Notification Submission

Zurich Life Insurance Malaysia

No.	Claim Type	Guideline for Loss Date
1.	Accident	Date of the accident happened
2.	Hospitalisation	Date of the admission to hospital
3.	Death	Date of death (Insured)
4.	Dread Disease/Critical Illness	Date of the illness diagnosed (Insured)
5.	Total & Permanent Disability	Date of the disability begins (Insured)
6.	Waiver of Premium due to
a)	Death	Date of death (policy holder)
b)	Dread Disease/Critical Illness	Date of the illness diagnosed (policy holder)
c)	Total & Permanent Disability	Date of the disability begins (policy holder)

Claim Notification

Notifier Details

Full Name (as per NRIC/ID) *

In Relation to this claim I am *

Mobile Number *

House Phone Number

Email Address *

Claim Details

Zurich Policy Number *

Request Type *

Claim Reference No. *

Event Person ID Type *

Only Zurich ValueLife Junior policy allow to select "Not available".

Event Person ID Number *

Loss/Claim Date *

Claim Type *

Cause of Event *

How it happened/Diagnosis

Check Up Type *

Please click here if either "MC Date" or "Medical Expenses" (or both) are not applicable for this claims submission.

Date of MC started *

Date of MC ended *

Medical Expenses (RM) *

Date of Admission to hospital *

Date of Discharged from hospital *

Admission covered by Zurich Medical Card *

Remark

Claimant Details

Claimant is the policy holder? *

Full Name (as per NRIC/ID) *

ID Type *

ID Number *

Correspondence Address *

Post Code *

Town *

State *

Mobile Number *

Email Address *

Bank Name *

Bank Account Number *

Document Details

Please upload the Claimant's Statement form and all supporting documents.

To view Document Checklist/Guide, please click here.

Note: We may defer the claim in the event the document(s) submitted to us require further verification on its originality/ authenticity.

Each file upload maximum size is 10MB only.
Available to upload file with extension { .jpeg, .jpg, .pdf, .tiff } only.

