National Insurance Company Berhad

Other Claim

IMPORTANT STATEMENT PURSUANT TO SECTION 37(4) OF THE INSURANCE ORDER 2006 - You are to disclose in this claim form, fully and faithfully all the facts which you know or ought to know, otherwise the claims issued hereunder may be invalidated.

POLICY NUMBER*

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POLICY HOLDER NAME*

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PHONE*

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EMAIL*

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DATE OF LOSS*

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DESCRIPTION OF LOSS*

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DECLARATION: I/We declare that the information that I have provided is accurate. I/We further agree to accept any outcome subject to the usual provisions and conditions prescribed by the Company therein.