COMMUNITY POLICING MALAYSIA
Program Kepolisan Komuniti Malaysia

LANGUAGES : BM | ENGLISH


BORANG INSURANS KEMALANGAN DIRI
PERSONAL ACCIDENT INSURANCE FORM
Dengan Kerjasama
Supported by

Nama Penuh mengikut Kad Pengenalan / Full Name of Insured as in NRIC / 姓名**
No. Kad Pengenalan Baru / New I/C No. / 身份证号码**
Tarikh Lahir / Date of Birth / 出生日期
Alamat E-mel ⁄ E-mail Address ⁄ 电子邮址
Umur / Age / 年龄**
Jantina / Gender / 性别**
   P / F / 女        
   L / M / 男  
Pekerjaan / Occupation / 职业**
Alamat Semasa / Current Address / 现时住址**
No. Telefon Bimbit / Handphone No. / 手机号码**
Tempoh Diansuranskan / Period of Cover / 受保期限
Nama Penuh Pewaris / Beneficiary Name / 受益人姓名**
No. Kad Pengenalan Baru Pewaris / Beneficiary New I/C No. / 受益人身份证号码**
No. Telefon Bimbit / Handphone No. / 手机号码
Hubungan dengan Penama Diinsuranskan / Relationship with Insured / 与投保人之关系
DECLARATION

I to the best of my knowledge hereby confirm that the statements contained in this form are true and correct and I have not concealed mis-represented or mis-stated any material act.

I agree that the statements and declaration contained in this proposal form shall be the basis of the contract of insurance with the company and are deemed to be incorporated in the contract.
Tandatangan / Signature of Insured / 投保人签名
Tarikh / Date / 日期

Submitted by: Co chop & Initial

  I hereby confirm that I have read and accept the terms and conditions stated in the form.
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