Signature Declaration Form

Borang Pengesahan Tandatangan

Proposal Number / Policy Number

Nombor Cadangan / Nombor Polisi

Name of Life Assured / Assured

Nama Hayat Diinsurankan / Pemunya Polisi

STATEMENT OF SIGNATURE DECLARATION / KENYATAAN PENGESAHAN TANDATANGAN

FOR NEW BUSINESS ONLY

I hereby declare that the:-
Saya dengan ini mengesahkan bahawa tandatangan di dalam:-
Conditional Acceptance / Exclusion letter dated ____________________ was signed by me.
Surat Penerimaan Bersyarat atau Berkecuali bertarikh ____________________ adalah tandatangan saya.

Declaration and Consent on Medical Examination Form dated ____________________ was signed by me.
Pengesahan dan Persetujuan pada Borang Pemeriksaan Kesihatan bertarikh ____________________ adalah tandatangan saya.

Other Forms / Questionnaire (_____________________________________) dated ___________________ was signed by me.

Borang-Borang Lain / Borang Soal Selidik (_________________________________) bertarikh __________________ adalah tandatangan saya.

Amendment Form dated ____________________ was signed by me.

Borang Pindaan bertarikh ____________________ adalah tandatangan saya.

Signature of Life Assured / Assured as in Proposal Form Signature of Agent / Tandatangan Ejen
Tandatangan Hayat Diinsurankan / Pencadang seperti Borang Cadangan Agents Name / Nama Ejen:
Agents Code / Kod Ejen:
Date / Tarikh: Date / Tarikh:

STATEMENT OF SIGNATURE CHANGE / KENYATAAN PENGUBAHAN TANDATANGAN

FOR POLICY SERVICING ONLY

I, hereby declare that I have changed my signature. Listed below is the sample of my new signature. My previous signature on record with Prudential
Assurance Malaysia Berhad would now be treated as withdrawn.
Saya mengesahkan bahawa saya telah menukar tandatangan seperti berikut. Rekod tandatangan saya dengan Prudential Assurance Malaysia Berhad
sebelum ini tidak akan lagi digunapakai.

This signature change belongs to: Life Assured / Assured / Spouse / Joint Life /
Assignee / Trustee (Note: Circle whichever is applicable)
Tandatangan ini dimiliki oleh: Hayat Diinsurankan / Pemunya Polisi /
Pasangan Hidup / Ibubapa bersama / Penyerahhak / Pemegang Amanah (Nota:
Sila bulatkan mana-mana berkenaan)
Name / Nama:
I/C No / No K/P:
Tel No / No Tel:
Address / Alamat:

I, hereby declare that I have sighted the original NRIC/birth certificate/passport, and verified the identity of the above mentioned person. I hereby certify
the above signature was made in my presence and that to my own personal knowledge it is the signature of the above mentioned person.
Saya dengan sendirinya telah melihat salinan asal kad pengenalan/sijil surat beranak/pasport, dan mengesahkan bahawa salinan tersebut adalah
kepunyaan hayat yang diinsuranskan/ pencadang seperti nama di atas. Saya dengan ini mengesahkan bahawa tandatangan di atas dibuat di hadapan
saya dan setakat yang saya ketahui tandatangan tersebut ialah tandatangan Hayat yang Diinsuranskan/Pencadang seperti nama di atas.

Important Note
The witness must be completed by an authorized Quality Agent, Quality Leader, Branch Head, Customer Service Representative of Prudential Assurance
Malaysia Berhad; or Commissioner for Oath, Notary Public.
Saksi mesti dilengkapkan oleh Ejen Berkualiti, Pemimpin Agensi, Ketua Cawangan, Wakil Khidmat Pelanggan Kepada Prudential Assurance Malaysia
Berhad yang disahkan; atau Pesuruhjaya Sumpah, Notari Awam.

Signature of Witness / Tandatangan Saksi: Name / Nama:

Agents Code / Kod Ejen:
I/C No / No. K/P:
Tel No / No Tel:
Address / Alamat:

Date / Tarikh:

Prudential Assurance Malaysia Berhad (107655-U)

Level 17, Menara Prudential, No. 10, Jalan Sultan Ismail, 50250 Kuala Lumpur, P.O. Box 10025, 50700 Kuala Lumpur
Customer Service Hotline: 603-2116 0228, Fax: 603-2032 3939, E-mail: customer.mys@prudential.com.my

Form ID 10701003 Version 07/2011