Proposal Specially Designed for You

Proposed Insured: Madam Rafidah Age: 29 (Non-Smoker)

YOUR PLAN(S) AND PREMIUM(S)

SUM INITIAL REGULAR

COVER UP TO
PLAN(S) INSURED PREMIUM (MYR)
AGE
(MYR) ANNUAL MONTHLY
- AXA Medic Essential – Smart 81 - 938.00 82.07
Your Total Initial Premium is 938.00 82.07

Prepared by : KUSMAADIKAWIRA BIN SUPARMANTO

Agent code : 12562
Tel. No.:
Fax/Email :
Date prepared : 28/06/2021
THE TERMS AND FIGURES SET OUT IN THIS DOCUMENT ARE BY WAY OF ILLUSTRATION ONLY
AND ARE NOT INTENDED TO BE BINDING ON EITHER AXA AFFIN LIFE INSURANCE BERHAD OR
YOU. NEITHER YOU NOR AXA AFFIN LIFE INSURANCE BERHAD IS OBLIGED TO ENTER INTO ANY
CONTRACT ON THE EXACT TERMS SET OUT IN THIS DOCUMENT.
Note :
· The initial monthly premiums shown above indicate the amounts payable under monthly payment mode and are provided
for Your reference only. All projections of benefits in this proposal are based on annual premiums.
· If after purchasing this Policy, You realise that it does not fit Your financial needs, You may cancel Your Policy by returning
the Policy within 15 days from the date of Your receipt of this Policy. The premiums that You have paid less any medical
fee incurred will be refunded to You. However, no refund can be made when a claim has been admitted.
AXA AFFIN Life Insurance Berhad 200601003992 (723739-W)
8th Floor, Chulan Tower, No.3 Jalan Conlay, 50450 Kuala Lumpur. Telephone : +603 2117 6688. Fax : +603 2117 3698

MEN04D|
Date: 28/06/2021
Page 1 of 9
 AXA Medic Essential – Smart
SUMMARY ILLUSTRATION
Occupation Class: 1

End of Policy Year Annual Premium Paid Per Year Insured Age at End of Policy Year
1 938.00 30
2 938.00 31
3 1,119.00 32
4 1,119.00 33
5 1,119.00 34
6 1,119.00 35
7 1,119.00 36
8 1,341.00 37
9 1,341.00 38
10 1,341.00 39
11 1,341.00 40
12 1,341.00 41
13 1,644.00 42
14 1,644.00 43
15 1,644.00 44
16 1,644.00 45
17 1,644.00 46
18 2,093.00 47
19 2,093.00 48
20 2,093.00 49
25 2,566.00 54
30 3,139.00 59
35 3,952.00 64
40 5,004.00 69
45 6,122.00 74
50 6,988.00 79
52 6,988.00 81

Notes:
· This illustration assumes that premiums are paid annually and includes additional premium imposed due to higher than standard Medical /
Occupation Rating (if any).
· The illustrated premium rates are not guaranteed.
· Premium will be charged according to Your attained age at renewal and the renewal premiums increase accordingly to Your age.

AXA AFFIN Life Insurance Berhad 200601003992 (723739-W)

8th Floor, Chulan Tower, No.3 Jalan Conlay, 50450 Kuala Lumpur. Telephone : +603 2117 6688. Fax : +603 2117 3698
Proposed Insured : Rafidah (Non-Smoker) Date: 28/06/2021
Prepared by : KUSMAADIKAWIRA BIN SUPARMANTO Ver 7.14.0 Page 2 of 9
 AXA Medic Essential – Smart
PRODUCT NOTES
IMPORTANT
· The information set out below forms part of Your Sales Illustration.
· AXA AFFIN Life Insurance Berhad believes it is important that You fully appreciate all the benefits under Your Policy.
· The illustration includes a schedule that shows how the premium of Your Policy changes over time.
· You should satisfy Yourself that this plan serves Your needs and that You can afford the premium. If You need clarification, please
contact Us or Your agent.
Product Description
· AXA Medic Essential is a non-participating regular premium standalone medical plan which provides medical and hospitalisation benefit
that includes in-patient and surgical benefit, out-patient benefit and special benefit. The coverage is up to age 81 of the Insured. Please
refer to the Product Disclosure Sheet for the Schedule of Benefits and the benefit details
Total Premium Paid
· This is the amount that You pay for this Policy at the beginning of the year.
· The premium payment period is 52 years. The premium rates are not guaranteed and may increase upon renewal. We reserve the right to
revise the premium rates by giving You at least 90 days notification.

