e-payment registration form - merimen e-claims · pdf filei hereby give my consent to tmim to...
TRANSCRIPT
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
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2 I/We shall indemnify TMIM for any loss, damage or claims incurred as consequence of acting on such reliance.
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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.
.
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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