No.	Document Description	Claim Type	Sub Header Ind	Required Ind	Document Name
1	Claimant Statement *	A	0	1	Claimant_Statement
2	Claimant NRIC / Passport / Residence card *	A	0	1	Claimant_NRIC
3	Attending Physician Statement (Accident & Hospitalisation Claim) (for claim amount exceeding RM500) *	A	0	1	Attending_Physician_Statement
4	Medical Certificates or Light Duty Certificates *	A	0	1	Medical_Certificate
5	Original Bills and Receipts (applicable for reimbursement claims) *	A	0	1	Original_Bills_and_Receipts
6	Other relevant Medical Reports	A	0	0	Other_Relevant_Medical_Reports
7	Police Report	A	0	0	Police_Report
8	Newspaper Cutting, if any (Kindly translate in English or Bahasa Melayu if article is not in these languages)	A	0	0	Newspaper_Cutting
9	Photograph of Dismemberment / Injured Part (applicable for Permanent Dismemberment / Disablement claims)	A	0	0	Photograph_of_Dismemberment
10	Imaging Reports i.e. MRI, X-ray, CT Scan (applicable for Broken Bones and Burns claims)	A	0	0	Imaging_Reports
11	Claimant Statement *	C	0	1	Claimant_Statement
12	Claimant NRIC / Passport / Residence card *	C	0	1	Claimant_NRIC
13	Confidential Medical Certificate - depends on the type of disease or illness or Life Claim Questionnaire *	CI	0	1	Confidential_Medical_Certificate
14	Relevant Diagnosis Imaging / Post-Surgical Report	CI	0	0	PolRelevant_Diagnosis_Imagingice_Report
15	Histopathology / Histology Report (for Cancer claim only)	CI	0	0	Histopathology_Report
16	Other relevant Medical Reports	CI	0	0	Other_Relevant_Medical_Reports
17	Letter of Consent	CI	0	0	Letter_of_Consent
18	Claimant Statement *	D	0	1	Claimant_Statement
19	Claimant NRIC / Passport / Residence card *	D	0	1	Claimant_NRIC
20	Death Certificate *	D	0	1	Death_Certificate
21	Marriage Certificate (if claimant is spouse) or Birth Certificate of Claimant (if claimant is child) or Birth Certificate of Deceased (if claimant is parents) as Proof of Relationship	D	0	0	Marriage_Certificate
22	Letter of Consent	D	0	0	Letter_of_Consent
23	Report of death abroad from National Registration Department (NRD) - if insured dies abroad	D	0	0	Report_of_death_abroad
24	Letter of Administration / Grant of Probate / Distribution Order (applicable for policy without nomination)	D	0	0	Letter_of_Admission
25	Deceased NRIC / Passport / Residence card	D	0	0	Deceased_NRIC
	If death due to Illness of natural cause, please submit item 9 below (if applicable)	D	1	0
26	Physician Statement Form (for policy duration within 2 years from the issue Date or Reinstatement Date, whichever is the later, except for Senior Gold policies)	D	0	0	Physician_Statement_Form
	if death due to Accident, please submit item 10 - 13 below (if applicable)	D	1	0
27	Post Mortem / Coroner Report (for policy duration less than 5 years from the Issue Date or Reinstatement Date, whichever is the later) *	D	0	1	Post_Mortem
28	Toxicology Report	D	0	0	Toxicology_Report
29	Police Report	D	0	0	Police_Report
30	Newspaper Cutting, if any (Kindly translate in English or Bahasa Melayu if article is not in these languages)	D	0	0	Newspaper_Cutting
31	Claimant Statement *	H	0	1	Claimant_Statement
32	Claimant NRIC / Passport / Residence card *	H	0	1	Claimant_NRIC
33	Attending Physician Statement (Accident & Hospitalisation Claim) *	HFOC	0	1	Attending_Physician_Statement
34	Histopathology Report (applicable for Female Illnes claims i.e. Fibroid, Ovarian Cyst etc) *	HFOC	0	1	Histopathology_Report
35	Original Bills and Receipts *	HFOC	0	1	Original_Bills_and_Receipts
36	Admission and Discharge Notes / Summary or Hospital Bills / Invoices	HFOC	0	0	Admission_and_Discharge_Notes
37	MRI, X-ray, CT Scan or other Radiology / Medical Reports	HFOC	0	0	Imaging_Reports
38	Attending Physician Statement (Accident & Hospitalisation Claim) *	HHIB	0	1	Attending_Physician_Statement
39	Admission and Discharge Notes / Summary or Hospital Bills / Invoices *	HHIB	0	1	Admission_and_Discharge_Notes
40	MRI, X-ray, CT Scan or other Radiology / Medical Reports	HHIB	0	0	Imaging_Reports
41	Blood Test / Pap Smear / Mammogram / Abdomen / Pelvis Ultrasound Report *	HMCA	0	1	Blood_Test
42	Original Bills and Receipts *	HMCA	0	1	Original_Bills_and_Receipts
43	Child Birth Certificate *	HNBA	0	1	Child_Birth_Certificate
44	Claimant Statement *	T	0	1	Claimant_Statement
45	Claimant NRIC / Passport / Residence card *	T	0	1	Claimant_NRIC
46	Total and Permanent Disability Claim Form (Part B - Attending Physician Statement) *	T	0	1	TPD_Claim_Form
47	Neurological Examination Report (NER) *	T	0	1	Neurological_Examination_Report
48	Other Medical Report (if relevant)	T	0	0	Other_Medical_Report
49	EPF Withdrawal Letter (if applicable)	T	0	0	EPF_Withdrawal_Letter
