Non Motor Insurance Claim Form

Important Notice:
 The participant/policy holder/claimant must give complete and accurate information.
 For your convenience, this claim form is made available at our website: www.etiqa.com.my

General
Policy no.:

Name / Name of Company:

MyKad / Army / Police / Passport
Trade / Occupation:
no./ Company registration no.:
Phone no.: Mobile: Home: Office:
Contact
details: Email:

Address:

Postcode: Town: State: Country:

Bank name: Account no.:

Details of incident
Fire Flood Windstorm Robbery

Theft Cheating Other:

Date of incident (dd/mm/yyyy): Time (am/pm):

Location of the property at the time

of the incident:
Brief description of the incident

Was the incident reported to the Yes, please furnish a copy of police report. No
police?
Was the incident (if fire) reported to Yes, please furnish a copy of fire brigade report. No
the fire brigade?
Who discovered the incident?

Have you experienced the same Yes, please state: No

incident before?
No. of occurrence:

Date of the most recent incident:

Are you the sole owner of the lost, Yes No, please provide:
damaged or destroyed property?
Name of other interested party:

Nature of their interest:

Was the premise unoccupied at the Yes, please state: No

time of loss or damage?
Date (dd/mm/yyyy) when last occupied:

Is this loss or damage covered by Yes, please provide a copy of the policy (ies)/ certificate. No
any other insurance policy (ies)?
Additional information
Was the loss/ damage caused by a Yes, please provide details: No
specific individual/ party?
Name:
Address:

Postcode: Town: State: Country:

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 Did the incident arise from activities Yes, please provide: No
of persons in your direct
employment? Name of employee:
Was there anyone (other than your Yes, please provide details of the third party: No
own employees) who sustained
injury or damage to their property?
Name:

Address:

Postcode: Town: State: Country:

Details of loss
Value at the time Sum claimed for
of loss after repair/
Full description of lost or damaged Name and address whom article was Date of purchase
Price paid allowing for age, replacement
article(s) purchased or by whom presented or received
wear & tear and based on present
depreciation value

Declarations
I/We declare that the above statements and particulars are correct and complete in every aspect and I/We have not concealed, misrepresented or misstated any material
fact in relation to this claim.
I/We agree that if such statements and particulars are written by any other person, such person shall be deemed to have been my/our Agent for the purpose of filing in this
form and his statement shall be binding upon me/us.

I/We hereby agree to give my/our fullest cooperation to Etiqa Insurance Berhad/ Etiqa Takaful Berhad or its authorized representative in relation to this claim.

Signature of policyholder (affix company stamp, if non individual) Date:

Note:
Please include the following documents:
1) Claim form
2) Copy of MyKad/ Passport of claimant
3) Photographs depicting the damage(s)
4) Police report (if any)
5) Fire brigade report (if any)
6) Purchase invoice/ bills
7) Copy of internal report

Etiqa Takaful Berhad (266243D) Page 2 of 2

Etiqa Insurance Berhad (9557T)
Level 19, Tower C, Dataran Maybank, 1, Jalan Maarof, 59000 Kuala Lumpur, Malaysia Etiqa Oneline 1300 13 8888
T +603 2297 3888 F +603 2297 3800 E info@etiqa.com.my www.etiqa.com.my Claim Assist 1300 88 1007