Borang Pra-kebenaran

Pre-Authorisation Form
Private and Confidential / Sulit dan Persendirian

Bahagian 1 (Untuk diisi oleh Pesakit / Penuntut)

Part 1 (To be completed by Patient / Claimant)

1. Nama Pesakit / Patient Name:

2. K.P. (Lama & Baru) / NRIC (Old & New):

3. (a) Tarikh lahir / Date of Birth:

(b) Umur / Age:

(c) Jantina / Sex:

4. No. Polisi / No. Ahli / No. Sijil / Pelan / Nama Syarikat

Policy No. / Member ID / Certificate No / Plan / Company Name:

5. Tarikh kemasukan hospital:

Admission / Planned Admission Date:

6. Nama Hospital
Hospital Name:

7. Nama Doktor yang merawat/ Kepakaran:

Name of Attending Doctor / Speciality:

Sila tanda ( X ) dan jawab soalan yang berkenaan

Admission Reason ( X ) and answer accordingly

8. Kemalangan / Accident

(a) Berlaku pada Tarikh Masa pagi / petang

Occurred on: Date _________________________ Time _________ am / pm

(b) Butir-butir kemalangan

Details of Accident

9. Penyakit / Illness

(a) Tarikh simptom tersebut bermula: Tarikh

Symptoms first appeared on: Date

(b) Doktor-doktor yang dilawati bagi penyakit ini

Doctor(s) consulted for this condition

(c) Alamat & Telefon Doktor

Doctor’s or Clinic Contact(Address & Telephone)

NOTA: MELENGKAPKAN BORANG PERMINTAAN INI TIDAK SEMESTINYA MENJAMIN BAHAWA SURAT JAMINAN AKAN
DIKELUARKAN.
NOTE: COMPLETION OF THIS PRE AUTHORISATION FORM DOES NOT GUARANTEE THE ISSUANCE OF GUARANTEE LETTER.

ZT0008/2/P/G/S/M
Pengisytiharan dan pemberikuasa / Declaration and authorization

Saya mengisytiharkan bahawa jawapan yang diberikan di atas adalah benar dan lengkap setakat pengetahuan dan kepercayaan
saya.

Saya memahami bahawa penyerahan borang ini, tidak sama sekali boleh dianggap sebagai pengakuan liabiliti Zurich General
Takaful Malaysia Berhad ini ke atas tuntutan saya/Assured dan saya bersetuju bahawa bayaran kepada hospital oleh Zurich
General Takaful Malaysia Berhad atau wakilnya tidak akan ditafsirkan sebagai pengakuan muktamad liabiliti Zurich General
Takaful Malaysia Berhad dan Zurich General Takaful Malaysia Berhad berhak menjalankan penilaian sewajarnya berhubung
tuntutan ini atau apa-apa tuntutan yang timbul selanjutnya.

Saya memahami sepenuhnya had-had insurans perubatan saya di bawah Polisi yang tersebut di atas. Saya dengan ini berjanji
akan menyelesaikan sebarang amaun yang melebihi had kelayakan saya, yang tidak dilindungi oleh insurans berkenaan.

Saya yang bertandatangan di bawah, dengan ini membenarkan pada setiap masa, mana-mana organisasi, institusi atau individu
yang mempunyai apa-apa rekod atau pengetahuan tentang kesihatan dan latar belakang atau rawatan atau nasihat perubatan
saya/Assured/Insured, yang telah atau mungkin kemudian dari ini dirujuk untuk mendedahkan kepada Zurich General Takaful
Malaysia Berhad atau wakilnya segala maklumat tersebut. Saya bersetuju membenarkan Zurich General Takaful Malaysia Berhad
atau wakilnya untuk mengguna dan mendedahkan apa-apa maklumat yang dikumpul atau dipegang kepada pihak ketiga (di
dalam atau di luar Malaysia, termasuk syarikat induk, anak syarikat atau syarikat berkait dalam Zurich General Takaful Malaysia
Berhad, reinsurer, pemeriksa perubatan, penyiasat tuntutan dan pertubuhan/persekutuan industri dan lain-lain.) berkaitan dengan
tuntutan ini. Pengesahan ini hendaklah mengikat waris-waris dan penama saya/Assured/insured dan kekal sah meskipun setelah
kematian saya/Assured/insured setakat yang dibenarkan di sisi undang-undang. Salinan pengesahan ini adalah sah. Saya
bersetuju sekiranya saya membuat pengakuan palsu atau tidak mendedahkan maklumat yang berkaitan, Zurich General Takaful
Malaysia Berhad berhak membatalkan tuntutan saya dan menarik balik sebarang tuntutan awal yang telah dibayar.

