e-payment registration form - merimen e-claims · pdf filei hereby give my consent to tmim to...

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Please complete the details herein this Form with capital letters and cross (X) the appropriate box. Policy Holder Agent Broker Reinsurer Adjuster Repairer Lawyer Financial Institution Service Provider Others (Please specify) Section A: PERSONAL DETAILS Beneficiary Name : Business Registration No (non-individual) : NRIC No (individual) : Address : Telephone No: Handphone No. Contact Person 1: Email: Contact Person 2: Email: Banker (Please select from drop down list or Appendix A) Bank Code Bank Account Number (please ignore all dashes:'-') Section B: DOCUMENTS TO BE ATTACHED HEREWITH THIS FORM For verification purpose, kindly attach the following supporting document that confirm the said account belongs to you/your company Photocopy of top portion of the bank statement of Current Account, OR Front page of the Savings Account Passbook, OR Confirmation letter from bank Section C:DECLARATION 1 2 I/We shall indemnify TMIM for any loss, damage or claims incurred as consequence of acting on such reliance. 3 4 5 Authorised Signatory Name Position Date FOR OFFICE USE ONLY : To be completed by relevant department: Department/branch MO Code Agent Name Client Code Agent Code Verified by Signature/Date To be completed by Finance department: Date received Data Entry by Finance Signature/Date Verified by Finance Signature/Date I understand that I have the right, upon payment of a prescribed fee, to request access to my Personal Data that is being processed by TMIM and to request correction of my Personal Data. Such request shall be submitted to the Head of Finance, TMIM; and I understand that the supply of my Personal Data herein is voluntary and it is necessary for TMIM to process my Personal Data for effecting and administrating the electronic payments to me. I hereby give my consent to TMIM to disclose my Personal Data provided in this E Payment Registration Form to TMIM, TMIM's service providers and bankers and such service providers and bankers have my consent to process my Personal Data for the purpose of effecting and administrating the electronic payments to me (including without limitation, my name, personal identification number, contact details and any other personal data obtained hereafter collectively known as “Personal Data”). TOKIO MARINE INSURANS (MALAYSIA) BERHAD 29th Floor, Menara Dion, 27, Jalan Sultan Ismail, 50250 Kuala Lumpur. Telephone : 03-20269808/27838383 PLEASE RETURN ORIGINAL SIGNED FORM TO TMIM Company/Agency Stamp E-PAYMENT REGISTRATION FORM I/We hereby authorize Tokio Marine Insurans (Malaysia) Berhad (TMIM) to credit all monies due to me/us to my/our bank account indicated above by way of Giro Fund Transfer/Rentas and confirm that: I/We hereby declare that the above is my personal account/our company account, NOT joint account and the information given is true and accurate to the best of my/our knowledge and record. .

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Page 1: E-PAYMENT REGISTRATION FORM - Merimen e-Claims · PDF fileI hereby give my consent to TMIM to disclose my Personal Data provided in this E Payment Registration Form to ... MALAYAN

Please complete the details herein this Form with capital letters and cross (X) the appropriate box.

Policy Holder Agent Broker Reinsurer Adjuster

Repairer Lawyer Financial Institution Service Provider Others

(Please specify)

Section A: PERSONAL DETAILS

Beneficiary Name :

Business Registration No (non-individual) :

NRIC No (individual) :

Address :

Telephone No: Handphone No.

