MMT Care

Quotation
If you're looking for clinic/hospital quotation, click here
Primary Nature of Service
QE Category
Limit of Liability (G)
Limit of Liability (GP2)
Limit of Liability (GP)
Limit of Liability (GPR)
Limit of Liability (GP-O&G)
Limit of Liability (GP-Cos)
Limit of Liability (Chiro)
Limit of Liability (GD)
Limit of Liability (GD2)
Limit of Liability (Ortd)
Limit of Liability (Ortd2)
Limit of Liability (Perd)
Limit of Liability (Perd2)
Limit of Liability (Dent)
Limit of Liability (Dent2)
Limit of Liability (Endo)
Limit of Liability (Endo2)
Limit of Liability (Prostho)
Limit of Liability (Prostho2)
Limit of Liability (OrM)
Limit of Liability (OrM2)
Limit of Liability (OrP)
Limit of Liability (OrP2)
Limit of Liability (Aud)
Limit of Liability (Aud2)
Limit of Liability (Bld)
Limit of Liability (Bld2)
Limit of Liability (Ccyt)
Limit of Liability (Ccyt2)
Limit of Liability (Cgen)
Limit of Liability (Cgen2)
Limit of Liability (Ccim)
Limit of Liability (Ccim2)
Limit of Liability (ComH)
Limit of Liability (ComH2)
Limit of Liability (CosA)
Limit of Liability (CosA2)
Limit of Liability (Derm)
Limit of Liability (Derm2)
Limit of Liability (Endo)
Limit of Liability (Endo2)
Limit of Liability (FamMed)
Limit of Liability (FamMed2)
Limit of Liability (GenM)
Limit of Liability (GenM2)
Limit of Liability (GenitM)
Limit of Liability (GenitM2)
Limit of Liability (GeriM)
Limit of Liability (GerimM2)
Limit of Liability (Haem)
Limit of Liability (Haem2)
Limit of Liability (Immu)
Limit of Liability (Immu2)
Limit of Liability (InfD)
Limit of Liability (InfD2)
Limit of Liability (IntMed)
Limit of Liability (IntMed2)
Limit of Liability (Neph)
Limit of Liability (Neph2)
Limit of Liability (NucM)
Limit of Liability (NucM2)
Limit of Liability (OccuH)
Limit of Liability (OccuH2)
Limit of Liability (Onco)
Limit of Liability (Onco2)
Limit of Liability (Opht)
Limit of Liability (Opht2)
Limit of Liability (Paed)
Limit of Liability (Paed2)
Limit of Liability (Palia)
Limit of Liability (Palia2)
Limit of Liability (Patho)
Limit of Liability (Patho2)
Limit of Liability (PharmP)
Limit of Liability (PharmP2)
Limit of Liability (Physio)
Limit of Liability (Physio2)
Limit of Liability (PrevM)
Limit of Liability (PrevM2)
Limit of Liability (Psych)
Limit of Liability (Psych2)
Limit of Liability (RehM)
Limit of Liability (RehM2)
Limit of Liability (RenM)
Limit of Liability (RenM2)
Limit of Liability (Resp)
Limit of Liability (Resp2)
Limit of Liability (Rheum)
Limit of Liability (Rheum2)
Limit of Liability (SportM)
Limit of Liability (SportM2)
Limit of Liability (ThorM)
Limit of Liability (ThorM2)
Limit of Liability (AccE)
Limit of Liability (AccE2)
Limit of Liability (Anaes)
Limit of Liability (Anaes2)
Limit of Liability (Cardio)
Limit of Liability (Cardio2)
Limit of Liability (CardioT)
Limit of Liability (CardioT2)
Limit of Liability (ColSu)
Limit of Liability (ColSu2)
Limit of Liability (Cosm)
Limit of Liability (Cosm2)
Limit of Liability (Endo)
Limit of Liability (Endo2)
Limit of Liability (Gastro)
Limit of Liability (Gastro2)
Limit of Liability (GenSu)
Limit of Liability (GenSu2)
Limit of Liability (ICU)
Limit of Liability (ICU2)
Limit of Liability (Neo)
Limit of Liability (Neo2)
Limit of Liability (Neurol)
Limit of Liability (Neurol2)
Limit of Liability (OphtS)
Limit of Liability (OphtS2)
Limit of Liability (Oral)
Limit of Liability (Oral2)
Limit of Liability (ENT)
Limit of Liability (ENT2)
Limit of Liability (PaedSu)
Limit of Liability (PaedSu2)
Limit of Liability (Radio)
Limit of Liability (Radio2)
Limit of Liability (Radioth)
Limit of Liability (Radioth2)
Limit of Liability (ThorSu)
Limit of Liability (ThorSu2)
Limit of Liability (Urol)
Limit of Liability (Urol2)
Limit of Liability (VascuS)
Limit of Liability (VascuS2)
Limit of Liability (BarSu)
Limit of Liability (BarSu2)
Limit of Liability (CosMeSu)
Limit of Liability (CosMeSu2)
Limit of Liability (Gynae)
Limit of Liability (Gynae2)
Limit of Liability (NeuroSu)
Limit of Liability (NeuroSu2)
Limit of Liability (ObGyn)
Limit of Liability (ObGyn2)
Limit of Liability (OrthSu)
Limit of Liability (OrthSu2)
Limit of Liability (PlasSu)
Limit of Liability (PlasSu2)
Limit of Liability (SpineSu)
Limit of Liability (SpineSu2)
Limit of Liability (MedAst)
Limit of Liability (Nurse)
Limit of Liability (Std&Staf)
Limit of Liability (Lecturer)
Limit of Liability (Allied)
Coverage Start Date

DayMonthYear
Coverage End Date

DayMonthYear
Calculation
Period of coverage is less than 6 months
Defence Cost Extension
Coupon
If available
Gross
Final before SST & stamp
Contribution (RM)
incl. 8% SST and stamp

Would you like to add more specialty on top of your primary nature of service?
It is recommended to include all services or sub-specialties related to your main practice if necessary. This information is important for us to better understand your practice and provide appropriate coverage. i.e. General Dentist category, you may add implant, orthodontist etc. For Anaesthetist, you may add ICU; for Neurosurgery you may add Spine.

Please note that the rate may vary and is subject to underwriting. Kindly wait for our quotation email before making any payment.

Click Yes to add, or Next to skip. Click here if you need assistance.
Please note that the rate may vary and is subject to underwriting. Kindly wait for our quotation email before making any payment.

Instructions
1. This form is intended for individual healthcare practitioners.
2. You must answer all the questions where neccessary.
3. At the end of this form, you are required to upload your Identity Card (IC) or Passport (non citizen), and Latest APC/equivalent.
4. If you have any questions concerning this proposal, please click Contact Us
5. Applying through this form, means that you have agreed with our Privacy Policy.

Application Form
Title
title 2
Full Name (as per IC/Passport)
Please DO NOT capitalize all character
Nationality
NRIC
without dash (-)
Passport
Substring YY
DOB - CALC
DOB - OLD (Don't delete yet)

DayMonthYear
Date of Birth
DD-MM-YYYY
Tax Identification Number (TIN)
Optional
Gender
Correspondence Address
House / Hospital / Clinic in Malaysia only
Postcode
City
State
Correspondence Address (don't delete yet)
Primary Practice Location
Mobile Phone Number
Malaysia Mobile Number
Malaysian phone number with WhatsApp onlyFormat: 60100000000[0].
International Mobile Number
International Phone Number with country code (without +)Format: 00000000[0][0][0][0][0][0][0].
Phone Number
Phone Number (Whatsapp)
Email
Please use the same email address you used to login User Portal. If you have never registered to our new User Portal, just proceed filling in this form. We will automatically create a user portal account for you using this email.

Existing / Previous Coverage
Do you currently have any medical malpractice individual practitioner’s Takaful/Insurance?
If YES, please upload your certificate (only from STMAB)

Cancelof
Or provide the details of coverage here
Name of insurer, policy number & coverage limit
Have you ever had any application or had any medical malpractice individual practitioners Takaful/Insurance coverage refused, rescinded or cancelled?
If YES, please upload the details noting the Section number

Cancelof

Details of E-Payment

Please fill your bank details to facilitate e-payment for any amount due and payable to YOU (optional)
Bank Account Number
Account Holder Name
Bank Name

Personal Documents
Copy of IC / Passport

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Latest APC

For student, please upload your student card
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Signature
Date

DayMonthYear
Date
Promo Code
Should be Empty: