IMCIS INSURANCE BERHAD 435910.) Head Office: Wisma MCIS, Jalan Barat 46200 Petaling Jaya Selangor Darl Ehsan, Malaysia Postal Adress: P.O.Box 345, dalan Sultan, 46916 Petaling Jaya, Selangor Darl Ehsan Malaysia. INSURANCE Kopada To: MCIS INSURANCE BERHAD PER/ RE POLISINO/ POLCYNO: “TL 201601218443 ‘Saya meminta MCIS INSURANCE BERHAD (mer kepada MCIS) menghvectkanbayaren insures saya ke akaun bank seprt yang inyatakan i bavah- "hry request ht payment(s) due fo me by MCIS INSURANCE BERHAD (eeatr refered to as MCS) onthe abovementioned ply be cect tomy bank account as stated below ad cont that = 1. Saya mengizinkan MCIS member deta peiba saya kepada pihak bank untuk memudehkn pembayaran insure. | consent to MCIS releasing the below data to its banker in order to facilitate the payment(s) 2. Saya mengssahkan behav maklumat yang dnyatakan ols saya adalah benar dan teat. Sekranya terdapat percanggahan makiumat, ‘pembayaran akan Stangainkan. {conti the information rouded herein ae tue and accurate aint payment il be delayed ‘3. _Perictaan saya tidak boleh dbetatkan tap pesetujuan MCIS, MCIS boleh pad bilathla masa menukar cra pembayaran Kepada ‘saya dengan Kasdan. [My rquest herein shal be ievocable wiht the consent of MCIS. MCIS may a anytime ints absoktecscotion ect payments) tome by ther methods 4. Saye dengan ini menyertakan satin penyata bank halaman yang bekatan dengan akaun simpanan yang jelas menunjukkan nama ‘aya, rombor ident dan nombor aku bank I hereby attach a legible copy ofthe top pation ofthe bank statement / relevant page othe savings account book whch cleay inceate my name, Idertty Ne. and bank account no. 5. Pithanekaun bank dan burn di saya adsah sper dnyatakan of bawah |My prtered bank account and contact details ras stted below. Nama Bank / Bank Name sane SIMPANAN NASIONAL vent | have made an enor or omission, | understand the No Akaun Bank Bank Account —:! QT a lo1g) ol 2 olololtl2 dro + hota + Noo ts Frater sae fea No lent seperti t Akaun Bank Plaiietailea| BM 6 Ientity Ne. a8 por bark A/C WUoBls ~ 03-6247 No Tele Bint - Mobile Phone No. Ol - 9530160 ‘Alamat eel E-mail Adress 3 jakimiamirul @ gmail.com Noma / Name Nie natin Amreu 8H YACcOR Tk / Date 13/3/2019 ‘Afin Bark Bhd Ain lame Bank Bhd 2 ‘AmBank (M) Bhd / Amislamic Bank Bhd ‘Raro Bank / Bank Pertanian ‘Al Rah Bank Malaysia ‘Bank Muamalat Malaysia CCIMB Bank / MB Islamic Bank Berhad ona’ Leona Bank / Hong Leong islamic Bank Boshad Ln tl ‘OCBC Bank Malaysia / OCBC ALA Bank Berhad RHB Bank Berhad / RH Islamic Bank Bhd | United Oversea Bank ‘Sonal adalah uniukrjukan sahaja. Bank iain dalam Malaysia) yang ada dalam senara tas juga dierima, Bank Listed above are reference only. Other banks (In Malaysia) nt Histed ae acceptable.