TOTAL & PERMANENT DISABILITY CLAIM FORM

For Maybank use only. Compulsory to fill up for RTA / RTT or application will be incomplete.

Loan Type: ASB Mortgage / Others

Loan Status: Full Settlement Outstanding

Full Settlement Date:

SECTION A

Every question must be fully answered. The Company reserves the right to require further information should it deem necessary. Submission of
this Claim Form does not guarantee admission of liability.

Policy No: _________________

Agent's name & code: __________________________________________________ Agent’s Contact No.: _____________________________

Instruction – Supporting documents required

 Total and Permanent Disability Claim form
 Total & Permanent Disability Statement of Medical Examiner (latest condition after 6 months from the first date of disability occurred)
 Certified copy of Participant and/or Claimant's IC
 Medical Boarded Out / Employment Termination Letter from Participant's employer (if employed)
 Certified copy of clinic / hospital consultation card
 PERKESO / SOCSO report and Approval Letter (if any)
 Other supporting documents (if applicable)

Life Assured’s Details

Name of Life Assured: …………………………………………………………………………….………………………………….…………………….…….
New IC No.: …………………………………………………………… Old IC No.: ………………………………. Age: …………………….……………..
Correspondence Address: …………….……………………………………………….…………………………………………………………………..…….
…………….………………………………….…………………………………………………….…………………………….….
Mobile Phone No.: ……………………………………………….………… E-mail address: ……………………..….………………………………………
House Phone No.: ……………………………..… Office Phone No.: …………………………………. Fax No.: ……………………….……..…………
Highest education level:  Primary  Secondary  Diploma  Bachelor Degree  Master  PhD
Please list the jobs held in the past 3 years (Begin with the most recent jobs):
Dates (dd/mm/yyyy) Average Monthly
Job Title & Employer’s Address Exact Duties
(From – To) Income (RM)

Claimant’s Details (If other than Life Assured)

Name of Claimant: …………………………………………………………………………………………………………….…………………………….…….

New IC No.: …………………………………………………………… Old IC No.: ………………………………. Age: …………………….……………..
Correspondence Address: ……………………………….…………………………….…………………………………………………………………..…….
…………………………………….………….…………………………………………………….…………………………….….
Mobile Phone No.: ……………………………………………….………… E-mail address: ……………………..……………….…………………………
House Phone No.: ……………………………..… Office Phone No.: …………………………………. Fax No.: …………………………..…..…………

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Please state bank account details in order for us to credit the payment directly into Claimant’s bank account.
Account Bank: ………………………………………… Branch: ……………………….. Account No.: ……………………….…………………………..
Account Holder's Name: ………………………….………………………………………………………………………..…………….................................
NRIC (as per bank account): ………………………...…………………………………………………………………………………..……………………..
Type of account : Individual Joint
Company Registration No. (If payment to company): ………………………………………………………………………………………………………..

Employment Details Prior to Disability

1. Type of Employment:  Full-time  Part-time  Self-employed (details: ………………………….………………….……)
 Unemployed *if unemployed, please continue to “Details of Disability” section.
2. Name of Employer prior to onset of disability: ……………………………...…………………………….……………………….………………
3. Address of Employer prior to onset of disability: …………………………………………………………………………….……………………
............................................................................................................................. Office Phone No.: …………………………………………
4. Period of Employment: From: ………..…………… (dd/mm/yyyy) To: ………..…………… (dd/mm/yyyy)
5. Job Title / Position prior to onset of disability: ………………………………………………………….……………………………………………….
6. Please indicate your working environment:  Factory  Office  Outdoors  Others (details: ………..………..…...)
7. Type of industry: ………………………………………………………………………………………………………………………………………
8. Please indicate your exact duties / activities and time allocation for each activity prior to the onset of disability:
Type of Activities / Duties Time Allocated For Each
(Administrative, standing for long hours, driving, labour work, operating machineries etc.) Activity (hours / day)

9. Are you in management or supervisory capacity?  Yes  No

If yes, please provide details:
………………………………………………………………………………………………………………………………………….………………..
10. Do you operate any machine or special equipment?  Yes  No
If yes, please indicate the type of machine / equipment used
……………………………………………………………………….………………………………………………………………………………….
11. What is the qualification needed for the job?
…………………………………………………………………………………………………….…………………………………………………….
12. Does your job requires any special skills / knowledge?  Yes  No
If yes, please provide details:
……………………………………………………………………….…………………………………………………………………………………..
13. What is your normal working hours and days?
…………………………………………………………………………….……………………………….…………………………………………….
14. Are you required to work on shift, weekends, public holidays or on-call basis?  Yes  No
If yes, please provide details:
……………………………………………………………….…………………………………………………………………………………………..
15. Does your job requires travelling?  Yes  No
If yes, please state how many KM/week: …………………………. KM/week OR  Others (details: ………………....……………..)
16. Please state your last working date: …………………….…………………………………………………………………… (dd/mm/yyyy)

