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FOREIGNER'S OUESTIONNAIRE (To be completed by Assured)
SOALSELIDIK WARGANEGARA ASING ((Ilntuk diisi oleh Hayat Diinsuranskan)

Proposal Number /ly'ombor Cadangan Agency No I No Agensi Agent's NamelNama Agen

Full name of Assured I Nama penuh Hayat yang diinsurankan :

Cld Tgerun4l+rl
Passport Number / Nombor Pasport Nationality I Kewarganegaraan City of origin lBandar A.sal

Aa#f 3VA lPnoNt/f //./DD P.et t4

1. Currently, where is your pennanent place of residence?/Pada masa ini, dimanakah tempat tinggal
tetap anda?

2. (a) When did you arrive in fvlalaysial Month/ Yearl


Bilakah anda tiba di Mhlaysia? Bulan: lt Tahun: )777

(b) How long do you intend to stay in Malaysia?


Berapa lamakah anda bercadang untuk tinggal di Malaysia? PFeu eE

3. What is your official status in Malaysia?lApakah status rasmi anda di Malaysia?

I I Employment PasslPas perkerjaanl I Dependant's Pass/Pas tanggungan

t I Student's PasslPas pelajar I I Social PasslPas sosial

I V )Holderof "Malaysia-MySecondHome" programlPemegangprogram"Malaysia-My


. SecondHome,, _ F-etrpe/Vce p*+l

4. (a) Name of your present employerlNama majikan anda seknrang:

BlLuNsF/et D rtTt& tJ*T?ouq a Qte',ovp


(b) Address of employer/A lamat majikan:
I Otr dlrv P22r2eatt2tc4
iro gt XW tzt*tt t4ott
frrnail luu ptt /dnafc . 6a'?m F-uacre tvz)Pt 4
(c) Current position you hold within this company:
Jawatan yang sedang anda pegang di dalam syarikat ini:
A<coo'Arr7''t/T
(d) Annual Income (N)lPendapatan Tahunan (RM):

rn 3$/6DD' dO
t1030101s]

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Do you have the following based in Malaysia?lAdaknh anda mempunyai seperti yang beikut di
Malaysia?

Yes/ No/ Ifyes, state details/


Ya Tidak Jika ya, nyatakon butirannya:

Bank Accountl Akaun B ank r../ rl ntrl&nfi t, 4rr7B, fin& o^l E Ccavpa aec)

PropertylHarta t It
Business/Perniagaan t It
Investment (eg. shares)/ t It
P elaburan ( s ep erti s aharn)

Family members or relatives/ t ,,/ lt I o* C ctNe fltotrul)


Ahlikeluarga atau saudara mara

6. Where did you reside and what was your occupation during the last 5 years?
Dimana anda tinggal dan-apakah pekerjaan anda dalam tempoh 5 tahun yang lepas?

7. Why do you need a Malaysia class policy?


Mengapa anda memerlukan polisi kelas Malaysia?

kcqotc cone,.,/p &g"y' ro fi@/cgltrs , ea/ c/// frrub


norrbe n ll4a/aA(;oa.
8. What do you intend to do with the policy when you leave Malaysia?
Apalah yang anda aknn lakukan dengan polisi tersebut bila anda meninggalkan Malaysia?

dunf ceazlaue o/ rtn 76//o^14 6aaylr


t 9. Please provide details ofyour existing insurance cover including proposals about to be sumitted.
Nyatalan keterangan polisi sedia ada anda termasuk cadanganyang akan dikemukakan.

Year ofPurchase Country Tvoe of olan Sum Assured

10. Does your spouse reside with you?


Adakah pasingan anda tinggil bersama anda? -tlatGLE
| )YeslYa |/ )Noriao*

u030101sI

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11. Is your spouse a Malaysi:rn?
Adakah pasangan anda warganegara Malaysia?

| )YeslYa | - lNolTidak

Occupatior/Pekerjaan
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Nationality/Ke wa r g ane g araan

I the life proposed, confirm that the entire marketing and selling process is respect of my proposed
insurance application has been conducted in Malaysia, which includes but not limited to :

l. I received all of the insurance related marketing materials in Malaysia.


2. The Agent / Sales staff has explained the details of my proposed insurance plan (s) in
Malaysia
I have signed all the documents in respect of my insurance application (including but
not limited to the Proposal Form) in Malaysia.
4. I have paid the initial premium in respect of my proposed insurance application in
Malaysia.

I declare that the answers I have given are, to the best of my knowledge, true and that I have not
withheld any material information that may influence the assessment or acceptance of this proposal.
I agree that this form will constitute part of my proposal for life assurance and that failure to disclos
any material facts known to me may invalidate the contract.

Saya, Hayat yang diinsurankan, mengesbhkan bahawa seluruh proses pemasaran dan penjualan
cadangan insuran saya telah dilakukan di Malaysia, termasuk tetapi tidak dihadkan kepada :
1. Saya telah menerima semuo bahan pemasaran mengenai insuran di Malaysia
2. Agen/knkitangan jualan telah menjelaskan butir-butir cadangan insuran saya di
Malaysia
3. Saya telah menandatangani semua dokumen-dokumen yang berkaitan dengan
permohonan cadangan insuran saya (termasuk tetapi tidak dihadlcan kepada
borang cadangan) di Malaysia
4. Saya telah membayar premium pertamayang berkaitan dengan permohonan
cadangan insuran saya di Malaysia.

Saya mengaku bahawa jawapan yang telah saya berikan adalah, sepanjang pengetahuan saya,
benar dan saya tidak menyembunyikan sebarang maklumat penting yang mungkin akan
mempengaruhi penilaian atau penerimaan cadangan insurans ini. Saya berseruju bahawa
borang ini akan menjadi sebahagian dari borang cadangan untukinsurans hayat dan
kegagalan untuk mendedahkan sebarang maklumat penting yang saya ketahui berkemungkinan
membatalkan kontrak insurans tersebut.

Signed by I Ditandatangani o leh DatelTarikh.

Name of Life Proposed/


Nama penuh Hayat yang diinsurankan

In the presence of. I Disaksikan oleh

Name of Agent/Sales Staff / Nama Agen:

Date I Tarikh
[1030101s]

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