Professional Documents
Culture Documents
CIMB Aviva Takaful
Berhad (689263 - M)
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(formerly known as Commerce Takaful Berhad)
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Level3"-*3#%3+"(,"- 3"+"3,/30
8 338 Jalan Tuanku Abdul Rahman 50100 Kuala Lumpur
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Telephone: (603) 2612 3600 Facsimile: (603) 2698 7035
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Customer Service Line: 1 300 88 5055 Website: www.cimbavi
TAKAFUL HOSPITAL & SURGICAL CLAIM FORM
BORANG TUNTUTAN HOSPITAL DAN PEMBEDAHAN TAKAFUL
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The issuance and acceptance of this Claim Form is not an admission of Liability by the Company and if false statement or declaration be made in support of this clai
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claim shall be null & void.
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Pengeluaran danpenerimaan
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untuk menyokong tuntutan ini, maka tuntutan ini adalah batal dan tidak sah.
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Employment Date / Tarikh Mula Bekerja : "3
NRIC No. / No. Kad Pengenalan :
Postcode / Poskod
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Social Security $#
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Benefits? Faedah-faedah+
Sekuriti Sosial? */< Yes / Ya !8(# * No / Tidak
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Certificate No. / No. Sijil : #/;38.808?/;+1/$,/.'$0+(-#3-& - Perlindungan :
Period of Coverage / Tempoh
DECLARATION / PERAKUAN
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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 a
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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 hospita
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or physician to release any information required in theB">;/A+637+=38787=;/+=6/7=
course of My/Our e xamination on treatment.
Name of Referring Doctor and Address / Nama dan Alamat Doktor Rujukan :
Admitting Doctor / Doktor Kemasukan : Attending Doctors / Doktor-doktor rawatan : Specialty / Keistimewaan :
1b. Cause and Pathology (if applicable) of the above diagnosis / Sebab dan Patologi (jika bersesuaian) untuk diagnosis di atas
2a. When did patient first consult you for this condition?
Tarikh mula mendapat rundingan dengan Pegawai Perubatan untuk k eadaan ini?
2b. Was the patient previously treated for this condition? Yes / Ya No / Tidak
Pernahkah pesakit mendapatkan rawatan bagi keadaan ini?
Please give details and when / Sila nyatakan butiran dan bila
2c. How long in your professional opinion has the condition ex isted?
Sepanjang pengetahuan dan kepercayaan anda berapa lamakah keada an ini wujud?
4a. Please state Nature of Treatment and Investigation / Sila nyatakan Jenis Rawatan dan Siasatan :
OPERATION / PEMBEDAHAN BLOOD TESTS / UJIAN DARAH OTHERS, please give details / LAIN-LAIN, sila nyatakan butiran
I.
II.
III.
4c. Other present medical conditions? / Keadaan perubatan lain yang terkini?
since since since
semenjak semenjak semenjak
5. Was the condition / Adakah keadaan itu Congenital / Kongenital Nervous / Khuatira n Mental / Mental
6. Was the patient pregnant at the time of hospitalisation? (fo r females only)
Yes / Ya No / Tidak months / bulan
Adakah pesakit hamil ketika dimasukkan ke hospital? (untuk per empuan sahaja)
7. If the hospilisation was due to accident, please indicate d ate/time of accident / Jika kemasukkan ke hospital adalah akibat kemalangan, sila nyat akan tarikh/masa kemalanga n
Date / Tarikh
Signature and Name of Attending Doctor / Tandatangan dan Nama Doktor Rawatan Hospital Stamp / Cop Hospital
BASIC DOCUMENTS REQUIRED FOR CLAIMS / DOKUMEN-DOKUMEN YANG DIPERLUKAN UNTUK TUNTUTAN
Non Fatal / Kemalangan Bukan Maut Fatal / Kemalangan Maut
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APPENDIX A