I declare that the answers given above are true and complete to the best of my knowledge and belief.

I understand the delivery of this form is in no way an admission of Zurich General Takaful Malaysia Berhad’s liability and payment
to the hospital by Zurich General Takaful Malaysia Berhad or its representative shall not be construed as final admission of Zurich
General Takaful Malaysia Berhad’s liability and for this and any further claims arising, Zurich General Takaful Malaysia Berhad
reserves all rights for evaluation as appropriate.

I am fully aware of the limits as to my/Assured medical insurance under the above-mentioned policy. I hereby undertake to settle/
reimburse any medical expenses exceeding my entitlement under the said policy contract, or that is not covered by the same.

I hereby irrevocably authorize any organisation, institution, or individual that has any record or knowledge of my health and
medical history or treatment or advice that has been or may hereafter be consulted, other personal information or details of
related accident/injury, to disclose to Zurich General Takaful Malaysia Berhad or its representative such information. I agree that
Zurich General Takaful Malaysia Berhad or its representative may use or disclose any of the information collected or held to third
parties (within or outside Malaysia, including Zurich General Takaful Malaysia Berhad’s parent company, subsidiaries or any other
associated companies within Zurich General Takaful Malaysia Berhad’s Group, reinsurers, medical examiners, claims investigators
and industry associations/federations etc.) in relation to this claim. This authorization shall bind my/the Assured’s/Insured’s
successors and assigns and remain valid notwithstanding my/Assured’s/Insured’s incapacity in so far as legally possible. A
photocopy of this authorization shall be valid as the original. I agree that in the event I make, or have in the past made,
any false or untrue statement and/or suppressed and/or concealed any material facts in respect of my/the insured’s
condition, Zurich General Takaful Malaysia Berhad shall absolutely forfeit my/the Insured’s/Assured’s right to compensation and
further reserves the right to recover any amounts paid earlier as a result thereof.

Tandatangan Pesakit / Signature of Patient Nama Penuh/Full Name:

No K/P. / I/C No.:

No Telefon/Contact No:

Tarikh/Date: Email Address:

Tandatangan Pemilik Polisi /Penuntut /Signature of Assured/ Nama Penuh/Full Name:
Claimant
No K/P. / I/C No.:

No Telefon/Contact No:

Tarikh/Date: Hubungan dengan Pesakit

Relationship to Patient:
Tandatangan Saksi / Signature of Witness
Nama Penuh/Full Name:

No K/P. / I/C No.:

Tarikh/Date: No Telefon/Contact No:

Part 2 ADMISSION SECTION ( To be completed upon admission by Doctor )

1. (a) Patient name:

(b) NRIC (Old & New):

(c) Age:

(d) Sex: Male Female

2. Policy No. / Member ID/ Certificate No/ Plan/ Company Name:

3. Admission No. / MRN and Hospital Name/ Hospital Contact and Fax No:

4. Admission Date and Time:

5. Expected days of stay / Discharge Date:

6. (a) Symptoms / Conditions requiring admission:

(b) How long is patient aware of the condition:

(c) Patient’s BP / Temp / Pulse:

(d) Date symptoms first appeared:

(e) Date first consulted:

7. (a) Any previous consultation / treatment / hospitalization for this symptom / illness or related Yes No
conditions, or other disorders whether in this hospital or any other facilities?

