Etiqa

Deceased Detail:Maklumat gemulah:

Full NameNama Penuh * (as on NRIC/ID)(Seperti yang tercatat di Kad Pengenalan)

ID TypeJenis Pegenalan ID*

Date of DeathTarikh Kematian *

Claimant Detail: Maklumat Penuntut:

Full NameNama Penuh * (as on NRIC/ID)(Seperti yang tercatat di Kad Pengenalan)

ID TypeJenis Pegenalan ID *

Mobile NumberNombor Telefon *

Contract Number Nombor Kontrak *

Contract Holder Name Nama Pemegang Kontrak *

Relationship to deceasedHubungan dengan almarhum *

EmailEmel*

Payee Details: Maklumat Penerima Bayaran:

Relationship to Payee *

Bank Name Nama Bank *

Bank Account Number Nombor Akaun Bank *

Waris NRIC No Kad Pengenalan Waris *

Death CertificateSijil Kematian *

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(Please upload the documents in one single file and not more than 5MB.)(Pastikan dokumen dimuatnaik melalui satu file sahaja dan tidak melebihi 5MB.)

Marriage Certificate/Birth CertificateSijil Kematian/Sijil Lahir *

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Copy of Bank Account Book/e-statementSalinan Buku/Penyata e-bank *

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Bank Name (Contract Holder) Nama Bank (Pemegang Kontrak) *

Bank Account (Contract Holder) Nombor Akaun Bank (Pemegang Kontrak) *

Company Registration Number (ROC) Nombor Pendaftaran Syarikat (ROC) *

Death CertificateSijil Kematian *

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(Please upload the documents in one single file and not more than 5MB.Pastikan dokumen dimuatnaik melalui satu file sahaja dan tidak melebihi 5MB.)

Copy of Bank Book/Statement account of payeeSalinan Buku/Penyata e-bank penerima bayaran *

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(Please upload the documents in one single file and not more than 5MB.Pastikan dokumen dimuatnaik melalui satu file sahaja dan tidak melebihi 5MB.)

Death CertificateSijil Kematian *

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(Please upload the documents in one single file and not more than 5MB.Pastikan dokumen dimuatnaik melalui satu file sahaja dan tidak melebihi 5MB.)

RESTRICTIONS TO THE FUNERAL EXPENSE BENEFITTertaluk Kepada Pengecualian Seperti Berikut:

If the covered member commits suicide while sane:Sekiranya Orang Yang Dilindungi membunuh diri ketika siuman:
1. Within one year from the Commencement Date of the Certificate of Takaful, the total contribution paid will be refunded.Dalam masa satu (1) tahun dari tarikh Sijil dikeluarkan,kami akan membayar jumlah sumbangan yang dibayar.
2. After one year from the Commencement date of the Certificate Takaful, 60% of the Sum Covered will be payable.Selepas satu (1) tahun dari tarikh Sijil dikeluarkan,kami akan membayar enam puluh (60%) daripada jumlah asas yang dilindungi.
If the Covered member commits suicide while insane, the full Sum Covered will be payable.Sekiranya Orang yang dilindungi membunuh diri ketika tidak siuman, kami akan membayar penuh jumlah asas yang dilindungi.
On the death of Covered Member, due to natural cause, within 30 days from the Commencement Date or reinstatement date.
This applies only when the person first covered. This restriction shall not be applicable after the first yearof cover.
However, if there is a break of the Cover Period or the Certificate of Takaful is not renewed, this 30 days waiting period will again apply. Kematian Orang yang dilindungi adalah disebabkan oleh factor semulajadi dalam tempoh tiga puluh hari (30) dari Tarikh Sijil berkuatkuasa.
Death must have occurred whilst the Certificate of Takaful of the Covered Member is In-force at the date of death.Kematian berlaku semasa sijil takaful orang yang dilindungi telah tamat tempoh pada tarikh kematian.
On death of the Covered Member, due to natural cause (s), within thirty (30) days from the Commencement Date or reinstatement date. This applies only when the person is first covered. This restriction shall not be applicable after the first year of cover. However, if there is a break in the Cover Period or the Certificate of Takaful is not renewed, this thirty (30) days waiting period will again apply.Sekiranya kematian disebabkan oleh kejadian semulajadi (bukan kemalangan) dalam tempoh 30 hari dari tarikh sijil berkuatkuasa, tiada pembayaran manfaat akan dibuat. Sekatan atas tempoh menunggu 30 hari tidak terpakai selepas tahun pertama perlindungan. Walau bagaimanapun, jika terdapat pemberhentian atau tempoh perlindungan sijil takaful ini tidak diperbaharui, 30 hari tempoh menunggu akan berkuatkuasa semula. Nota: Jika pemegang kontrak adalah majikan, manfaat pembayaran khairat kematian akan dibayar kepada majikan

NOTE:NOTA:

Approval of Funeral Expenses claim does not mean Basic Death Sum Covered is approved automatically.Kelulusan tuntuan Khairat, tidak bererti tuntuan Kematian Asas di luluskan secara automatic.

DECLARATION AND AUTHORISATION

	Please click the checkbox below Sila klik pada kotak deklarasi
	I hereby declare that I am the proper claimant / nominee / administrator / beneficiary for the Takaful benefit of the deceased and further declare as follows:-

I confirm that the information given on this online submission Claim Form is to the best of my knowledge and belief, true in every aspect and that I have withheld no material facts from Etiqa Family Takaful.
I understand and agree that if I have in this or any further declaration in respect of this Claim Form, make any false or fraudulent statement or suppress, conceal or falsely state any material fact whatsoever or provide any insufficient information, Etiqa Family Takaful has the sole discretion to reject this application.
I shall fully cooperate with Etiqa Family Takaful in relation to this claim and I hereby authorize any medical practitioner, surgeon person, hospital, clinic and any other institution or organization to furnish Etiqa Family Takaful Berhad or its representative any information that may be required concerning the deceased health conditions, for settlement of this claim. I agree that Etiqa Family Takaful Berhad or its representative may use or disclose any of the information collected or held to third parties such as reinsurers, medical examiner or medical consultant, claims investigator and etc. within or outside Malaysia for the purpose of processing the claim4. I have read Etiqa Family Takaful Privacy Notice and agree, consent and allow Etiqa Family Takaful Berhad (hereinafter called "Etiqa Family Takaful") to process my personal data (including sensitive personal data) ('Personal Data') with the intention of processing this Claim Form, in compliance with the provisions of the Personal Data Protection Act 2010.
I understand and agree that any Personal Data collected or held by Etiqa Family Takaful contained in this Claim Form may be held, used, processed and disclosed by Etiqa Family Takaful to individuals and/or organizations related to and associated with Etiqa Family Takaful or any selected third party (within or outside Malaysia, including medical institutions, solicitors, industry associations, regulators, statutory bodies and government authorities) for the purpose of processing this Claim Form and providing subsequent service related to it and to communicate with me for such purposes.