Request for Information

Thank you for taking the time to register your request for information about our insurance products. Please fill in as much information as you can to help guide us to respond properly to your request with the information you require.

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Contact Information

Title:	Mr.Ms.Mrs.Miss.Dr.
Surname:
Other Name(s):
Business Title:
Organisation:
Street Address 1:
Street Address 2:
City:
State:
Postal Code
Country:
Phone:
Fax:
Email Address:

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Insurance Product(s):

What Insurance Product information are you requesting? (Please check all that applies.)

All Risks
Boiler and Pressure Vessel
Bond
Burglary
Contractors All Risk (CAR)
Employer's Liability
Equipment
Erection All Risks (EAR)
Fidelity Guarantee
Fire
Golfer's
Goods-in-Transit
Hospital Income Plan
Homeowners (Building)
Machinery and Equipment

Machinery Breakdown-Loss of Profit
Machinery Breakdown
Marine Cargo
Marine Hull
Money
Personal Accident (Continental Scheme)
Personal Accident (Unit Scheme)
Plate Glass
Professional Indemnity
Public Liability
Sporting Guns
Traveler's Personal
Vehicle Occupants
Workmen's Compensation
Yacht & Pleasure Craft

Please have an agent contact me as soon as possible.

Your Comment Please:

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Pacific & Orient Insurance Co. Berhad (No. 12557-W)
11^th Floor, Wisma Bumi Raya
No 10, Jalan Raja Laut
50350 Kuala Lumpur, Malaysia
Teleinsurance: 1-800-88-2121
Telephone Number: 03 2698 5033 Fax Number : 03 2693 8145 (General)
Fax: 03 2692 6700 (Marketing) Fax: 03 2693 8490 (Finance) Fax: 03 2694 0936 (Claims)
Email: poi@pacific-orient.com