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IKHLAS Point, Tower 11A, Avenue 5, Bangsar South,

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TAKAFUL IKHLAS FAMILY BERHAD
Registration No. 200201025412 (593075-U)
IKHLAS Point, Tower 11A, Avenue 5, Bangsar South,
No. 8, Jalan Kerinchi, 59200 Kuala Lumpur
Tel : 03-2723 9999 Fax : 03-2723 9998
IKHLAS Care : 03 2723 9696 Website: www.takaful-ikhlas.com.my
(Licensed under Islamic Financial Services Act 2013 and regulated by Bank Negara Malaysia)
Peringatan / Reminders
Penerimaan borang ini bukanlah bermakna dengan sendirinya tanggungan akan diakui oleh syarikat.
Acceptance of this form does not mean admission of liability by the company.
NO. SIJIL / CERTIFICATE NO. :
Jenis-jenis tuntutan (sila tandakan √ di petak yang berkenaan) Type of claims (please tick √ in the related box provided)
Boleh tanda (√) lebih dari 1 petak
You may tick (√) more than 1 box
Tuntutan Kematian Tuntutan Pengecualian Sumbangan
Death Claim Waiver of Contribution Claim
Tuntutan Keilatan Kekal Menyeluruh (TPD)
Tuntutan Manfaat Pendapatan Keluarga (Family Income)
Total & Permanent Disability Claim Family Income Benefit
Tuntutan Keilatan Kekal Separa (PD) Tuntutan Komprehensif Kemalangan Diri Berkumpulan (CPAB)
Partial & Permanent Disability Claim Comprehensive Personal Accident Claim
Tuntutan Elaun Hospital (HIB) Tuntutan Manfaat Ikhlas W anita / Manfaat Cara Hidup
Hospital Income Benefit Ikhlas Wanita Claim / Living Benefit
Tuntutan Penyakit Kritikal
Tuntutan Ganjaran Tunai
Critical Illness Benefit
Cash Reward
Lain-lain, sila nyatakan
Others, please state
A.
MAKLUMAT PESERTA / PARTICIPANT'S DETAILS
1 a.
Nama Peserta / Name of Participant :
b.
No. Kad Pengenalan/ NRIC No. : Baru/ New : Lama/ Old :
2
Alamat / Address :
3 No. Telefon : a.
Telefon Bimbit / H/p : c. Pejabat / Office :
Telephone No. :
b. Rumah / House : d. Sambungan/ Extention No. :
4
E-Mel/ E-Mail :
5 Pekerjaan Semasa : Nama Majikan & Alamat :
Present Occupation : Name of Employer & Address :
6
Nama Bank/ Name of Bank :
7 No. Akaun Bank Peserta / W aris : Contoh: MBB0001.
Participant/ Beneficiary Bank Account No. : E.g: MBB0001.
** Sila lampirkan salinan muka hadapan buku bank / ** Please enclose a copy of the front page of the saving book.
B.
MAKLUMAT ORANG YANG DILINDUNGI / PERSON COVERED'S PERSONAL DETAILS
1
Nama Orang yang dilindungi (jika berbeza dengan A) / Name of Person covered (if differs from A) :
2
No. Kad Pengenalan/ NRIC No. : Baru/ New : Lama/ Old :
3
Alamat / Address :
4
E-Mel/ E-Mail :
BORANG TUNTUTAN - KELUARGA
CLAIM FORM - FAMILY
Poskod / Postcode :
Negeri / State :
Poskod /
Postcode
:
Town
Negeri / State :
C. BUTIR-BUTIR PENUNTUT (UNTUK TUNTUTAN KEMATIAN SAHAJA)
CLAIMANT'S DETAILS (FOR DEATH CLAIM ONLY)
Sila lengkapkan jika lain daripada A dan B / Please complete if differ from A and B
Lama/ Old :
c. Pejabat / Office :
d. Sambungan/ Extention No. :
Hibah / Hibah
Pemegang Serah Hak / Assignee
Claimant's Bank Account No. :
** Sila lampirkan salinan muka hadapan buku bank / ** Please enclose a copy of the front page of the saving book
D. MAKLUMAT KEJADIAN/ PARTICULARS OF EVENT.
(Sila isikan keterangan pada bahagian yang berkaitan sahaja) Please complete the information in the relevant section
1 a) Sebab kejadian.
Kemalangan/ Accident
Sakit / Disease Others / Lain-lain
Cause of event.
Keterangan mengenai kejadian.
Details of event.
b) Nama Penyakit/ Diagnosis :
c)
Nama Hospital/ Hospital's Name :
d)
Tarikh kejadian/ Date of event :
HH/DD BB/MM TT/YY
e) Tarikh Masuk W ad : i) f) Tarikh Keluar W ad : i)
Date Of Admission :
HH/DD BB/MM TT/YY Date Of Discharge : HH/DD
BB/MM
TT/YY
ii) ii)
HH/DD BB/MM TT/YY HH/DD
BB/MM
TT/YY
iii) iii)
HH/DD BB/MM TT/YY HH/DD
BB/MM
TT/YY
2
Sila nyatakan tarikh kali pertama/ Please state the exact date (first date)
a)
menerima rawatan/ received treatment :
HH/DD BB/MM TT/YY
b)
disahkan mendapat penyakit tersebut/ diagnosed with the illness :
HH/DD BB/MM TT/YY
3 Sila nyatakan sebab mendapatkan rawatan atau rujukan dari doktor tersebut.
Please state the reason for seeking treatment or referral from the said doctoror.
4 Sudah berapa lamakah Peserta menghidapi kesakitan/ kecederaan ini?
How long have you been suffering from these illness/ injuries?
5 Jika diakibatkan oleh kemalangan, sila nyatakan seperti berikut:
If accidental case please state the following:
HH/DD BB/MM TT/YY
a)
Tarikh kemalangan/ Date of accident : Masa:
Time: am/pm
b) Bagaimana kemalangan berlaku :
Details description of the accident :
*Sila lampirkan salinan laporan polis/ laporan bedah siasat (jika ada)