Declaration:
I confirm that I have read and understood the information provided in this illustration. My agent has fully explained to me the features and
charges that will be made on this plan.

Applicant's Name: Signature: Date:

Agent's Name: Signature: Date:

AXA AFFIN Life Insurance Berhad 200601003992 (723739-W)

8th Floor, Chulan Tower, No.3 Jalan Conlay, 50450 Kuala Lumpur. Telephone : +603 2117 6688. Fax : +603 2117 3698
Proposed Insured : Rafidah (Non-Smoker) Date: 28/06/2021
Prepared by : KUSMAADIKAWIRA BIN SUPARMANTO Ver 7.14.0 Page 3 of 9
 AXA Medic Essential – Smart
PRODUCT DISCLOSURE SHEET
Read this Product Disclosure Sheet and the Proposal Specially Designed For You before You decide to take out this product. Be sure to also
read the general terms and conditions.

1. What is this product about?

This is a non-participating regular premium standalone medical plan which provides medical and hospitalisation benefit that includes in-patient and
surgical benefit, out-patient treatment and special benefit in accordance with Your chosen plan. The coverage is up to age 81 of the Insured.

2. What is the cover / benefits provided?

Your chosen plan: Smart

Plan (MYR) Smart Care Classic Premier

Annual Limit
100,000 120,000 120,000 220,000
(applicable to benefit no.1 to no.11)
Lifetime Limit No Limit
Deductible
250 Nil
(applicable to benefit no.1 to no.10)
Section A: In-Patient and Surgical Benefit (for any one disability)
1 Hospital Room and Board
100 150 300
(daily maximum)
Maximum number of days 120 days for any one disability
2 Intensive Care Unit As charged
Maximum number of days 120 days for any one disability
3 In-Patient Related Fees
(a) Hospital Supplies and Services
(b) Surgical Fees
(c) Anaesthetist Fees
(d) Operating Theatre Fees
As charged
(e) In-Patient Prescribed Medicines
(f) In-Patient Diagnostic Procedures and In-Patient
Physiotherapy
(g) In-Patient Physician Visit
(up to 2 visits per day per physician)
(h) Medical Report Charges Up to 50 per
Up to 200 per hospitalisation
hospitalisation

4 Ambulance Fees Up to 350 per hospitalisation As charged

5 Child Daily Guardian Benefit
Not applicable As charged
(for child aged below 15 years)
Maximum number of days 60 days for any one disability
6 Daily Allowance for Hospitalisation in Government
60 per day
Hospital
Maximum number of days 60 days for any one disability
7 Additional Daily Allowance for Hospitalisation in
60 per day
Government Hospital Isolation Ward
Maximum number of days 30 days for any one disability

AXA AFFIN Life Insurance Berhad 200601003992 (723739-W)

8th Floor, Chulan Tower, No.3 Jalan Conlay, 50450 Kuala Lumpur. Telephone : +603 2117 6688. Fax : +603 2117 3698
Proposed Insured : Rafidah (Non-Smoker) Date: 28/06/2021
Prepared by : KUSMAADIKAWIRA BIN SUPARMANTO Ver 7.14.0 Page 4 of 9
 AXA Medic Essential – Smart
PRODUCT DISCLOSURE SHEET

