Upload Document Mandatory Documents to be uploaded: Scanned copy/photo image of receipt for COVID-19 testing Attach file: [Max: 10MB - jpg,png,pdf,heif only] Scanned copy/photo image of identity card (front) Attach file: [Max: 10MB - jpg,png,pdf,heif only] Scanned copy/photo image of identity card (back) Attach file: [Max: 10MB - jpg,png,pdf,heif only] Upload one of the following: Scanned copy/photo image of the signed Claim Form downloaded from this website, OR Scanned copy/photo image of Doctor's referral letter/Medical Advisory Note to indicate you are required to do COVID-19 test, OR Scanned copy/photo image of Order For Supervision And Observation At Home Form (As per Annex 14a of Guidelines COVID-19 Management in Malaysia). Attach file: [Max: 10MB - jpg,png,pdf,heif only] Scanned copy/photo image of Laboratory Report Attach file: [Max: 10MB - jpg,png,pdf,heif only] COVID-19 Declaration 1. Have you had any of the following symptoms over the past 14 days? *: No Symptoms Fever Cough Sore Throat Shortness of breath Other Symptoms (Please Specify) 2. Have you traveled to / resided in foreign country within 14 days before the onset of illness? No Yes, Select Country and Date of Departure from Country Select Country* Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic of The Cook Islands Costa Rica Cote Divoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic Peoples Republic of Korea, Republic of Kuwait Kyrgyzstan Lao Peoples Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, The Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and The South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Date of Departure from Foreign Country: 3. Have you been in close contact with a confirmed case of COVID-19, within 14 days before onset of illness? No Yes (Please state the contact details) Close contact defined as : Health care associated exposure without appropriate Personal Protective Equipment (including providing direct care for COVID-19 patients, working with health care workers infected with COVID-19, visiting patients or staying in the same close environment of a COVID¬19 patient). Working together in close proximity or sharing the same classroom environment with a COVID-19 patient Traveling together with COVID-19 patient in any kind of conveyance Living in the same household as a COVID-19 patient Confirmed case of COVID-19 defined as a person with laboratory confirmation of infection with the COVID-19 Close Contact Details 4. Have you attended an event associated with known COVID-19 outbreak? No Yes, ( Please state Event and Date of Event ) Outbreak Event Details Outbreak Event Date Personal Details Policy/Certificate Number*: Name of Insurance Company or Takaful Operator*: Name of Insurance Company or Takaful Operator AIA Bhd.(Life Insurance) AIA General Berhad (General Insurance) AIA Public Takaful Bhd. (Takaful Operators) AIG Malaysia Insurance Berhad (General Insurance) Allianz General Insurance Company (Malaysia) Berhad (General Insurance) Allianz Life Insurance Malaysia Berhad (Life Insurance) AmGeneral Insurance Berhad (General Insurance) AmMetLife Insurance Berhad (Life Insurance) AmMetLife Takaful Berhad (Takaful Operators) AXA Affin General Insurance Berhad (General Insurance) AXA AFFIN Life Insurance Berhad (Life Insurance) Berjaya Sompo Insurance Berhad (General Insurance) Chubb Insurance Malaysia Berhad (General Insurance) Etiqa Family Takaful Berhad (Takaful Operators) Etiqa General Insurance Berhad (General Insurance) Etiqa General Takaful Berhad (Takaful Operators) Etiqa Life Insurance Berhad (Life Insurance) FWD Takaful Berhad (Takaful Operators) Gibraltar BSN Life Berhad (Life Insurance) Great