50	SOCSO Offer Letter / SOCSO "Keputusan Jemaah Doktor Mengenai Keilatan" (if applicable)	T	0	0	SOCSO_Offer_Letter
51	Letter of Consent	T	0	0	Letter_of_Consent
52	Employment Termination Letter (if applicable)	T	0	0	Employement_Termination_Letter
	if disability due to Accident, please submit 10 - 11 below (if applicable)	T	1	0
53	Police Report	T	0	0	Police_Report
54	Newspaper Cutting, if any (Kindly translate in English or Bahasa Melayu if article is not in these languages)	T	0	0	Newspaper_Cutting
55	Claimant Statement *	W	0	1	Claimant_Statement
56	Claimant NRIC / Passport / Residence card *	W	0	1	Claimant_NRIC
57	Confidential Medical Certificate - depends on the type of disease or illness or Life Claim Questionnaire *	WCI	0	1	Confidential_Medical_Certificate
58	Relevant Diagnosis Imaging / Post-Surgical Report	WCI	0	0	PolRelevant_Diagnosis_Imagingice_Report
59	Histopathology / Histology Report (for Cancer claim only)	WCI	0	0	Histopathology_Report
60	Other relevant Medical Reports	WCI	0	0	Other_Relevant_Medical_Reports
61	Letter of Consent	WCI	0	0	Letter_of_Consent
62	Death Certificate *	WD	0	1	Death_Certificate
63	Marriage Certificate (if claimant is spouse) or Birth Certificate of Claimant (if claimant is child) or Birth Certificate of Deceased (if claimant is parents) as Proof of Relationship	WD	0	0	Marriage_Certificate
64	Letter of Consent	WD	0	0	Letter_of_Consent
65	Report of death abroad from National Registration Department (NRD) - if insured dies abroad	WD	0	0	Report_of_death_abroad
66	Letter of Administration / Grant of Probate / Distribution Order (applicable for policy without nomination)	WD	0	0	Letter_of_Admission
67	Deceased NRIC / Passport / Residence card	WD	0	0	Deceased_NRIC
	If death due to Illness of natural cause, please submit item 9 below (if applicable)	WD	1	0
68	Physician Statement Form (for policy duration within 2 years from the issue Date or Reinstatement Date, whichever is the later, except for Senior Gold policies)	WD	0	0	Physician_Statement_Form
	if death due to Accident, please submit item 10 - 13 below (if applicable)	WD	1	0
69	Post Mortem / Coroner Report (for policy duration less than 5 years from the Issue Date or Reinstatement Date, whichever is the later) *	WD	0	1	Post_Mortem
70	Toxicology Report	WD	0	0	Toxicology_Report
71	Police Report	WD	0	0	Police_Report
72	Newspaper Cutting, if any (Kindly translate in English or Bahasa Melayu if article is not in these languages)	WD	0	0	Newspaper_Cutting
73	Total and Permanent Disability Claim Form (Part B - Attending Physician Statement) *	WTPD	0	1	TPD_Claim_Form
74	Neurological Examination Report (NER) *	WTPD	0	1	Neurological_Examination_Report
75	Other Medical Report (if relevant)	WTPD	0	0	Other_Medical_Report
76	EPF Withdrawal Letter (if applicable)	WTPD	0	0	EPF_Withdrawal_Letter
77	SOCSO Offer Letter / SOCSO "Keputusan Jemaah Doktor Mengenai Keilatan" (if applicable)	WTPD	0	0	SOCSO_Offer_Letter
78	Letter of Consent	WTPD	0	0	Letter_of_Consent
79	Employment Termination Letter (if applicable)	WTPD	0	0	Employement_Termination_Letter
	if disability due to Accident, please submit 10 - 11 below (if applicable)	WTPD	1	0
80	Police Report	WTPD	0	0	Police_Report
81	Newspaper Cutting, if any (Kindly translate in English or Bahasa Melayu if article is not in these languages)	WTPD	0	0	Newspaper_Cutting
82	Additional Document	02	0	0	Additional_Document

I hereby declare that the above information is true and complete to the best of my knowledge and belief. I am fully understand that Zurich Life Insurance Malaysia Berhad (“you”) upon believing the information provided by me to be accurate and correct, will rely and act on the information given.

I hereby give my unconditional and unequivocal consent to you and all your related companies to process my/ Insured Person’s personal data revealed hereto.You are at liberty to process the data and share the information revealed thereto with any of your service providers and your other related companies provided that the revelation of my / Insured Person’s personal data strictly for the purposes in relation to the insurance claim made hereto. The consent given hereto is in line with the requirement set forth in the Personal Data Protection Act 2010. Kindly visit Personal Data Protection Notice Details to know more about our privacy/ PDPA policy.

I hereby allow Zurich Malaysia and/or its intermediaries to contact me on matters relating to this submission. For this Purpose, Zurich Life Insurance Malaysia Berhad and all other Zurich Insurance Group Subsidiaries operating in Malaysia, will also be referred to as ‘Zurich Malaysia’.

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Supporting Documents Required

Event Person ID

Table of Guideline

Claim Notification