Section B: Out-Patient Benefit (for any one disability)

8 Day Surgery and Daycare Surgical Procedure As charged
9 Pre-Hospitalisation Benefit
(within 60 days before hospitalisation)
Up to 2,000 Up to 3,000
(a) Consultation
(b) Diagnostic Procedures
10 Post-Hospitalisation Benefit
(within 150 days after hospital discharge)
Up to 4,000 Up to 6,000
(a) Medication and Treatment
(b) Out-Patient Physiotherapy
11 Emergency Accidental Out-Patient and Follow-up
Treatment Up to 2,000 Up to 3,000
(within 30 days from the date of an accident)
Section C: Special Benefit (additional limit on top of the Annual Limit)
12 Up to 5,000
Home Nursing Care Up to 4,000 per lifetime
per lifetime
Maximum number of days 180 days per lifetime
13 Out-Patient Kidney Dialysis Treatment Up to 200,000 Up to 390,000
Up to 280,000 per lifetime
14 Out-Patient Cancer Treatment per lifetime per lifetime
15 Funeral Expenses 1,000 2,000 5,000
16 Accidental Death 1,000 10,000 20,000
17 Death due to Dengue Fever, Zika or during
1,000 20,000 40,000
Hospitalisation in Isolation Ward

· You must first pay the Deductible amount (if any) for the total eligible expenses incurred for any one disability and We will reimburse the excess.
· Additional Daily Allowance for Hospitalisation in a Government Hospital Isolation Ward is payable in addition to the Daily Allowance for
Hospitalisation in a Government Hospital.
· Funeral Expenses is payable in addition to Accidental Death and Death due to Dengue Fever, Zika or during Hospitalisation in Isolation Ward.
· For Death during Hospitalisation in Isolation Ward, the confinement in the isolation ward must be a mandatory quarantine required by law or
prescribed by Ministry of Health, Malaysia.
· Benefits no. 12 to no. 17 are not subject to Annual Limit, and any claims made under these benefits will not reduce the Annual Limit.
· Duration of coverage is up to Age 81.
· Grace Period: You are given 31 days of grace period after the due date to make Your premium payment.

Note: Please refer to the Policy Contract for full benefit description.

3. How much premium do I have to pay?

The premium that You have to pay and the plan terms may vary depending on the underwriting requirements of AXA AFFIN Life Insurance Berhad.
· The estimated premium that You have to pay: MYR82.07 monthly.
· Premium duration: 52 years.

Premiums will be charged according to Your attained Age at renewal. Renewal premiums increase according to the attained age as shown in the schedule
below. Premium rates are not guaranteed and may increase upon renewal. We reserve the right to revise the premium rates by giving You at least 90 days
notification if the actual claims experience is worse than expected. Such changes will be applicable to all Policy owners regardless of their individual
claims experience.

AXA AFFIN Life Insurance Berhad 200601003992 (723739-W)

