Forms


 
click the icon to download
 

Claim Form - GoLootlo Cardholders

HyperLink
 

Agency Contract

HyperLink

  1. Group Health Family Takaful

  1.1 Participant Services
 

1.1.1 Family Health Questionnaire

HyperLink
 

1.1.2 Enrollment Form

HyperLink
 

1.1.3 Short Form Health Description

HyperLink
 

1.1.4 Additions of Member

HyperLink
 

1.1.5 Deletions of Member

HyperLink
 

1.1.6 Fluctuation – Upgrade/Downgrade etc.

HyperLink
 

1.1.7 Proposal Request Form - Health

HyperLink
 

1.1.8 Group Health Takaful Confirmaiton Form

HyperLink
  1.2 Claim Services
 

1.2.1 Pre-Authorization Information Form

HyperLink
 

1.2.2 Hospitalization Reimbursement Claim Form

HyperLink
 

1.2.3 Out-patient Reimbursement Claim Form

HyperLink

  2. Group Term Family Takaful

  2.1 Participant Services
   

2.1.1 Health Questionnaire (for takaful coverage above FCL)

HyperLink
 

2.1.2 Additions of Member

HyperLink
 

2.1.3 Deletion of Member

HyperLink
 

2.1.4 Fluctuation – Upgrade/Downgrade etc.

HyperLink
 

2.1.5 Group Term Takaful Confirmation Form

HyperLink
 

2.1.6 Nomination Form

HyperLink
 

2.1.7 Declaration of Good Health

HyperLink
  2.2 Claim Services
 

2.2.1 Employer’s Statement – D1 (for Death Claim)

HyperLink
 

2.2.2 Physician's Statement – D2 (for Death Claim)

HyperLink
 

2.2.3 Employer’s Statement – DS-1 (for Disability due to Accident)

HyperLink
 

2.2.4 Physician's Statement – DS-2 (for Disability due to Accident)

HyperLink
 

2.2.5 Employer’s Statement – S-1 (for Disability due to Sickness)

HyperLink
 

2.2.6 Physician's Statement – S-2 (for Disability due to sickness)

HyperLink

  3. Individual Family Takaful

  3.1 Participant Services
 

3.1.1 Change in Contact Detail

HyperLink
 

3.1.2 Change In Nominee

HyperLink
 

3.1.3 Withdrawal Form

HyperLink
 

3.1.4 General Services Request (GSR)

HyperLink
 

3.1.5 Assignment Notice - Company

HyperLink
 

3.1.6 Assignment Notice – Loved Ones

HyperLink
 

3.1.7 Assignment Notice - Provident Fund

HyperLink
 

3.1.8 Reassignment Notice

HyperLink
 

3.1.9 Special Illustration Request Form

HyperLink
 

3.1.10 Declaration of Health & Occupation (DHO)

HyperLink
 

3.1.11 Non-Medical Application Form

HyperLink
  3.2 Claim Services
 

3.2.1 Claimant’s Statement (for Death Claim)

HyperLink
 

3.2.2 Physician's Statement (for Death Claim)

HyperLink
 

3.2.3 Claimant’s Statement (for Disability/Illness Claims)

HyperLink
 

3.2.4 Physician's Statement (for Disability/Illness Claims)

HyperLink

  4. Misc Forms

 

4.1 Complaint Form

HyperLink