INTERNATIONAL ISLAMIC COLLEGE dolla Zalfaalfl Aalesil eee tn aN STAFF CONSENT FORM (Salary Deduction) Purpose: Hospitalization & Surgical Insurance 2019 NAME OF EMPLOYEE, | IC / PASSPORT NO. DEPARTMENT/SCHOOL/CENTRE CONTACT NO DEPENDENT NAME NewNRIC/Passpor | PME OTB | og No. /Birth Cer. No. | (44/sam/sy) (as per NRIC/Passport/Birth Certificate) SPOUSE CHILDRENS | 1.INTERNATIONAL ISLAMIC COLLEGE Auplleall alfunlfl Aalesll KOLEJ ISLAM ANTARABANGSA, GROUP HOSPITALIZATION & SURGICAL INSURANCE 2019 Please be informed that all staffs allowed to choose yous insurance plan that you wish to join ‘The yeatly premiums for Group Hospitalization and Surgical (GHS) Insurance 2019 with 30% of co sharing of annual premium are as follows: Plan 1 (RM200) 1 | Employee Only 2 | Employee & Spouse 1,755.60 2,508.00 3 Employee & Children 1,755.60 2,508.00 4 | Employee & Family 2,808.40 4012.00 Plan 2 (RM150) 1 | Employee Only 651.00 2 | Employee & Spouse 1,627.50 3 | Employee & Children 1,627.50 2,325.00 4 | Employee & Family 2,604.00 3,720.00 Plan 3 (RM100) Employee Only 614.60 Employee & Spouse 1,536.50 Employee & Children 7,536.50 Employee & Family 2,458.40 2,195.00 3,512.00 af ol nlStaff can choose any of the four (4) coverage offer by the company for both plan. The monthly payments for coverage are as follows (kindly choose one (1) of your plan): Plan 1 (RM200) RM30.09 2 | Employee & Spouse 752.40 "752.40 /10= RM75.24 3 ‘Employee & Children 752.40, 752.40/10= RM75.24 4 | Employee & Family 1,203.60 1,208.60/10= (for married staff only) RM120.36 Plan 2 (RM150) Employee Only RM27.90 2 | Employee & Spouse 697.50 697.50/10= RM69.75, 3 Employee & Children 697.50, 697.50/10= RM69.75 4 | Employee & Family 1,116.00 1,116.00/10= (for married staff only) RMI11.60Plan 3 (RM100) No Coverage Stait30% Monthly Payment | Please (@®M) Tick fa Employee Only 263.40 263.40/10= RM26.34 2 | Employee & Spouse 658.50 658.50/10= 7 RM65.85 3 Employee & Children 658.50 658.50/10= ] RM65.85 4 | Employee & Family 1,053.60 1,053.60/10= (for married staff only) _ RM105.36 Staff will be allowed to make salary deduction up to a maximum of ten (10) months. Although the payment is divided by ten (10) months but the coverage covers up to twelve (12) months effective 1" January 2019 until 31 December 2019. * Kindly be informed that there will be a co-payment system for actual bills incurred, staff will be required to pay 10% from the actual bills. Company will deduct the amount due thru salary deduction up to a maximum of twelve (12) months. I hereby agree with the stated deduction based on the above calculation for the duration of ten (10) months effective January 2019 until October 2019. Signature of Employee Date: Name: Confirmed as correct info, Signature of HR Rep Date: