Registration Form
E-Payment
Section A: Personal Details
Account Holder Name:
First Name
Last Name
Account Holder Address:
Business Registration No. (Non-individual):
NRIC No./ID No./Passport No. (Individual):
Telephone No:
Format: (000) 000-0000.
Handphone No:
Format: (000) 000-0000.
Contact Person 1:
Email:
example@example.com
Contact Person 2:
Email:
example@example.com
Bank Name
Bank Code
Bank Account Number (please ignore all dashes: '-')
Current Account
Saving Account
Individual Account
Joint Account
Others (Support
NRIC No./ID No./Passport No. (individual) for the 1st name
Section B: Declaration
I/We hereby authorize Tokio Marine Insurans (Malaysia) Berhad (TMIM) to credit all monies due to me/us to my/our bank account indicated above by way of Giro Fund Transfer/Rentas and confirm that:
1. I/We hereby declare that the above is my personal account/our company account, and the information given is true and accurate to the best of my/our knowledge and record and I confirm that the account number written under this E-payment form is correct.
2. I/We shall indemnify TMIM for any loss, damage or claims incurred in whatsoever manner as a consequence of acting on such instruction.
3. I/We hereby give my consent to TMM to disclose my Personal Data to TMIM's service providers and/or financial institutions for the purpose of effecting and administrating the electronic payments (Personal Data includes name, personal identification number, contact details and any other details not specifically mentioned herein).
4. I/We understand that the supply of my Personal Data herein is voluntary and it is necessary for TMIM to process my Personal Data for effecting and administrating the electronic payments to me.
Notice:
Any future changes on the customer personal data, customer are required to write-in to us on the changes. Therefore, kindly provide the email address for the customer to notify the Person In Charge (PIC) to change his/her personal details and email to "letusknow@tokiomarine.com.my".
Authorised Signatory Name:
*Company/Agency Signatory & Stamp
Position:
*Select where applicable
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
FOR OFFICE USE ONLY
To be completed by relevant department:
Client Code:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
*Mandatory to proceed with payment processing on change request: This must be verified with a follow-up call with Payee / Counterpart with Contact details provided
Requestor's Name & Signature/Stamp:
Requestor's Reporting Supervisor Name & Signature/Stamp
*Call-Back Verification Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
*Verified by payee/counterpart on record with TMIM
Yes
No
Supported with email confirmation on call-back verification
Date received:
Created by:
Verified by:
*Verifier Name & Signature
*Reporting Supervisor/HOD Name & Signature
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Tokio Marine Insurans (Malaysia) Berhad
Level 20, Menara Hap Seng 3, Plaza Hap Seng, No. 1, Jalan P. Ramlee, 50250 Kuala Lumpur, Malaysia
T: (03)2027 8200 / 2789 8800 F: (03) 2022 2295
Customer Service Hotline:
1800 88 0812
tokiomarine.com
A member of the Tokio Marine Group
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