Quotation Requisition Form (MED - GHS)

GROUP
HOSPITALISATION &
QUOTATION
SURGICAL REQUISITION FORM
For office use only.
All questions should be answered in full.
1. GENERAL INFORMATION
Company Name: GLAMPING PARK TRAVEL AND TOUR SDN BHD
Nature of Business or Activity: HOSPITALITY, HOTEL, ADVENTURE ACTIVITIES TE
Broker or Agent:
Person In Charge: MOHD NOR ARIF BIN MOHD AZMI
2. ELIGIBILITY DEFINITION
a) How many people does this Company/Organisation employ? 30 EMPLOYEES
b) Is cover to apply to all Employees? .................................................................................................................................................... Yes or No
c) If “No” please define the class of Employees or Persons for whom cover is required. (For example “All employees earning over RMx per month”
or “All directors, managers, supervisors, technicians and administrative staff”, etc.)
3. TYPE OF ENROLMENT
a) Will Eligible Persons contribute towards the cost of this insurance .................................................................................................... Yes or No
b) Will all Eligible Persons be enrolled? ................................................................................................................................................. Yes or No
c) Will Eligible Persons have the choice to join or not join? .................................................................................................................. Yes or No
4. OCCUPATIONAL RISKS
a) Are any persons to be insured engaged in any regular offshore, underwater, underground, manual or field work exposures: Yes or No
If “Yes” please give details including the number of employees involved.
b) Are any persons to be insured frequently in remote areas more than 150 kms distant from adequate medical facilities? Yes or No
If “Yes” please give details including the number of employees involved.
5. BREAKDOWN OF ELIGIBLE PERSONS TO BE COVERED

Type of Category/Plan Plan A Plan B Plan C Plan D Plan E Plan F
Employee Only
Employee & Spouse
Employee & Children
Employee & Family
Total number of members
6. TYPE OF BENEFITS/COVERAGE
Benefit & Coverage/Plan Plan A Plan B Plan C Plan D Plan E Plan F

Room & Board
Basis (IL-Inner Limit, AC-As Charged)
Annual Overall Limit
Additional Benefits Plan A Plan B Plan C Plan D Plan E Plan F
1 F-TP-033-V0
7. PREVIOUS MEDICAL AND HEALTH RELATED COSTS
a) Are they now or have they previously been insured for Hospitalization & Surgical type of benefits?.............................................. Yes or No
If “Yes” please state name of Insurer/s and the Period of Insurance during the past 3 years AIA EMPLOYEE BENEFITS
b) If no health insurance has been arranged previously, has the Company provided or funded staff
medical benefits?................................................................................................................................................................................. Yes or No
c) Please provide the following information on the total cost of medical and health related or insurance claim costs, both paid and outstanding,
during the last 3 years.
(NB: If no previous insurance was covered please provide the same information with regard to company funded staff medical benefits).
Total number of claims Total Amount Total number of Persons/

Year
(Actual or estimated) Paid Outstanding Dependants then insured
1) 2020 - - - -
2) 2021 - - - -
3)
d) Please describe briefly the type and level of benefits then provided or alternatively attaches the Schedule of your previous policy.
 Local Hospitalisation and Surgery Cover, including daily cash benefits
 Oversea hospitalisation following an accident
 Emergency Medical Evacuation and Repatriation
e) What annual premium is currently being paid or alternatively what is your approximate annual budget for providing the benefits proposed?
f) Has the Insured Person ever made a claim against any insurance company for injury or sickness?.................................................... Yes or No
If “Yes”, please provide details as follows:
Name of Claimant Nature of Disability (state the surgical procedure, if available) Date of Disability Amount Settled (RM)
8. OTHER OPTIONS OR REQUIREMENTS

Please indicate any other requirements or options you wish to consider:
10. DECLARATION
I hereby confirmed the information stated in this form is true and correct and I have not concealed and misrepresented any material fact.
Signature of Authorised Official: Date: 21 JANUARY 2022

Note: We would remind you of the need to disclose to us, fully and faithfully, the facts you or your Company know or ought to know, otherwise no benefit
may be received from the Policy.
Important Note:
2 MSIG.
1. The quotation will be subject to other classes of Insurance insured with F-TP-033-V0
2. MSIG shall only consider Take-Over Policy at the time of proposal and any appeal after the policy is issued will not be entertained.

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GROUP

Nature of Business or Activity: HOSPITALITY, HOTEL, ADVENTURE ACTIVITIES TE

b) Will all Eligible Persons be enrolled? ................................................................................................................................................. Yes or No

If “Yes” please give details including the number of employees involved.

5. BREAKDOWN OF ELIGIBLE PERSONS TO BE COVERED

Benefit & Coverage/Plan Plan A Plan B Plan C Plan D Plan E Plan F

Total number of claims Total Amount Total number of Persons/

8. OTHER OPTIONS OR REQUIREMENTS

Signature of Authorised Official: Date: 21 JANUARY 2022

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