MCIS INSURANCE BERHAD (435318-U)

Ibu Pejabat: Wisma MCIS, Jalan Barat, 46200 Petaling Jaya, Selangor Darul Ehsan, Malaysia.
Tel: 03-7652 3388 Fax: 03-7957 1562 E-mail: customerservice@mcis.my Website: www.mcis.my

ACCIDENT QUESTIONNAIRE

IMPORTANT NOTE

Pursuant to Section 129 and Schedule 9 of The Financial Services Act 2013, you are to take reasonable care to answer all the questions below fully
and truthfully. If there is any misrepresentation, We can avoid the policy and refuse all claims or treat the policy as subsisting on different terms

DETAILS OF THE LIFE ASSURED / PROPOSER OR PAYER* (* Please delete whichever is not applicable)

Proposal No. Gender Male Female Age

Name

NRIC No. (Old) NRIC No. (New)

Address

E-mail

1. What was the date of accident?

2. Please briefly describe how the accident happened?

3. Please list the injury sustained?

4. Please provide the name and address of doctor who treated you?

5. Were you unconscious and if so, for how long?

6. Was any surgical correction performed? (Which part of body or organs)?

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 7. Have you had any headache, dizziness or fainting spells, since then? (Please state date and frequency)?

8. Do you have any deformities, scars or disability as a result of the accident?

9. Is there any plating done and was it removed?

10. Are you able to perform your normal duties now, without any limitation?

I hereby declare that the particulars and answers provided in this QUESTIONNAIRE is complete and true to the best of my
knowledge and that together with the other document / information provided during my application will form the basis of the
Policy between myself and the MCIS Insurance Berhad.

Signature of Life Assured : __________________________________________________________________

Name of Life Assured: __________________________________________________________________

NRIC No : ______________________ Date : _______________________________________

MCISZ MVA (LA) / 2013

Note: Please attach annexure if column provided for any answer is insufficient.

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