(b) Was this patient referred? If Yes, please provide details below:

(c) If this condition existed before symptoms became apparent to the patient, please indicate in your
professional opinion how long has the condition existed:
Date
Disease / Disorder
Details of Treatment / Hospitalization
Doctor / Hospital/ Clinic

(d)Can the condition be managed under the Outpatient basis: Yes No

If no please provide reasons of admission:
8. (a) Admitting Diagnosis: (c) Diagnosis confirmed on
or Advised patient on
(b) Provisional Diagnosis:

(d) Cause and pathology underlying the present diagnosis:

(e) Any possibility of relapse? Yes No

9. Estimated Total Costs : RM

10. Admission requires: Hospitalisation Day Care On Patient’s Request

11. Is the illness / condition related to: (please tick (X) if YES). Please provide details:
(a) Pregnancy / Childbirth / Infertility / Caesarean section / miscarriage
Or any complications arising therefrom.
(b) Congenital / Hereditary diseases
(c) Influence of Drugs / Alcohol
(d) Nervous / Mental / Emotional / Sleeping Disorder
(e) Cosmetic reason / Dental care / refractive errors correction
(f) AIDS / STD / VD / HIV
(g) Self-inflicted injuries / Violation of laws / Strike / Riots
(h) None of the above

12. Medical treatment, Investigations and Surgical procedure to be performed, if any (please supply copy of all investigation
results):

13. Any other medical/surgical conditions present? Yes No

details below:

(a)

since ______/_____/_____

(b)

since / /

14. Was the patient pregnant at the time of hospitalization? (For Female Only) Yes No
months

15. (a) If hospitalization was due to injury, please describe circumstances and cause of injury:

(b) Please indicate date/time of accident: (dd/mm/yy) / / (hrs) am / pm

16. I hereby certify that I have personally examined and treated the Patient for his/her injuries/illness
described above and that the facts as stated above represent my medical opinion of his/her condition.

Name & Signature of Attending Doctor Doctor / Hospital Stamp

DR’s Contact no and Email addresss:

Tarikh/Date :
DISCHARGE SECTION (To Be Completed Upon Discharge by Doctor)

17. Undertaking Letter Ref No:( If available )

18. Date of Discharge:

19. (a) Final Diagnosis:

(b) Cause and pathology of the diagnosis:

ICD code:

20. Treatment given / Investigation done: ( Please supply copy of all investigation results ).

21. (a) Surgical procedures performed:

(b) Date of surgery / procedure:

MMA code / PHFSR code:

22. (a) Recovery complication that arose (if any):

(b) In the case of DEATH, please advise Date/ Time and Cause of death :

23. I hereby certify that I have personally examined and treated the Patient for his/her injuries/illness
described above and that the facts as stated above represent my medical opinion of his/her condition.

Name & Signature of Attending Doctor Doctor / Hospital Stamp

Tarikh/Date :
Zurich General Takaful Malaysia Berhad (1260157-U)
11th Floor, Menara Zurich, No.12, Jalan Dewan Bahasa,
50460, Kuala Lumpur, Malaysia
Tel: 03-2146 8000 Fax: 03-2144 0352
www.zurich.com.my
Borang Pra-kebenaran
Pre-Authorisation Form
Private and Confidential / Sulit dan Persendirian

Bahagian 1 (Untuk diisi oleh Pesakit / Penuntut)

Part 1 (To be completed by Patient / Claimant)

JOANNA JOSEPH
DIISI OLEH PESAKIT
1. Nama Pesakit / Patient Name: / PENUNTUT
880917-43-6897
2. K.P. (Lama & Baru) / NRIC (Old & New):
17.09.1988
3. (a) Tarikh lahir / Date of Birth:

(b) Umur / Age: 30

(c) Jantina / Sex: FEMALE

4. No. Polisi / No. Ahli / No. Sijil / Pelan / Nama Syarikat

Policy No. / Member ID / Certificate No / Plan / Company Name:
TIDAK PERLU DIISI

5. Tarikh kemasukan hospital: 23/04/2018

Admission / Planned Admission Date:

