Declaration & Authorisation

I understand and agree that any personal information collected or held by the Administrator (whether contained in this form or otherwise obtained) may be held, used and disclosed by the Administrator to individuals / organisation related to and associated with the Administrator or any selected third party (within or outside of Malaysia, including reinsurance/retakaful and claims investigation companies and industry associations / federations) for the purpose of processing this application and to communicate with me for such purposes. I understand that I have a right to obtain access to and to request correction of any personal information held by the Administrator concerning me. Such request can be made to my own insurance company or takaful operator.

I understand and agree that

• I am allowed to claim this benefit once only, irrespective of the number of policies/certificates that I have with multiple insurers/takaful operators and is subject to availability of the fund;
• The Administrator's acceptance of this claim form is not an admission of the Administrator’s liability of my/our claim.
• I have read & understand the Terms & Conditions of COVID-19 Test Fund.

I hereby request that payment(s) due and payable to me by the Administrator be paid to bank account stated above by way of Inter-bank Giro/RENTAS/TT and confirm that :-

• I consent to the Administrator releasing the above data to its banker(s) in order to facilitate payment(s) to me by way of Inter-bank Giro/RENTAS/TT.
• All information provided herein are correct and accurate.
• My request herein shall be irrecoverable without the consent of the Administrator. The Administrator may at any time in its absolute discretion effect payment(s) to me by other mode(s).
• I shall keep the Administrator and its banker(s) indemnified against any loss and/or damage howsoever arising from any matters in relation to Inter-bank Giro/RENTAS/TT requested by me herein including but not limited to error/misdescription in information furnished, delayed payment(s) and any other circumstances beyond the Administrator and its banker(s)'s control.

Note on Administrator: The disbursement of the Covid-19 Test Fund is jointly administered by Life Insurance Association of Malaysia (LIAM), Persatuan Insuran Am Malaysia (PIAM) & Malaysian Takaful Association (MTA), together with all members of these associations.