Eastern General Insurance (Malaysia) Berhad (General Insurance) Great Eastern Life Assurance (Malaysia) Berhad (Life Insurance) Great Eastern Takaful Berhad (Takaful Operators) Hong Leong Assurance Berhad (Life Insurance) Hong Leong MSIG Takaful Berhad (Takaful Operators) Liberty Insurance Berhad (General Insurance) Lonpac Insurance Bhd (General Insurance) Manulife Insurance Berhad (Life Insurance) MCIS Insurance Berhad (Life Insurance) MPI Generali Insurans Berhad (General Insurance) MSIG Insurance (Malaysia) Bhd (General Insurance) Pacific & Orient Insurance Co. Berhad (General Insurance) Progressive Insurance Bhd (General Insurance) Prudential Assurance Malaysia Berhad (Life Insurance) Prudential BSN Takaful Berhad (Takaful Operators) QBE Insurance (Malaysia) Berhad (General Insurance) RHB Insurance Berhad (General Insurance) Sun Life Malaysia Assurance Berhad (Life Insurance) Sun Life Malaysia Takaful Berhad (Takaful Operators) Syarikat Takaful Malaysia Am Berhad (Takaful Operators) Syarikat Takaful Malaysia Keluarga Berhad (Takaful Operators) Takaful Ikhlas Family Berhad (Takaful Operators) Takaful Ikhlas General Berhad (Takaful Operators) The Pacific Insurance Berhad (General Insurance) Tokio Marine Insurans (Malaysia) Berhad (General Insurance) Tokio Marine Life Insurance Malaysia Bhd. (Life Insurance) Tune Insurance Malaysia Berhad (General Insurance) Zurich General Insurance Malaysia Berhad (General Insurance) Zurich General Takaful Malaysia Berhad (Takaful Operators) Zurich Life Insurance Malaysia Berhad (Life Insurance) Zurich Takaful Malaysia Berhad (Takaful Operators) Policy/Certificate Holder Name* (state the name of employer if group policy/certificate): Insured/Covered Person Name (person tested for COVID-19) *: Gender*: Select Gender Male Female Age* (in years): Nationality*: Select Nationality Malaysian Non-Malaysian Insured/Covered Person IC number or Other ID*: Insured/Covered Person Home Address *: Select State Johor Kedah Kelantan Malacca Negeri Sembilan Pahang Penang Perak Perlis Sabah Sarawak Selangor Terengganu WP Kuala Lumpur WP Labuan WP Putrajaya Insured/Covered Person Phone Number (Home)*: Insured/Covered Person Phone Number (Mobile)*: Payment Details Bank Account Holder Name: (Must be either Policy/Certificate Holder or Insured/Covered Person)*: Payee IC/ Other ID Number:*: Bank Name*: Select Bank Name Affin Bank Berhad Affin Islamic Bank Berhad Agrobank Al Rajhi Banking & Invesment Corporation (Malaysia) Berhad Alliance Bank Malaysia Berhad Alliance Islamic Bank Berhad AmBank Islamic Berhad AmBank(M) Berhad Bangkok Bank Berhad Bank Islam Malaysia Berhad Bank Muamalat Malaysia Berhad Bank of China (Malaysia) Berhad Bank Rakyat Bank Simpanan Nasional CIMB Bank Berhad CIMB Islamic Bank Berhad Citibank Berhad Hong Leong Bank Berhad Hong Leong Islamic Bank Berhad HSBC Amanah Malaysia Berhad HSBC Bank Malaysia Berhad Industrial and Commercial Bank of China (Malaysia) Berhad Kuwait Finance House (Malaysia) Berhad Malayan Banking Berhad Maybank Islamic Berhad MBSB Bank OCBC Al Amin Bank Berhad OCBC Bank (Malaysia) Berhad Public Bank Berhad Public Islamic Bank Berhad RHB Bank Berhad RHB Islamic Bank Berhad Standard Chartered Bank Malaysia Berhad Standard Chartered Saadiq Berhad United Overseas Bank (Malaysia) Berhad Bank Account No:*: E-mail Address:*: Notes: You will be notified by email once the payment has been made. Please ensure that the bank account information provided in this Form is accurate. Administrator shall not be liable if payments are erroneously credited due to inaccurate account number provided. No joint name account is allowed. 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. Submit