6. Nama Hospital
CURE & CARE MEDICAL CENTRE
Hospital Name:

7. Nama Doktor yang merawat/ Kepakaran:

DR STEVEN LAU/ CONSULTANT PHYSICIAN
Name of Attending Doctor / Speciality:

Sila tanda ( X ) dan jawab soalan yang berkenaan

Admission Reason ( X ) and answer accordingly

8. Kemalangan / Accident

(a) Berlaku pada Tarikh Masa pagi / petang

20/04/2018 6AM
Occurred on: Date _________________________ Time _________ am / pm

(b) Butir-butir kemalangan

Details of Accident MOTOR VEHICLE ACCIDENT

9. Penyakit / Illness

(a) Tarikh simptom tersebut bermula: Tarikh 20/04/2018

Symptoms first appeared on: Date

(b) Doktor-doktor yang dilawati bagi penyakit ini

DR SITI,KLINIK FA'IE
Doctor(s) consulted for this condition

(c) Alamat & Telefon Doktor

Doctor’s or Clinic Contact(Address & Telephone) 0333249091

NOTA: MELENGKAPKAN BORANG PERMINTAAN INI TIDAK SEMESTINYA MENJAMIN BAHAWA SURAT JAMINAN AKAN
DIKELUARKAN.
NOTE: COMPLETION OF THIS PRE AUTHORISATION FORM DOES NOT GUARANTEE THE ISSUANCE OF GUARANTEE LETTER.

ZT0008/1/P/G/S/M
Pengisytiharan dan pemberikuasa / Declaration and authorization

Saya mengisytiharkan bahawa jawapan yang diberikan di atas adalah benar dan lengkap setakat pengetahuan dan kepercayaan
saya.

Saya memahami bahawa penyerahan borang ini, tidak sama sekali boleh dianggap sebagai pengakuan liabiliti Zurich Takaful
Malaysia Berhad ini ke atas tuntutan saya/Assured dan saya bersetuju bahawa bayaran kepada hospital oleh Zurich Takaful
Malaysia Berhad atau wakilnya tidak akan ditafsirkan sebagai pengakuan muktamad liabiliti Zurich Takaful Malaysia Berhad dan
Zurich Takaful Insurance Malaysia Berhad berhak menjalankan penilaian sewajarnya berhubung tuntutan ini atau apa-apa
tuntutan yang timbul selanjutnya.

Saya memahami sepenuhnya had-had insurans perubatan saya di bawah Polisi yang tersebut di atas. Saya dengan ini berjanji
akan menyelesaikan sebarang amaun yang melebihi had kelayakan saya, yang tidak dilindungi oleh insurans berkenaan.

Saya yang bertandatangan di bawah, dengan ini membenarkan pada setiap masa, mana-mana organisasi, institusi atau individu
yang mempunyai apa-apa rekod atau pengetahuan tentang kesihatan dan latar belakang atau rawatan atau nasihat perubatan
saya/Assured/Insured, yang telah atau mungkin kemudian dari ini dirujuk untuk mendedahkan kepada Zurich Takaful Malaysia
Berhad atau wakilnya segala maklumat tersebut. Saya bersetuju membenarkan Zurich Takaful Malaysia Berhad atau wakilnya
untuk mengguna dan mendedahkan apa-apa maklumat yang dikumpul atau dipegang kepada pihak ketiga (di dalam atau di luar
Malaysia, termasuk syarikat induk, anak syarikat atau syarikat berkait dalam Zurich Takaful Malaysia Berhad, reinsurer, pemeriksa
perubatan, penyiasat tuntutan dan pertubuhan/persekutuan industri dan lain-lain.) berkaitan dengan tuntutan ini. Pengesahan ini
hendaklah mengikat waris-waris dan penama saya/Assured/insured dan kekal sah meskipun setelah kematian saya/Assured/
insured setakat yang dibenarkan di sisi undang-undang. Salinan pengesahan ini adalah sah. Saya bersetuju sekiranya saya
membuat pengakuan palsu atau tidak mendedahkan maklumat yang berkaitan, Zurich Takaful Malaysia Berhad berhak
membatalkan tuntutan saya dan menarik balik sebarang tuntutan awal yang telah dibayar.

