AMBD, No.1, Jalan Lumut, 50400 Kuala Lumpur, Malaysia. GPO Box 10956, 50730 Kuala LumpurTel: (603) 4043 2100 Fax: (603) 4043 8680
 To: The Manager From:
 
Claims Department - LifeHead Office
CLAIMS NOTIFICATION ADVICE
Policy No :Date Of Notification :
 
Claim No :
 
Date Received :
HEAD OFFICE USE ONLY
Name Of Policy Owner :Name Of Life Assured :(
If different from policyowner) 
Correspondence Address :Tel No’s: House : ____________________________ 0ffice :Mobile No : _________________________ 
 
TYPE(S) OF CLAIM (
Please tick where applicable) 
Death Claim Hospitalisation Benefit ClaimTotal & Permanent Disability Claim Hospitalisation & Surgical ClaimCritical Illness Claim Accident Benefit ClaimPayor Benefit Claim Maternity Benefit ClaimOther Types Of Claim, please specify
Date of event leading to this claim
 
Cause of event
 
leading to this claim
 Name of person notifying this claim
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