Claim Form

INFORMATION

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T 3 T H E F T C O V E R - CLAIM FORM

The claimant is requested to note:-

•	Before submitting details of loss the claimant is requested to read the terms and conditions of the policy.
•	The claimant is required to state the information below as fully and accurately as possible.
•	Completion of this form is without prejudice to the terms and conditions of the Policy and should not be regarded as a waiver by the Company of any breach of the conditions the Insured may have committed.
•	The acceptance of this form is not in itself an admission of Policy liability on the part of the Company.
•	As it is a condition of the policy that it shall be void if any false statement or declaration be made in support of a claim, care should be exercised in completing this form.
•	When dispatching this claim form via registered mail or courier please ensure that you enclose the “original Police report”, the “original Proof of purchase” and the “T3 key” to avoid any delays with the speedy settlement of your claim.

Claimant's Information

The following field with ( * ) is required to fill-in.

*Name :
*NRIC No :	*Passport No :
*Address :	*Date of Birth :	(e.g: dd/mm/yyyy)
*Contact No :	*Email :

Property Details

*Type :

*Brand :

*Make & Model :

*Serial No :

*Invoice Date :

(e.g: dd/mm/yyyy)

*Invoice Value :

*Date/Time of Loss :

(e.g: dd/mm/yyyy, hh:mm)

*Location of Loss :

*Describe in detail
how the loss
occurred :

*Is your property currently insured with another insurance company ?
YesNo

If Yes, please provide a copy of the policy.

Declaration
I/We declare that, to the best of my/our knowledge, the statements herein are true.

--------------------------------------------
Signature &/or Company Chop
(whichever is applicable)

-------------------------
Date (dd/mm/yyy)

NOTE
The Claimant shall furnish the following documents which are required to substantiate the claim.

   a) Print and sign this Claim Form
   b) Original Police Report
   c) Original Purchase Invoice of the stolen property
   d) T3 Security Key
   e) A copy of the other insurance policy (where applicable)

The claimant is required to send the above by registered mail or courier service to the following address:-

   TISS-MSC Sdn Bhd
   3A12 Block C
   Damansara Intan
   No. 1 Jalan SS 20/27
   47400 Petaling Jaya
   Selangor Darul Ehsan
   Malaysia.

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