I declare that the answers given above are true and complete to the best of my knowledge and belief.

I understand the delivery of this form is in no way an admission of Zurich Takaful Malaysia Berhad’s liability and payment to the
hospital by Zurich Takaful Malaysia Berhad or its representative shall not be construed as final admission of Zurich Takaful
Malaysia Berhad’s liability and for this and any further claims arising, Zurich Takaful Malaysia Berhad reserves all rights for
evaluation as appropriate.

I am fully aware of the limits as to my/Assured medical insurance under the above-mentioned policy. I hereby undertake to settle/
reimburse any medical expenses exceeding my entitlement under the said policy contract, or that is not covered by the same.

I hereby irrevocably authorize any organisation, institution, or individual that has any record or knowledge of my health and
medical history or treatment or advice that has been or may hereafter be consulted, other personal information or details of
related accident/injury, to disclose to Zurich Takaful Malaysia Berhad or its representative such information. I agree that Zurich
Takaful Malaysia Berhad or its representative may use or disclose any of the information collected or held to third parties (within
or outside Malaysia, including Zurich Takaful Malaysia Berhad’s parent company, subsidiaries or any other associated companies
within Zurich Takaful Malaysia Berhad’s Group, reinsurers, medical examiners, claims investigators and industry associations/
federations etc.) in relation to this claim. This authorization shall bind my/the Assured’s/Insured’s successors and assigns and
remain valid notwithstanding my/Assured’s/Insured’s incapacity in so far as legally possible. A photocopy of this authorization
shall be valid as the original. I agree that in the event I make, or have in the past made, any false or untrue statement
and/or suppressed and/or concealed any material facts in respect of my/the insured’s condition, Zurich Takaful Malaysia
Berhad shall absolutely forfeit my/the Insured’s/Assured’s right to compensation and further reserves the right to recover any
amounts paid earlier as a result thereof.

DIISI OLEH PESAKIT

/ PENUNTUT
Tandatangan Pesakit / Signature of Patient Nama Penuh/Full Name:
JOANNA JOSEPH

No K/P. / I/C No.: 880917-43-6897

No Telefon/Contact No: 016-3198675

Tarikh/Date: 25/05/2018 Email Address: joannajoseph@hotmail.my

Tandatangan Pemilik Polisi /Penuntut /Signature of Assured/ Nama Penuh/Full Name: KESHAV RAO A/L MAHENDRAN
Claimant
860716-43-5639
No K/P. / I/C No.:
016-5054075
No Telefon/Contact No:

Tarikh/Date: 25/05/2018 Hubungan dengan Pesakit

Relationship to Patient: SPOUSE
Tandatangan Saksi / Signature of Witness
Nama Penuh/Full Name: SURI JOSEPH
WAJIB DIISI OLEH
SESIAPA SELAIN No K/P. / I/C No.: 870112-10-6798
PESAKIT & PEMEGANG 012-3130975
Tarikh/Date: 25/05/2018 No Telefon/Contact No:
POLISI

Part 2 ADMISSION SECTION ( To be completed upon admission by Doctor ) DIISI OLEH

JOANNA JOSEPH DOKTOR YANG
1. (a) Patient name:
MERAWAT
880917-43-6897
(b) NRIC (Old & New):
30
(c) Age:

(d) Sex: Male Female

2. Policy No. / Member ID/ Certificate No/ Plan/ Company Name:

3. Admission No. / MRN and Hospital Name/ Hospital Contact and Fax No: 75025/CURE&CARE MEDICAL
CENTRE/ 03-33183000/FAX:03-33182500

