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Section A - Insurance Policy Information
Insured Name
Class Of Insurance
Select Class
Marine Cargo
Goods In Transit
Freight Forwarder’s Liability
Erection All Risk
Contractor’s All Risk
Fire And Burglary
Motor
Hospitalization And Surgical
Travel
Group Personal Accident
Policy Number
Insurer
Select Insurer
CHUBB Insurance Malaysia Berhad
RHB Insurance Berhad
Tokio Marine Insurance Berhad
Zurich Insurance Malaysia Berhad
QBE Insurance Berhad
AXA Affin Insurance Berhad
Section B - Client Information
Company Name
Name
(person-in-charge)
Contact
(person-in-charge)
Email
(person-in-charge)
Section C - Claim Information
Description of Loss
Estimate Of Loss
Date of Loss
Submit
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