* Please enclose a copy of police report or post mortem report (if any)
Tidak / No
Ya / Yes
1 Nama / Name :
2 No. Kad Pengenalan/ NRIC No. : Baru/ New :
3 No. Telefon : a. Telefon Bimbit / H/p :
Telephone No. : b. Rumah / House :
4 Hubungan dengan simati / Relationship with the deceased :
Wasi / Executer
5 Alamat / Address :
Poskod / Postcode :
Negeri / State :
6 E-Mel/ E-Mail :
7 Adakah simati pernah menunaikan hajj semasa hayat beliau:
Has the deceased ever performed hajj during his lifetime:
8 Nama Bank/ Name of Bank :
9 No. Akaun Bank Penuntut :
6 Nama dan alamat doktor yang pernah merawat.
Name and address of the doctors that have been consulted.
7 Sila nyatakan ujian yang telah dilakukan oleh doktor :
Please state the nature of investigations performed by the doctor :
i.e. X-ray, ECG,blood test,etc
8
Sila nyatakan jenis rawatan atau prosedur yang telah diberikan :
Please state the nature of treatments or procedures given :
E.
LAIN LAIN TAKAFUL ATAU PAMPASAN / OTHER TAKAFUL OR COMPENSATION
Adakah Peserta membuat tuntutan atau pampasan dari syarikat insuran atau takaful yang lain?
YA / YES
TIDAK / NO
Is the Participant claiming the benefits under any other insurance companies or takaful operators?
Jika YA, sila berikan maklumat lanjut / If YES, please give details :
F.
PENGAKUAN OLEH PENUNTUT / DECLARATION BY THE CLAIMANT
Tandatangan Penuntut / Peserta
Tandatangan Saksi
Signature of Claimant / Participant Signature of Witness
Nama/ Name : Nama/ Name :
No. KP/ NRIC No. :
No. KP/ NRIC No. :
Tarikh/ Date :
Tarikh/ Date :
Cop Syarikat/ Company Stamp : Hubungan/ Relationship :
(For Group Master Certificate)
Alamat Klinik / Hospital
(Clinic or Hospital address)
Tarikh Rawatan/ Kemasukan
Hospital
(Date of treatment / Hospital
admission)
Saya / Kami ___________________________ No. KP ___________________________ pihak y
ang membuat tuntutan mengakui bahawa semua jawapan dan
kenyataan yang tercatat di atas adalah lengkap dan benar sepanjang pengetahuan dan keyakinan Saya / Kami dan Saya / Kami tidak menyembunyikan atau
merahsiakan butir-butir penting dari syarikat ini. Saya / Kami dengan ini menuntut manfaat Takaful dan lain-lain perolehan di bawah Pelan Takaful yang berkenaan
daripada Takaful Ikhlas Family Berhad (selepas ini dirujuk sebagai pihak Syarikat) dan bersetuju bahawa kenyataan dan maklumat dari semua doktor yang memberi
rawatan kepada simati / peserta semasa hayatnya dan segala dokumen lain diberi untuk menyokong ini adalah menjadi bukti kematiannya / keilatannya. Selanjutnya, Saya /
Kami bersetuju bahawa borang ini dan lain-lain dokumen tambahan yang diberikan mengenainya dan tindakan-tindakan siasatan dan pemeriksaan oleh pihak
Syarikat tidak boleh ditaksir atau dianggap persetujuan menanggung tuntutan oleh pihak Syarikat dan tidak membuktikan ada sebarang aqad Takaful yang
berkuatkuasa mengenai diri yang diperkatakan atau sesuatu pelepasan sebarang hak atau pembelaan oleh pihak Syarikat. Saya / Kami dengan ini bersetuju membenarkan
doktor-doktor atau lain-lain pihak atau hospital dan sebagainya memberi kepada pihak Syarikat penerangan atau maklumat yang mungkin diperlukan mengenai simati / peserta.
I / We ___________________________ NRIC ___________________________ as the claimant hereby declare that all foregoing answers and information stated
above are complete and true to the best of my / our knowledge and belief and I / We have not concealed any important details from this company. I / We hereby claim
Takaful benefits and other acquisition under the relevant Takaful Plan from Takaful Ikhlas Family Berhad (hereinafter referred as the Company) and agree that all
information disclosed by the doctors treating the deceased / participant during his lifetime and all documents provided to support this claim is proof of his / her death /
disability. Further, I / We agree that this form and other additional related documents and investigations or examinations by the Company cannot be interpreted or
assumed as admission of liability by the Company and is not proof of any agreement which take effect on the said person or discharged of any right or defense by
the Company. I / We hereby give consent to doctors or related parties or hospitals etc. to disclose to the Company any explanation or information which is
deemed necessary with regards to the deceased / participant.
Pen
yakit
(Diagnosis)
Nama Doktor
(Doctor's Name)
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IKHLAS Point, Tower 11A, Avenue 5, Bangsar South,

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Completed 8 April 2022

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