4. Admission Date and Time: 23/04/2018

3 DAYS / 26/04/2018
5. Expected days of stay / Discharge Date:

FEVER,LETHARGY,MUSCLE SPASM
6. (a) Symptoms / Conditions requiring admission:

(b) How long is patient aware of the condition: 4 DAYS

120/80,38 DEGREE CELSIUS,80 BPM

(c) Patient’s BP / Temp / Pulse:

(d) Date symptoms first appeared: 20/04/2018

23/04/2018
(e) Date first consulted:

7. (a) Any previous consultation / treatment / hospitalization for this symptom / illness or related Yes No
conditions, or other disorders whether in this hospital or any other facilities?

(b) Was this patient referred? If Yes, please provide details below:
YES,REFERRED FROM KLINIK FA'IE

(c) If this condition existed before symptoms became apparent to the patient, please indicate in your
professional opinion how long has the condition existed:
Date 20/04/2018
Disease / Disorder VIRAL FEVER
Details of Treatment / Hospitalization OUTPATIENT TREATMENT IN KLINIK FA'IE
Doctor / Hospital/ Clinic DR SITI,KLINIK FA'IE

(d)Can the condition be managed under the Outpatient basis: Yes No

If no please provide reasons of admission:
8. (a) Admitting Diagnosis: (c) Diagnosis confirmed on 23/04/2018
or Advised patient on 23/04/2018
(b) Provisional Diagnosis: VIRAL FEVER

(d) Cause and pathology underlying the present diagnosis:

(e) Any possibility of relapse? Yes No

9. Estimated Total Costs : RM 4000

10. Admission requires: Hospitalisation Day Care On Patient’s Request

11. Is the illness / condition related to: (please tick (X) if YES). Please provide details:
(a) Pregnancy / Childbirth / Infertility / Caesarean section / miscarriage
Or any complications arising therefrom.
(b) Congenital / Hereditary diseases
(c) Influence of Drugs / Alcohol
(d) Nervous / Mental / Emotional / Sleeping Disorder
(e) Cosmetic reason / Dental care / refractive errors correction
(f) AIDS / STD / VD / HIV
(g) Self-inflicted injuries / Violation of laws / Strike / Riots
(h) None of the above

12. Medical treatment, Investigations and Surgical procedure to be performed, if any (please supply copy of all investigation
results):
IV FLUIDS,IV ANALGESICS,PCM,ANTIHISTAMINE,FBC,DENGUE SEROLOGY,BUSE,CRP

13. Any other medical/surgical conditions present? Yes No

details below:

(a) HYPERTENSION

since ______/_____/_____

(b)

since / /

14. Was the patient pregnant at the time of hospitalization? (For Female Only) Yes No
months

15. (a) If hospitalization was due to injury, please describe circumstances and cause of injury: DIISI OLEH
MOTOR VEHICLE ACCIDENT DOKTOR YANG
MERAWAT
*UNTUK KES
KEMALANGAN
(b) Please indicate date/time of accident: (dd/mm/yy) 20 / 04 / 2018 (hrs) am / pm
SAHAJA*
16. I hereby certify that I have personally examined and treated the Patient for his/her injuries/illness
described above and that the facts as stated above represent my medical opinion of his/her condition.

Name & Signature of Attending Doctor Doctor / Hospital Stamp

DR’s Contact no and Email addresss:
DR STEVEN LAU
CONSULTANT PHYSICIAN
CURE & CARE MEDICAL CENTRE

012-3456789

26/05/2018
stevelau@gmail.com Tarikh/Date :
DISCHARGE SECTION (To Be Completed Upon Discharge by Doctor)

17. Undertaking Letter Ref No:( If available )

18. Date of Discharge: 26/04/2018

19. (a) Final Diagnosis: ARTHROPOD-BORNE DISEASE

(b) Cause and pathology of the diagnosis: ARTHROPOD-BORNE DISEASE

A90
ICD code:

20. Treatment given / Investigation done: ( Please supply copy of all investigation results ).
IV FLUIDS,PCM,FBC,DENGUE SEROLOGY,NS1,CRP

21. (a) Surgical procedures performed: NIL

(b) Date of surgery / procedure: N/A

MMA code / PHFSR code:

22. (a) Recovery complication that arose (if any): NIL

(b) In the case of DEATH, please advise Date/ Time and Cause of death : N/A

23. I hereby certify that I have personally examined and treated the Patient for his/her injuries/illness
described above and that the facts as stated above represent my medical opinion of his/her condition.

