MyClaims Non Motor - Notification

Zurich General Insurance Malaysia

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MYA Travel Insurance Claim Notification Form

MYA Confirmation No/PNR No *

Insured’s Date of Birth *

Incident Date *

(When did the incident happen?)

Master Policy No *

Certificate of Insurance No *

Your Zurich Policy Number *

Policy number is required

Class

Claimant's Name *

Client Type *

New IC No. *

Claimant's New IC *

- -

New IC is required

OLD IC/Passport No

Claimant's OLD IC/Passport No

Business Reg No

Claimant's Email Address *

Hand Phone Number Claimant's Mobile Number

(Please include your country code)

Loss State *

Please tell us what happened *

(Where,Who,Why,What and How?)

Have you received compensation from other insurer to cover the damage or loss?

Other Insurer’s Name *

Compensation received *

Benefit Type *

Recovery Action *

Occupied As *

Risk Item *

Cause Of Loss *

Type Of Loss *

Source Of Estimation *

Estimate Loss Amount *

Was anyone Injured ? *

Injured Person Name *

Injured Person Tel No *

Injured Person ID Type *

Injured Person ID *

Claim Type *

Do you have any other Insurance to cover the damange or loss ?

Insurer

Please provide as much details as possible. Use the reverse side of the form if you wish to give more details or provide a sketch overview to give us a better understanding of the incident.

Please provide your bank details so we can process your claim payment if your claim is payable.

Bank Location *

(Country)

Bank Name *

Currency Code *

Bank Address *

SWIFT Code *

Account Number *

(Exclude Spaces & Symbols)

Account Holder Name *

Account Holder ID Type *

Account Holder ID *

If the payment is to a bank account outside of Malaysia, any overseas remittance fees will be borne by you.

At Zurich, we aim to provide a seamless and pleasant experience in servicing your claims. Hence, your feedback is valuable to us. Once your claim has been settled, we will send you an invitation to answer a survey. It will only take less than a minute.

Your privacy is very important to us. Please read these privacy terms on our website here (Refer to 8. Privacy & Data Protection). For more information on Personal Data Protection Notice, please visit us on www.zurich.com.my/PDPA .

I agree that Zurich Malaysia can contact me for the purpose of the claim notification form above.

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