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17. Have you been advised to change your job scope to suit your disability?  Yes  No
If yes, please give details ………………………………..……………………………………………………………………………………………
Please provide the effective date of your new job scope: ………………………. (dd/mm/yyyy)
18. What aspects of your disability prevent you from performing the following:
a) Your own occupation
Details …………………………………………………………………………………………………………………………………….……..
b) Any other occupation
Details ………………………………………….……………………..…………………………………………………………………………
19. Please state the date you are expected to resume your work and daily activities: …………………….…………….……..…. (dd/mm/yyyy)
20. Are you currently engaged in duties of any occupation or endeavor for wages, profit, compensation or volunteerism?
 Yes  No
If yes, please provide details: …………………….……………………………………..…………………………………………………………..
21. Do you intend to seek another employment?  Yes  No
If yes, please state the nature of work
………………………………………………….………………………………………………………………………………………………………..
If no, please provide reason
………………………………………………………………………………..………………………………………………………………………….
22. Please provide your medical boarded out date / employment termination date: …………………………………………..…(dd/mm/yyyy)

Details of Disability
1. Condition/Disability due to Accident
(a) Please provide details of the accident:
Date: …………………… (dd/mm/yyyy) Time: ……….. (AM / PM) Place: ………………….…………………………………..
(b) Please describe what were you doing at the time of Accident?
……………………………………………………………………………………………………………………………………………………..
(c) Please describe in detail how did the Accident happened
……………………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………...……………
2. Condition/Disability due to Illness
(a) Please fully describe the symptoms for which you consulted a medical practitioner.
……………………………………………………………………………………………………………………………………………………
(b) When did you first had the symptoms? …………………………………………………………………………….. (dd/mm/yyyy)
(c) When did you first consulted a doctor for this condition? ………………………………………………………… (dd/mm/yyyy)
(d) Please provide the name & address of the doctor you first consulted for this condition:
Name: ………………………………………………………………………………..………………………………………………………….
Address of Hospital / Clinic: ………………………………………………………..…………………………………………………………
(e) What was the diagnosis? ……....………………………………………..…………………..………………………………………………..
(f) What treatments are you currently receiving?
………………………………………………………………………………………………………….…………………………………………
(g) Have you previously suffered from, or received treatment for a similar or related illness?  Yes  No
If yes, please provide details:
Date of consultation Name of doctor Hospitals / Clinics
(dd/mm/yyyy)
(dd/mm/yyyy)

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(h) Please provide the name and address of your regular treating doctor.

Common illnesses (i.e fever, flu, cough) Related to the above disability

Doctor’s Name

Clinic / Hospital
Address

(i) Are you receiving any income from other sources?  Yes  No
If yes, please provide details: ….………………………………………….…………………………………………………………………..
(j) Please indicate whether you are left or right handed:  Right handed  Left handed

Are there other policies in force on your life taken with other insurers / takaful operators?  Yes  No
If yes, please provide details:

Name of Policy / Certificate Date Policy / Certificate Plan / Type of Amount of Benefit
Company(s) (dd/mm/yyyy) No Coverage (RM)

(dd/mm/yyyy)

CLAIMANT’S DECLARATION & AUTHORISATION

I hereby declare that the foregoing answers and statements in this claim form are complete and true to the best of my knowledge and belief, and
that I have withheld no material facts from the Company.

And I hereby authorize any medical practitioner, surgeon person, hospital, clinic and any other institution or organization to furnish to Etiqa Life
Insurance Berhad or its representative any information that maybe required concerning my health conditions, for settlement of this claim. I agree
that Etiqa Life Insurance 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 claim. I agree that
a photocopy of this authorization shall be considered as effective and valid as original.

………………………………………………………...… ……..………..…………………………………………………………….
Signature / Thumb print of Life Assured Signature / Thumb print of Claimant (if other than Life Assured)

Name: ……………………………………………..…… Name: ………………………………………………………….

Date: ………………………………….… (dd/mm/yyyy) Date: …………………………………………. (dd/mm/yyyy)
Contact No.: ……………………………………………………
Designation & official stamp is required for Company or Bank:

………………………………………………..………….
Signature of Witness

Name: ………………………………………………………….
NRIC: ………………………………………………………….
Date: …………………………………………. (dd/mm/yyyy)
Contact No.: ……………………………………………………

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LETTER OF AUTHORISATION / CONSENT

To Obtain Further Medical information

To Whom It May Concern,

Name of Life Assured: …………………………………………………………………………………………………………………….……

NRIC No.: ……………………………………………………………… (New) …………………………………………………………….. (Old)

Policy No.: ……………………………………………………………...