Name & Signature of Attending Doctor Doctor / Hospital Stamp DITANDATANGANI

DR STEVEN LAU OLEH DOKTOR
CONSULTANT PHYSICIAN
CURE & CARE MEDICAL CENTRE
DR STEVEN LAU
CONSULTANT PHYSICIAN
Tarikh/Date :
26/05/2018
Zurich General Takaful Malaysia Berhad (1260157-U)
11th Floor, Menara Zurich, No.12, Jalan Dewan Bahasa,
50460, Kuala Lumpur, Malaysia
Tel: 03-2146 8000 Fax: 03-2144 0352
www.zurich.com.my
E-Payment Registration Form
New Registration Change of Details

Part I. Beneficiary Details

Name of Applicant/ Company

NRIC No. / Co. Registration No.

Address

Telephone No. Fax No.

Person In-Charge Name 1. 2.

Email Address 1. 2.

Telephone No. 1. 2.

Part II. * Beneficiary Banking Details

Name of Bank

Bank Address

Bank Account No. SWIFT Code

IBAN Code (If applicable)

Part III. Declaration

I/We hereby request that payment(s) due and payable to me/us by Zurich General Takaful Malaysia Berhad be paid to my/our bank
account stated above by way of Inter-bank Giro/RENTAS/TT and confirm that :-
1. I/We consent to Zurich General Takaful Malaysia Berhad releasing the above data to its banker(s). In order to facilitate payment(s)
to me/ us by way of Inter-bank Giro/RENTAS/TT.
2. All information provided herein are correct and accurate.
3. My/Our request herein shall be irrecoverable without the consent of Zurich General Takaful Malaysia Berhad. Zurich General
Takaful Malaysia Berhad may at any time in its absolute discretion effect payment(s) to me/us by other mode(s).
4. I/We shall keep Zurich General Takaful Malaysia Berhad and its banker(s) indemnified against any loss and/or damage
howsoever arising from any matters in relation to Inter-bank Giro/RENTAS/TT requested by me/us herein including but not limited
to error/misdescription in information furnished, delayed payment(s) and any other circumstances beyond Zurich General
Takaful Malaysia Berhad and its banker(s)’s control.
Authorised Signatory (ies) Company Stamp
Name Date
Designation

Part IV. ZurichGeneral Takaful Malaysia Berhad Office Use Only

Department/Branch

Profile Agent Workshop Adjuster Vendor Others, please specify

Agent/Workshop/Adjuster/Vendor Code

Entered by Date

Verified by Date

* Important :
1. This facility allows payment to be credited into the above mentioned account only.
2. Please attach (i) copy of NRIC or Passport or Business Registration Form whichever is applicable and (ii) 1st page of (a) your bank
statement; or (b) your bank saving book showing the account name and account number; or (c) details of your bank account
obtained from your bank’s website that has been certified by your bank; or (d) letter from your bank confirming your bank
account details.

Zurich General Takaful Malaysia Berhad (1260157-U)

11th Floor, Menara Zurich, No.12, Jalan Dewan Bahasa,
50460 Kuala Lumpur, Malaysia
Tel: 03-2146 8000 Fax: 03-2144 0352
www.zurich.com.my
E-Payment Registration Form
New Registration Change of Details
*WAJIB DIISI UNTUK
Part I. Beneficiary Details
KESHAV RAO A/L MAHENDRAN
MENERIMA PENYATA
Name of Applicant/ Company
BAYARAN

NRIC No. / Co. Registration No. 860716-43-5639

NO 45,JALAN MENTARI,TAMAN PALMGROVE

Address
43120 KLANG SELANGOR

Telephone No. 016-5054075 Fax No. NIL

Person In-Charge Name 1. *TIDAK PERLU DIISI 2. *TIDAK PERLU DIISI

Email Address 1. keshavrao23@hotmail.my 2.

