DATE: _____________________________
NAME OF POLICY HOLDER: _____________________________ MOBILE NUMBER: ____________________
NAME OF CLAIMANT: _________________________________ EMAIL ADDRESS: ____________________
POLICY NUMBER: _____________________________________ BIRTHDAY: _________________________
ADDRESS: ___________________________________________
PLEASE TICK THE BOX OF THE BENEFIT YOU ARE CLAIMING
NON TRAVEL TRAVEL
DAILY HOSPITALIZATION EMERGENCY MEDICAL TREATMENT
MEDICAL REIMBURSEMENT COVID-19 (HOSPITALIZATION)
ACCIDENTAL DEATH ACCIDENTAL DEATH
MURDER & UNPROVOKED ASSAULT TRIP CANCELLATION
CALAMITY ASSISTANCE TRIP TERMINATION
FIRE ASSISTANCE FLIGHT DELAY
DISMEMBERMENT/DISABLEMENT BAGGAGE DELAY
COVID-19 (HOSPITALIZATION) LOSS OF BAGGAGE
DENGUE CASH ASSISTANCE DAMAGE TO BAGGAGE
LOSS OF LAPTOP
DAMAGE TO LAPTOP
LOSS OF CASH
LOSS OF TRAVEL DOCUMENTS
CAR RENTAL PROTECTION
PERSONAL LIABILITY
DATE & TIME OF INCIDENT
PLACE OF INCIDENT
BRIEFLY STATE HOW
THE INCIDENT HAPPENED
CLAIM COMPUTATION
ADMISSION DATE DISCHARGE DATE
DAILY HOSPITALIZATION
COVID-19 HOSPITALIZATION
MONTH AND YEAR LUGAGGE WAS AMOUNT
DAMAGE TO BAGGAGE PURCHASED
ITEM RECEIPTS NO/S. AMOUNT
MEDICAL REIMBURSEMENT
FLIGHT DELAY
BAGGAGE DELAY
LOSS OF BAGGAGE
EMERGENCY MEDICAL
TREATMENT
“Section 251 of the lnsurance Code, as amended, imposes a fine not exceeding twice the amount claimed and/or imprisonment of
two (2) years, or both, at the discretion of the court, to any person who presents or causes to be presented any fraudulent claim
for the payment of a loss under a contract of insurance, and who fraudulently prepares, makes or subscribes any writing with
intent to present or use the same, or to allow it to be presented in support of any claim.”
I hereby warrant that all personal information and sensitive personal information given by me are true, correct and updated
to the best of my knowledge, freely and voluntarily given to Malayan Insurance Company, Inc. (MICO).
I agree and consent that above information are being collected, used, processed and recorded for purposes which are relevant
and necessary in securing an insurance contract or transacting a business or any activity with MICO. I hereby authorize MICO,
its directors, officers, consultants, employees, and duly authorized representatives to keep, store, update, use, access and
process the information given to it, and to share, transfer or disclose the information, including this form to the Yuchengco
Group of Companies (YGC Companies), their and MICO’s affiliates, subsidiaries, contractors, partners, agents and
representatives, intermediaries, industry associations, and third parties such as but not limited to outsourced service providers,
adjusters, salvage buyers, banks, external auditors, and local and foreign regulatory authorities for purposes of marketing or
promotional information campaign, provision of any products, services, or offers through mail/email/fax/SMS/telephone or any
type of electronic facility, profiling, research, studies/customer satisfaction surveys, statistical and risk analysis, tax monitoring,
review, and reporting, compliance with court and other lawful order and requirements, with Anti-Money Laundering Act, Credit
Information System Act, and all other regulatory laws, and all other activities consistent with the provisions of the Data Privacy
Act and subject to appropriate security safeguards. If purchasing, transacting and/or acting in behalf of other person(s), I
hereby warrant that I am duly authorized to perform such acts and that I am duly allowed to give their information to MICO. I
hereby bind myself to advise all other persons in whose behalf I have acted, transacted with and/or purchased any product
from MICO of all the terms and conditions herein. I also authorize MICO and the YGC Companies to verify and investigate the
information given by me, including submitted documents from whatever source it may consider appropriate.
I have the right to access the given information, and I undertake to correct, rectify or supplement information should any
information be found to be inaccurate or incomplete. I shall notify MICO in writing of any changes in the information given
above.
I will hold MICO free and harmless from any liability that may arise as a result of the authorization given above.
I hereby declare and warrant the following: a.) the preceding statement of facts are true to my personal knowledge; b.) all
documents submitted are authentic/duly executed, and/or faithful reproduction of the originals; c.) I understand that any
misrepresentation relative to the foregoing is a valid ground for the denial of the subject claim, cancellation of the policy, as well
as, criminal prosecution under the law; and d.) I am authorized to attest and affirm the foregoing;
______________________________________
Name & Signature of the Claimant
______________________________________
Signed by the Assured
*SUBSCRIBED AND SWORN to before me this th day of , 20 at , affiant with
Community Tax Certificate No. issued at on 200 .
Doc. No. ;
Page No. : NOTARY PUBLIC
Book No. ;
Series of 200 _____.
C-B004-0722-0
