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E-CLAIMS MEMBERSHIP APPLICATION |
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FORM |
OneWorks Sdn Bhd (223528-T) |
M 4 |
No.19-1, Jalan 1/116B, Kuchai Entrepreneurs' Park, 58200 Kuala Lumpur. |
Tel 60 (3) 7989 0220 Fax 60 (3) 7989 0202 Url:http://www.eclaims.com.my |
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COMPANY PARTICULARS |
Name | IC No. |
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Company Name | Designation |
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Company No | Telephone |
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Address | Facsimile |
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Email |
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________________________ |
Postal Code
City |
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No Of Employees |
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No Of PCs In Your Organization |
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SERVICE DETAILS: www.eclaims.com.my |
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Charges |
Submission to subscribed Insurers electronically |
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* This will include: (i) Unlimited access to the case file (ii) Unlimited supplementary claims |
RM 10 |
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Prepare and print repair estimate only |
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* This allow the print-out of repair estimates and with no submission. |
RM 10 |
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Please include RM300.00 prepayment for claims processing charges. |
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* A prepaid balance of RM50.00 have to be maintained at all times. |
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PAYMENT |
Payment can only be made by Crossed Cheque/Money Order/Bank Draft made Payable to: OneWorks Sdn Bhd |
Please send payment to: OneWorks Sdn Bhd, No 19, Jalan 1/116B, Kuchai Entrepreneurs' Park, 58200 Kuala Lumpur. |
Payment can also be made directly into our Public Bank Account : 3103952219. Please send a copy of the bank-in slip. |
Bank |
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Amount |
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Cheque No |
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DECLARATION |
I/We represent and warrant that the above information given is true, correct and valid. OneWorks Sdn Bhd reserves the right |
to reject this application and / or terminate the service at any time without making any refund or payment should the above |
information is found to be false, incorrect or invalid. By using this service,I/We hereby agree to be bound by all terms and |
conditions as stated overleaf. |
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Organization/Company Stamp |
Date |
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Signature |
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