General Insurance Online Claim Form
Borang Tuntutan Insurans Am Online
Name
/
Nama
:
*
NRIC No.
/
NO. K/P Baru
:
*
(
eg/
cth:
800808-14-1234
)
Old IC No.
/
NO. K/P Lama
:
Passport No. (For Non Resident Only)
/
No. Pasport (Untuk Bukan Warganegara Sahaja)
:
Tel No.
/
No. Tel
(
House
/
Rumah
)
:
*
(
eg/
cth:
0322973888
)
(
Office
/
Pejabat
)
:
(
eg/
cth:
0327859698
)
(
Mobile
/
Bimbit
)
:
(
eg/
cth:
0122022333
)
Vehicle No. (if applicable)
/
No. Kenderaan (Jika Berkenaan)
:
Date of Loss/Accident
/
Tarikh Kerugian/Kemalangan
(
eg/
cth:
dd/mm/yyyy
)
Desciption of Loss/Accident
/
Butir-butir Kerugian/Kemalangan
Kindly attach the supporting documents for this claim (if any)
/
Sila lampirkan dokumen-dokumen sokongan untuk tuntutan ini. (jika ada)
Click to attach documents
/
Klik untuk melampirkan dokumen-dokumen
If you are satisfied with the information you have provided, please click the 'SUBMIT' button and we will have your case processed. You will be contacted by Etiqa if further information is required. Kindly click the 'CLEAR' button if you would like to re-fill the form./
Sekiranya anda berpuashati dengan maklumat yang telah dikemukakan, sila klik butang 'HANTAR' dan kami akan memproses tuntutan anda. Etiqa akan menghubungi anda jika maklumat lanjut diperlukan. Sila klik butang 'PADAM' jika ingin mengisi semula borang ini.