NETTIUM SDN BHD

NOMINEE FORM
(Read the Notes on the Reverse before completing the form)

SECTION A SECTION B
(To be completed by Employee) (To be completed by Witness)

NAME OF EMPLOYEE I hereby certify :-

(In Block Letters) :
a) that the signature / thumb print of
COMPANY : the said employee has been affixed
in my presence.
NRIC NO./ PASSPORT NO. :
*b) that the employee understands
I hereby nominate the person(s) named in the Schedule on the English and does not require this
reverse of this form to receive at my death the share(s) set down Nomination to be interpreted to
against their respective names of all sums due and payable to me him/her.
by the Company and all benefits arising from Group Term Life
Insurance Policy undertaken by the Company for my benefit, *c) that as the employee does not read
provided that the share of any nominee who dies before me shall be or write English, this nomination
passed to the surviving nominee(s) and shall be shared among before made by the employee has
them in the same proportion as the respective share of the been clearly interpreted to *him /
surviving nominee(s) bear to each other. her in _______________________
which dialect / language is
Notwithstanding the above nomination, I understand and declare understood by *him / her and *he /
that : she appeared to understand the
same.
a) the Company shall upon receipt of the full claim from the
Insurance Company after my death and in its absolute
discretion, pay the sums and benefits to all or any of the named
nominee(s) living at the date of my death;
- Signature of Witness :
b) the Company shall NOT be liable to my estate to anyone
claiming thereunder or to any of the named nominee(s) or their
respective estates in respect of the exercise of its discretion
referred to in (a) above;

c) If any of the named nominees shall, at any time of payment, - Full Name (in Block Letters)
have not attained the age of twenty-one (21) years, then the
receipt of his/her parents or guardian shall be a full and proper
discharge to the Company for the said payment.

- NRIC/Passport No.:

- Address :

_____________________________________
Signature or right thumb print of employee
(to be affixed in the presence of witness)

Dated this ________ day of ___________________ year __________ .

* Delete where appropriate

Page 1 of 2
 SCHEDULE OF PERSONS NOMINATED

Name of Nominee : Relationship :

(In Block Letters)
Contact No : (HP) (H)

Address :

*NRIC/Birth Cert./Passport No.: Date of Birth : Share :

Name of Nominee : Relationship :

(In Block Letters)
Contact No : (HP) (H)

Address :

*NRIC/Birth Cert./Passport No.: Date of Birth : Share :

Name of Nominee : Relationship :

(In Block Letters)
Contact No : (HP) (H)

Address :

*NRIC/Birth Cert./Passport No.: Date of Birth : Share :

Name of Nominee : Relationship :

(In Block Letters)
Contact No : (HP) (H)

Address :

*NRIC/Birth Cert./Passport No.: Date of Birth : Share :

Name of Nominee : Relationship :

(In Block Letters)
Contact No : (HP) (H)

Address :

*NRIC/Birth Cert./Passport No.: Date of Birth : Share :

* Delete where appropriate

IMPORTANT NOTES

1. The employee MUST ensure that the Nominee Form is properly completed before returning it to the Company.
Any omission or ambiguity may render the nomination invalid. Any cancellation, alteration or erasure MUST be
signed by the employee concerned.
2. The employee or his/her nominee(s) MUST NOT sign as witness. It is preferable that the witness be a
representative of the Company or a colleague of the employee.
3. When completing the relevant column for share, the fraction or percentage each nominee is to receive in the
event of the employee's death must add up to one (1) in the case of fraction or one hundred (100) in the case
of percentage. The word "whole" is to be inserted if there is only one nominee.
4. This nomination supersedes all prior nominations which are hereby deemed to be cancelled and shall remain
until such time a new Nominee Form is submitted to the Company by the employee.

Page 2 of 2