Scribd Logo
Upload

Welcome to Scribd!

  • Formulir Klaim Meninggal Dunia AFI

    Uploaded by

    Anonymous KEU60h
    6 views3 pages
    Klaim meninggal dunia

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    Klaim meninggal dunia

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    6 views3 pages

    Formulir Klaim Meninggal Dunia AFI

    Uploaded by

    Anonymous KEU60h
    Klaim meninggal dunia

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 3
    redefining / insurance Nomor Polis: (Dist och potas) Formulir Kiaim Meninggal Dunia “emaliviicrnitinia Death Claim Form Diisi oleh Pengaju Klaim (Filled by Claimant) atoton Pein. % Semua baglan dalam formule inl wold dsl dengan lengkap dan benar sehingga klalm dapat dproses dengan cepat dan akurat / Please fr ts form completely and comecty to ensure fast ana accurate processing. All fekss ore compulsory 2, Apabila olom yang ada tidak mencuikipl, mohon a ulskan di lembar lain / If tho space isnot enous, please writen on other sheets. 8, Seti koreks! penulisan/pengsian dalam bentuk etatan atas formulit int web dtandatangani oleh Pengaju Kim / Any corections ‘mado to nis form must bo sinea by tho Claimant. A. INFORMASI KEMATIAN / DEATH DETAILS s.angen Meninegel/osteoroeain = [| J7[ 1 ]Z[ [1] ]tsesmms yy) ‘2. Tempat Moning Place of Death J Rumah / Home [Raman Saki/ Hospitar [Lanny (sebutkan} / others (mentioned) 3, Penyebab tertanggung meninggal / Cause of death Ci Sakit/tiness ___[ Kecelakaan / Accident tainnya (sebutkan) / others (mentioned) 4, Kronologs Kematlan/ The chronological of death Riuayat Perawatan/Pengobatan / History of Treatment Nama Dokter atau Rumah sakit/| Alamat /Address | Diagnose Diagnosis | Tanggal perawatan / Date of treatment [Name of doctor's) or hospitals) (eam poy) B. INFORMASI LAIN TERTANGGUNG / OTHER INSURED DETAILS ‘ApakalTertanggung memiliki pois Asurans lana /Do you have any policies in another Insurance? ["|Ya/Yes _[-]Tidak/No- sika Ya" apa nama Perusahaan Asurane!tersebut dan Jonls Asurancnya / If yos, Desert the Insurance company nama and Insurance Pan . DETAIL KONTAK PENGAJU KLAIM / CLAIMANT'S CONTACT DETAILS Nomor Telepon Seluler/ Mobile Phone Number Alamat Email / Email Address Ise fran inn Ue rninteten menses Ges ote SES Lcori3 D, PERINCIAN PEMBAYARAN / PAYMENT DETAILS ‘Nama Pemilk Rekening dal pemogang pols atau ail warls/ Neme Account of Polley Holder or Bonofciary Nama Bank / Bonk’s Nome : I I ‘Alomat Bank / Bank's Address {cabang,/ Branch i No Rotenng an ank account namber = [|] Kode SWIFT Bank / Bank SWFT code ‘Untuk pentransferan ke Bank lar neger dengan mata vang USD / For transfer to a Forelin Bank with USD currencies E. INFORMASIKLAIM / CLAIM INFORMATION Untuk Informa Klsim, silahkan hubungi metal / for claim information, please contact vis DOKUMEN YANG DIPERLUKAN / DOCUMENT REQUIREMENTS: Daxumen Daerahnan DDokumen yang Diperukan (Type of Document submitted) | _ASN/ Orel Foquired Documents varves | Tidak/No_ | Ya/ves | Tiaak/no ‘Monon st Kotak yang tersenia dengan tanda 1) sesual dengan dokumen yang. Alserahkan / Please mark te box wth (i) 08 indlested by document submited ‘A. Dokumen berikut Ini arus ASLI/ Document submitted below must be Original Documents TFermulir Klien Meningeal: dst oleh Pengaju Klain (Claim Form Filled by a a a o Ctaimant) 2 Surat Keterangan Dokter : Dist olen Doktor yang merawst (Attending a Qo o o Physlelan’s statement: ied by Treating Doctor) 3. Buku Pois/Potey Book a a ao o 4. Proof of deny of insures o 4 o o + Kartu Pengenal Pemegang Pols / 1D of Polley holaer B + Marty Pengenal Tertanggung / 1B of insured a a o o 5. Proof ofldoauty of Bonofclary/ctaimant _ + Satu Pengenal /AKte Kelaniran Termashiahat /1/BIre certifeate a ao o ‘of Beneficiary + Sart Keluanga / Akte Nkah / Akte Adops!/ Famly Card / Marriage a Qo o corineate / adoption cantieate 6 No, Rekening Termaslanat atou Surat Kunsa diatas meterai untuk tujuon a a o o twansfor pombayaran kisim / Bank Account No of Bonoficlary or Pewar of attorney on stamp duty with referral for ansferred claim payment. 7 Akte kematian (catatan Sipil / (Death Certincate ~ released by cil a o o o -zovernment * +2 dar S Dokumen berkut in dinerikan anabiia alte Kemation tisak ada dan pat berupa doxumen ASL! atau Legalsit/ 2 ofS documents below are given if ‘an absant on doath cortifcate and must bo Orginal or Logalized document: & Surat Kemetian dari Rumah Sakiy Death certificate issued by a a u u ospta. Surat Ketorangan Kematian dari Pamong Praja / Death certiieste a a o o {ssved by oct council, ‘Surat bulti pomakaman dar dinas pemakaman / BuktiPengabuan / a a u ou Letter of funeral fom funeral serves / proof of erematton. Resi Akte Kematian eatetan spl) / Receipt of Death Certificate (om

    You might also like