Contact Person 1: Email:

Contact Person 2: Email:

Banker (Please select from drop down list or Appendix A) Bank Code Bank Account Number (please ignore all dashes:'-')

Section B: DOCUMENTS TO BE ATTACHED HEREWITH THIS FORM

For verification purpose, kindly attach the following supporting document that confirm the said account belongs to you/your company

Photocopy of top portion of the bank statement of Current Account, OR

Front page of the Savings Account Passbook, OR

Confirmation letter from bank

Section C:DECLARATION

1

2 I/We shall indemnify TMIM for any loss, damage or claims incurred as consequence of acting on such reliance.

3

4

5

Authorised Signatory

Name

Position

Date

FOR OFFICE USE ONLY :

To be completed by relevant department:

Department/branch MO Code

Agent Name

Client Code Agent Code

Verified by Signature/Date

To be completed by Finance department:

Date received

Data Entry by Finance Signature/Date

Verified by Finance Signature/Date

I understand that I have the right, upon payment of a prescribed fee, to request access to my Personal Data that is being processed by TMIM and to request

correction of my Personal Data. Such request shall be submitted to the Head of Finance, TMIM; and

I understand that the supply of my Personal Data herein is voluntary and it is necessary for TMIM to process my Personal Data for effecting and administrating

the electronic payments to me.

I hereby give my consent to TMIM to disclose my Personal Data provided in this E Payment Registration Form to TMIM, TMIM's service providers and bankers

and such service providers and bankers have my consent to process my Personal Data for the purpose of effecting and administrating the electronic payments

to me (including without limitation, my name, personal identification number, contact details and any other personal data obtained hereafter collectively

known as “Personal Data”).

TOKIO MARINE INSURANS (MALAYSIA) BERHAD

29th Floor, Menara Dion, 27, Jalan Sultan Ismail, 50250 Kuala Lumpur.

Telephone : 03-20269808/27838383

PLEASE RETURN ORIGINAL SIGNED FORM TO TMIM

Company/Agency Stamp

E-PAYMENT REGISTRATION FORM

I/We hereby authorize Tokio Marine Insurans (Malaysia) Berhad (TMIM) to credit all monies due to me/us to my/our bank account indicated above by way of Giro

Fund Transfer/Rentas and confirm that:

I/We hereby declare that the above is my personal account/our company account, NOT joint account and the information given is true and accurate to the

best of my/our knowledge and record.

.

Page 2: E-PAYMENT REGISTRATION FORM - Merimen e-Claims · PDF fileI hereby give my consent to TMIM to disclose my Personal Data provided in this E Payment Registration Form to ... MALAYAN

APPENDIX A

LIST OF BANKERS

Banker Bank Code Bank Account Number (please ignore all dashes:'-')

.

AFFIN BANK BERHAD PHBM (12)

AGRO Bank ( Bank Pertanian M'sia Bhd ) AGOB (17)

ALLIANCE BANK MALAYSIA BERHAD MFBB (15)

AL-RAJHI BANKING & INVESTMENT CORPORATION (MSIA) BHD RJHI (15)

AMBANK BERHAD ARBK (13)

BANK ISLAM MALAYSIA BERHAD BIMB (14)

BANK KERJASAMA RAKYAT BERHAD BKRM (12)

BANK MUAMALAT BERHAD BMMB (14)

BANK OF AMERICA BOFA (12)

BANK OF TOKYO-MITSUBISHI UFG (MALAYSIA) BERHAD BOTK (6)

BANK SIMPANAN NASIONAL BSNA (16)

CIMB BANK BERHAD CIBB (14)

CITIBANK BERHAD CITI (10)

DEUSTCHE BANK DEUT (10)

HONG LEONG BANK BERHAD HLBB (11)

HSBC BANK MALAYSIA BERHAD HBMB (12)

J.P. MORGAN CHASE BANK BERHAD CHAS (10)

KUWAIT FINANCE HOUSE (M) BERHAD KFHO (12)

MALAYAN BANKING BERHAD MBBE (12)

OCBC BANK (M) BERHAD OCBC (10)

PUBLIC BANK BERHAD PBBE (10)

RHB BANK BERHAD RHBB (14)

ROYAL BANK OF SCOTLAND BHD ABNA (7 to 9)

STANDARD CHARTERED BANK MSIA BHD SCBL (12)

SUMITOMO MITSUI BANKING CORPORATION MALAYSIA BERHAD SMBC (8)

UNITED OVERSEAS BANK UOVB (11)

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16

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