PRUDENTIAL BSN Amendment to Proposal for Family Takaful Pindaaan kepada Cadangan Takaful Keluarga Proposal Numbet/Nombor Cadamgan : 10318669 Name of Proposer/Nama Pencadang > MUHAMMAD FAZREQ AFIQ RIN MAT? {the above named proposer, hereby request that my aplication for family tekaful o beamended as follow:~ Se, pncadang spe ma ats dengan nl memokan permohonan tka Helga soy ends sepert beritut:- Due to occuPerhon . - Following Oeiail © 4) Proposer \ra Ses Assistant in if electric Enterpne Woh auhy jc Calling eleceal Preducts ie. TY, avard , WaShirg Mache Obl move Produete Pro poser Onl Sell ord rot a tehniGan, Duties im Showrem only &) No} involve ih ong heigict, installahon and repalnrg €) Job duher ony Selling 1 ceriy tht tere hasbeen no change in my conitkn of neath and that {have not rected any medical attention, consultation or examination whatsoever, since the date of my application and that all my answers: Satin he sa pplication ae sil. {gre tat is form il coasts pat af ny preps fr funy {skal and ht filuretodilose any mate fat known to me may invalidate the comract, ‘Sava mengot behave tadspervbahon tentang tadan kesthaton ava dan say ida mererimaapa-apa rain perubatn, dna pater ta pemerstan sak arth perahonan sya dn ema fvapon se ‘ang tercata ddan permohanon ini mash benar. Saya bersern bohawa borane It akon merlad Sehahegian cadangan takajul keluarga saya dan kegagalat mendedahkan fakie yang saia ketahut akan ‘mombataon kontrak okafs ii Signed tok 3 3D day o¢__]>- 20 DOK Planter eT et ‘Witnessed by = A Disa deh Sipura ep Pon Tandatargan Eien Tandarangan Pencadang Ageney No! No dgens!: OR00a4 [ 60102001 |PRLDENTIAL BSN Amendment to Proposal for Family Takaful Pinduaan kepada Cadangan Takaful Keluarga Proposal Nimber/Nombor Cadangan : 10318669 Name of Proposer/Nama Pencadang * MUHAMMAD FAZREQ AFIQ RIN MAT? {the above named proposer, hereby request that my aplication for family takaful o be amended as follow:= Saya, pencadang seperti nama di ates, dengan inl memolon permohonan takef keluarga save dgpind ‘sepert berltut:- @ — Net involve ih any voltage Sihiaher Lentty tha there has been no change in my condition oF health and that | have not received any medical ‘tention, consultation or examination whatsoever, since the date of my application and that all my answers ‘ated inthe said application are sill tw. | agree that this form will constitue par of my proposal for family ‘kal and that fillureto disclose any material fact Known to me may invalidate the contract. ‘Sava mengatu bahawa tide perebahan tentans keadaan ketihaton saya dan saya tidak menerime apa-apa ‘rawatan penubatan,Khidmai pakar atau pemeriksaan sik tarikkpermohonan saya dan semua javapan sae sing tercatat ai dalam permohonon ini masth bonar. Sapa berseriiu bakawa boreng Int aken menjadi sebahaglan cadengan takajul keluarga saya dan kegagalot mendedahkan fakte yang spe ketahul akan ‘membetalkan Rontrak okay in Speen —_ Fon this 23 tay ot_1> 300_20)5 Witessed by : ; Disaksikan oleh Signature oF ‘Signature of Proposer Tandatargan Elen Tandatangan Pencadons ‘Agency No'No.dgend : TRIODIZg {60102001 |