012-3130975
Telephone No. 1. 2.

Part II. * Beneficiary Banking Details

Name of Bank OBC BANK

OBC BANK,17 JALAN STESEN,KAW 5,41250 KLANG

Bank Address

501123956001 *TIDAK PERLU DIISI

Bank Account No. SWIFT Code

IBAN Code (If applicable)

Part III. Declaration

I/We hereby request that payment(s) due and payable to me/us by Zurich General Takaful Malaysia Berhad be paid to my/our bank
account stated above by way of Inter-bank Giro/RENTAS/TT and confirm that :-
1. I/We consent to Zurich General Takaful Malaysia Berhad releasing the above data to its banker(s). In order to facilitate payment(s)
to me/ us by way of Inter-bank Giro/RENTAS/TT.
2. All information provided herein are correct and accurate.
3. My/Our request herein shall be irrecoverable without the consent of Zurich General Takaful Malaysia Berhad. Zurich General
Takaful Malaysia Berhad may at any time in its absolute discretion effect payment(s) to me/us by other mode(s).
4. I/We shall keep Zurich General Takaful Malaysia Berhad and its banker(s) indemnified against any loss and/or damage
howsoever arising from any matters in relation to Inter-bank Giro/RENTAS/TT requested by me/us herein including but not limited
to error/misdescription in information furnished, delayed payment(s) and any other circumstances beyond Zurich General
Takaful Malaysia Berhad and its banker(s)’s control.
 *TIDAK PERLU DIISI
Authorised Signatory (ies) Company Stamp
Name KESHAV RAO A/L MAHENDRAN Date *TIDAK PERLU DIISI

Designation POLICY HOLDER

Part IV. ZurichGeneral Takaful Malaysia Berhad Office Use Only

Department/Branch

Profile Agent Workshop Adjuster Vendor Others, please specify

Agent/Workshop/Adjuster/Vendor Code

Entered by Date

Verified by Date

* Important :
1. This facility allows payment to be credited into the above mentioned account only.
2. Please attach (i) copy of NRIC or Passport or Business Registration Form whichever is applicable and (ii) 1st page of (a) your bank
statement; or (b) your bank saving book showing the account name and account number; or (c) details of your bank account
obtained from your bank’s website that has been certified by your bank; or (d) letter from your bank confirming your bank
account details.

Zurich General Takaful Malaysia Berhad (1260157-U)

11th Floor, Menara Zurich, No.12, Jalan Dewan Bahasa,
50460 Kuala Lumpur, Malaysia
Tel: 03-2146 8000 Fax: 03-2144 0352
www.zurich.com.my
 Ca r a Pengisia n Bo ran g Tu n tu tan & E-Pemb ayaran

Sila posk a n bo ran g yan g len g kap ke alamat:

CUEPACSCARE4 U SO LU T ION S SDN BH D

B-5-3A, Pusa t Perd ag an g an In tan ia,
J a la n I nt a n 1/KS1 , Persiaran Raja Mu d a Mu sa,
41200 Kla ng, Selan g o r d aru l Eh san

Si la s e r t a k a n d ok um en ya ng lengkap :

1) B o r a n g Tu n tuta n & E -Pembaya ran yan g len g kap

2) S a l i n a n ka d pengena la n pemegan g p o lisi d an salin an kad p en g en alan p e nunt ut
3) R e s i t a s a l / bil ter per inci
4) S a l i n a n p e nya ta ba nk a ta u muka d ep an b u ku b an k
5) L a p o r a n d o ktor