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FULL NAME of assured/insured

Home/Office Address

Mailing Address

Contact Information

INSURANCE POLICY INFORMATION

TYPES OF CLAIM

CHECKLIST OF REQUIRED CLAIM DOCUMENTS

Please tick on the documents that you may have already submitted to Malayan Insurance.


BASIC DOCUMENTS *



FOR HOSPITALIZATION / MEDICAL REIMBURSEMENT / DISMEMBERMENT / DISABLEMENT CLAIMS



FOR FIRE AND CALAMITY ASSISTANCE CLAIMS



FOR MOTORCAR CLAIMS



FOR DEATH CLAIMS

VALID IDs OF CLAIMANT

Narration of events leading to loss

Declaration

I hereby warrant that all personal information and sensitive personal information given by me are true, correct and updated to the best of my knowledge, freely and voluntarily given to Malayan Insurance Company, Inc. (MICO). I agree and consent that above information are being collected, used, processed and recorded for purposes which are relevant and necessary in securing an insurance contract or transacting a business or any activity with MICO. I hereby authorize MICO, its directors, officers, consultants, employees, and duly authorized representatives to keep, store, update, use, access and process the information given to it, and to share, transfer or disclose the information, including this form to the Yuchengco Group of Companies (YGC Companies), their and MICO's affiliates, subsidiaries, contractors, partners, agents and representatives, intermediaries, industry associations , and third parties such as but not limited to outsourced service providers, adjusters, salvage buyers, banks, external auditors, and local and foreign regulatory authorities for purposes of marketing or promotional information campaign, provision of any products, services, or offers through mail/email/fax/SMS/telephone or any type of electronic facility, profiling, research, studies/customer satisfaction surveys, statistical and risk analysis, tax monitoring, review, and reporting, compliance with court and other lawful order and requirements, with Anti-Money Laundering Act, Credit Information System Act, and all other regulatory laws, and all other activities consistent with the provisions of the Data Privacy Act and subject to appropriate security safeguards. If purchasing, transacting and/or acting in behalf of other person(s), I hereby warrant that I am duly authorized to perform such acts and that I am duly allowed to give their information to MICO. I hereby bind myself to advise all other persons in whose behalf I have acted, transacted with and/or purchased any product from MICO of all the terms and conditions herein. I also authorize MICO and the YGC Companies to verify and investigate the information given by me, including submitted documents from whatever source it may consider appropriate. I have the right to access the given information, and I undertake to correct, rectify or supplement information should any information be found to be inaccurate or incomplete. I shall notify MICO in writing of any changes in the information given above. I will hold MICO free and harmless from any liability that may arise as a result of the authorization given above.

Agreement

Anti-Fraud: Section 251 of the lnsurance Code, as amended, imposes a fine not exceeding twice the amount claimed and/or imprisonment of two (2) years, or both, at the discretion of the court, to any person who presents or causes to be presented any fraudulent claim for the payment of a loss under a contract of insurance, and who fraudulently prepares, makes or subscribes any writing with intent to present or use the same, or to allow it to be presented in support of any claim.
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