Form cover
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Group Personal Accident Coverage (GPA)

There might be further form from insurer to be filled in.

SCHOOL/ORGANIZATION/COMPANY NAME

COMPANY REGISTRATION NUMBER(for organization/company)

NATURE OF BUSINESS

OFFICE/SCHOOL/ORGANIZATION/COMPANY ADDRESS

Name of event / Activities / Project (if any) 

Event Details / Activities / Itinerary / Brochure
(Event / Risk Location in Full Address) or email to mfairuzramli@yahoo.com or whatsapp 0134555888

PERIOD OF COVER (START DATE - END DATE)

CHOOSE ONLY ONE PLAN:

Option 1: COVERAGE (DEATH/PERMANENT DISABLEMENT)

Option 2: Group Domestic Travel Personal Accident-more than 50km from home (More benefits) 

Cover Death/permanent disablement RM50K, accident medical expenses RM5K, Repatriation of Mortal RM50K

Upload List in excel (full name, ic no, designation) or email to mfairuzramli@yahoo.com or whatsapp 0134555888

NAME OF PERSON IN CHARGE (PIC)

EMAIL

PHONE NUMBER

Do you have spesific budget(RM)?

Do you have any request? Write below:

* * Quotation akan dikeluarkan dalam masa 2-4 hari bekerja. ** Proses ambil masa kerana Underwriter syarikat insurans/takaful akan menilai risiko sebelum meluluskan/menolak permohonan ini. Setiap kes adalah berbeza penilaian. Harap bersabar menunggu proses daripada pihak syarikat insurans/takaful.