AIA Register Form

National Union of Bank Employees, MALAYSIA

Member Registration Login

Branch

Member

Member Non-Member

Name

Date of Birth

NRIC New

NRIC Old

Gender

Bank Name

Branch Name

Bank Address

Occupation

Permanent Address

Country

State

City

Post Code

Correspondance Address

Correspondance Address

Country

State

City

Post Code

House Phone No

Office Phone No

Hand Phone No

Email Address

Personal Bank Account No

Bank Name

Bank Email Address

I understand that the premium amount is RM 1188 including GST/SST of 6% and I agree to this.

I understand that the premium amount is RM 1288 including GST/SST of 6% and I agree to this.

Reference Spouse / Children To Be Insured

* Husband / Wife (Requirement spouse shall not more than 65years old)

Name as per NRIC

NRIC NO

Date of Birth

IC copy of attachment for spouse

Max file size: 2Mb

* Child (Requirement >15 days old). Coverage till 19 years unmarried. If still pursuing studies at Institute of Higher Education, till age 23.

* (Confirmation Institute of Higher Education as in the Student Card / Letter of confirmation Institute of Higher Education, must be attached)

Name as per NRIC

NRIC NO

Date of Birth

IC copy of childrens

Max file size: 2Mb

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Health Declaration

I / We admit and verify that I am in a healthy condition and do not take any medical advice, counseling or treatment regarding heart disease, stroke, kidney failure/issues, tumors, high blood pressure, diabetes, gall bladder stones or any other diseases, operations, accident investigation, treatment or physical assessment other than mentioned.

I / We also verify that I have not hidden, falsified or given any false information regarding any of the important statements.

I have the following medical condition/s:

Name as per NRIC

Hospital Name

Local Treatment / Doctor's Name

Last date of treatment/Diagnosis

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SURAT PERSETUJUAN
INSURAN HOSPITAL & PEMBEDAHAN KELUARGA

Kepada,
Pengurus,

Tuan/Puan,

PERJANJIAN KOLEKTIF MCBA/NUBE ARTIKEL 24 (4) (a) (iv) DAN 24 (4) (b) (iv) BAYARAN BALIK RM1188.00 -INSURAN HOSPITAL DAN PEMBEDAHAN BAGI PASANGAN DAN KANAK-KANAK

Saya, (No KP: ) adalah seorang ahli NUBE.
Premium insuran adalah RM1188.00 setahun atau jumlah yang dinyatakan di bawah Artikel 24 (4) (a) (iv) dan 24 (4) (b) (iv) Perjanjian Kolektif MCBA/NUBE khususnya bagi pembelian insuran Hospital & Pembedahan Keluarga bagi pasangan dan anak-anak saya atas dasar pembayaran balik.
Saya dengan ini memberi kebenaran untuk pemotongan RM1188.00 setahun daripada peruntukan Faedah Perubatan Keluarga berjumlah RM2,000.00 setahun dan mererr.itkan bayaran terus kepada NUBE di pejabat berdaftarnya di No. 12 NUBE House, Tingkat 3, Jalan Tun Sambanthan 3, Brickfields, 50470 Kuala Lumpur.
Saya berhak menarik balik persetujuan saya ini dengan mengemukakan Notis Pembatalan lnsuran secara bertulis satu (1) bulan sebelum pembaharuan insuran ini.

Please sign here.

(TANDATANGAN)

(NAMA DALAM HURUF BESAR)

(NO KAD PENGENALAN)

(CAWANGAN BANK)

(TARIKH)

(Sila isi dua salinan)

Addition

* With this, I admit that every statement I have made above and in the document related to my admission is completely true according to my knowledge and beliefs.

* I give permission and allow AIA Bhd to retrieve my statement from the doctor that has treated me or any other insurance company that has insured me before.

* I agree that all statements and admission in the form above me is the base of agreement between AIA Bhd and myself.

Consent Letter

Max file size: 2Mb

IC Copy

Max file size: 2Mb

Application Form

Max file size: 2Mb

Other Attachments

Max file size: 2Mb

National Union of Bank Employees, MALAYSIA

SURAT PERSETUJUAN INSURAN HOSPITAL & PEMBEDAHAN KELUARGA

SURAT PERSETUJUAN
INSURAN HOSPITAL & PEMBEDAHAN KELUARGA