I, ………………………………………………………………………..., NRIC No. …………………………………………… hereby authorize and give my

consent to any medical practitioner, physician, surgeon, nurse, medical staff, clinic, hospital, medical centre, insurance company or organization or
individual concerned (“the information provider”) that may have any record or knowledge of health or medical history of the above stated (“Life
Assured”) and to provide such information to Etiqa Life Insurance Berhad and its authorized service provider and/or its employees in order to
process my Takaful claim.

I, agree, consent and allow Etiqa Life Insurance Berhad (hereinafter called “Etiqa Life Insurance”) 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 expressly waived all provisions of law or professional ethics forbidding the Information Provider(s) from disclosing any such information acquired
on myself in a professional and/or client capacity and I further release the Information Provider(s) and its agent/staff from any liability whatsoever
that may arise, in supplying such information requested by the Company.

This authorization/consent is irrevocable and a copy of it will have the same effect and validity as the original.

…………………………………………………………………………………………………….
Signature / Thumb print of Life Assured / Claimant (if Life Assured is a minor)

Name: ………………………………………………..……………………………..……………

NRIC: …………………………………………………………………………………………….

Old I/C: …………………………………………………………………………………………..

Birth Cert No (if minor): ………………………………………………………………………...

Relationship with Life Assured: ………………………………………………..………………

Contact No.: …………………………………………………………………………….……….

Date: ……………………………………………………………………….…….. (dd/mm/yyyy)

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WHY YOU SHOULD CHOOSE TO RECEIVE PAYMENTS VIA DIRECT DEPOSIT INTO A BANK ACCOUNT
(E-PAYMENT / AUTO-CREDIT)?

No Question Answer
1 Why should I choose to  Faster: funds are available once the payment has been processed by the
receive funds via e- bank.
payment / auto-credit?  Convenient: removes the need to travel and deposit the cheque at the bank
as payments are credited directly into your bank account.
 Safer: misplaced, lost, fraud or expired cheques will no longer be an issue.
 Environmental friendly: printing, posting and banking in of the cheque will
no longer require.
2 Will there be any No, you can enjoy the service free of charges.
registration fee?
3 What do I have to do to You must provide your bank’s saving / current account number together with the
receive funds via e- bank’s name in the proposal/claim/benefit/surrender form during the application.
payment / auto-credit?
Alternatively, you can also provide your bank saving / current account no with the
bank’s name, latest address, mobile phone no and email address for future Benefit
payment via submission of `Request For Change Form’.
Note: The completed form and necessary documents must be submitted together with
the required supporting documents to the nearest Etiqa Branch.
4 What are the required The following documents are required for verification :
supporting documents?  A copy of your IC or passport, ;&
 A copy of the bank statement / bank account passbook / details of your
account printed from your bank’s website.
5 Is there any restriction on You can provide any of your existing active saving / current account held under your
the type of bank account name or in the case of a joint account that has your name as one of the
that can be assigned for e- accountholders. The saving or current account must be maintained with one of the
payment / auto-credit? financial institutions offering MEPS Inter-Bank GIRO (IBG) service. You may refer to
the following website for current list of IBG members
http://www.meps.com.my/faq/interbank-giro.
6 Can I change my bank Yes, you are allowed to change your bank account details by submitting the Request
account information? For Change form with the required supporting documents substantiating your request
to Etiqa. No cost will be charged for this purpose.
7. When will the funds be Payment will be made electronically into your bank account by Etiqa within 5 working
credited to my bank days once your payment has been approved.
account?
8. Will I be notified once the Yes, a notification letter will be sent to you once your payment has been approved.
Company has made the You are encouraged to provide your email address/mobile phone number as Etiqa is
payment? currently developing the electronic notification via email / SMS.
9. How will my bank account Your bank account details and other related information:
information be used and  Will be used solely for the purpose of enabling payments to be credited
will it remain confidential? directly into your bank saving / current account; and
 Is protected under the Financial Services Act 2013 that strictly prohibits the
disclosure of such information to any person unless customer or his personal
representative has given written permission.
10 What will happen to funds If funds cannot be credited into your bank account due to for example, incorrect bank
that cannot be credited into account number, closed or inactive bank account, I/C no unmatched, the cheque will
my bank account? be issued and posted to you. However, this may lead to unnecessary delay to the
payment process. To avoid this issue, please ensure that your bank account is correct
and active upon providing such information to Etiqa.
11. Do I need to provide bank If you want all your payments to be paid to the same bank account, you need to
account information indicate so to Etiqa at the point of submitting your form.
separately for each of my
certificate if I have more
than one certificate?

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