8th Floor, Chulan Tower, No.3 Jalan Conlay, 50450 Kuala Lumpur. Telephone : +603 2117 6688. Fax : +603 2117 3698
Proposed Insured : Rafidah (Non-Smoker) Date: 28/06/2021
Prepared by : KUSMAADIKAWIRA BIN SUPARMANTO Ver 7.14.0 Page 5 of 9
 AXA Medic Essential – Smart
PRODUCT DISCLOSURE SHEET
Annual Premium Rates (MYR)
Attained
Male Female
Age
Smart Care Classic Premier Smart Care Classic Premier
0-5 872 985 1,094 1,631 794 897 996 1,493
6 - 10 692 758 842 1,255 630 690 766 1,148
11 - 15 692 850 968 1,443 630 773 881 1,321
16 - 20 692 910 1,052 1,568 630 828 958 1,435
21 - 25 761 1,003 1,157 1,610 742 953 1,129 1,607
26 - 30 817 1,062 1,193 1,677 938 1,073 1,256 1,779
31 - 35 864 1,089 1,210 1,714 1,119 1,227 1,363 1,937
36 - 40 1,026 1,237 1,374 1,918 1,341 1,470 1,633 2,261
41 - 45 1,326 1,454 1,615 2,186 1,644 1,801 2,001 2,820
46 - 50 1,705 1,868 2,075 2,894 2,093 2,294 2,548 3,594
51 - 55 2,345 2,827 3,141 4,442 2,566 3,093 3,436 4,838
56 - 60 3,108 3,916 4,351 6,104 3,139 3,955 4,394 6,191
61 - 65 3,923 4,728 5,253 7,354 3,952 4,763 5,292 7,471
66 - 70 4,991 5,469 6,076 8,526 5,004 5,483 6,092 8,546
71 - 75 6,405 7,018 7,797 10,789 6,122 6,708 7,453 10,415
76 - 80 7,678 8,413 9,347 12,822 6,988 7,657 8,507 11,885
Notes:
· The rates are applicable to standard risk and occupation class 1 and 2. Additional 15% loading shall be applied to occupation class 3.
· The rates assumes that premiums are paid annually.

4. What are the fees, charges and taxes that I have to pay?
Commission payable to intermediaries is borne by You and paid from Your premium. The commission payable varies according to the premium amount.
The percentage of the premium deduction for commission is as follows:

Policy Year 1 2 3 4 5 6 7 and above

% of Total Premium 65.00% 40.00% 26.00% 20.00% 10.00% 10.00% 0.00%

5. What are some of the key terms and conditions that I should be aware of?
· Importance of disclosure - all material facts such as medical condition must be disclosed and the Age must be stated correctly.
· Free-look period - You may cancel Your policy by returning the Policy to Us within 15 days from the date of Your receipt of this Policy. The
premiums that You have paid (less any medical fee incurred) will be refunded to You. However, no refund can be made when a claim has been
admitted.
· Waiting period - the eligibility for benefit under this Policy will only start after 120 days for Specified Illnesses and 30 days for any other causes
from the commencement of this Policy or reinstatement date, whichever is later, except for injuries due to accidents.
Specified Illnesses refer to the following disabilities and its related complications:
(a) Hypertension, diabetes mellitus or cardiovascular disease;
(b) Growths of any kind including tumours, cancers, cysts, nodules, polyps, kidney stones or gallbladder stones;
(c) Any diseases of the ear, nose (including sinuses) or throat;
(d) Hernias, haemorrhoids, fistulae, hydrocele or varicocele;
(e) Any diseases of the reproductive system including endometriosis; or
(f) Any disorders of the spine (including but not limited to a slipped disc) or any knee conditions.
· This plan is renewable at Your option. Unless renewed, the coverage will cease on the expiry date and AXA AFFIN Life Insurance Berhad shall
strictly not be liable for any claims that take place after the expiry date.
· Implication of switching policy to another insurer - One of the main disadvantages is new terms and conditions of the new Policy may be applied if
the current health status is less favourable to the new insurer. It is advisable to check with the insurer before making a final decision.

Note: This list is non-exhaustive. Please refer to the Policy Contract for the terms and conditions under this plan.

AXA AFFIN Life Insurance Berhad 200601003992 (723739-W)

8th Floor, Chulan Tower, No.3 Jalan Conlay, 50450 Kuala Lumpur. Telephone : +603 2117 6688. Fax : +603 2117 3698
Proposed Insured : Rafidah (Non-Smoker) Date: 28/06/2021
Prepared by : KUSMAADIKAWIRA BIN SUPARMANTO Ver 7.14.0 Page 6 of 9
 AXA Medic Essential – Smart
PRODUCT DISCLOSURE SHEET
6. What are the major exclusions under this plan?
All benefits under this plan will not be payable if the Insured's hospitalisation, surgery or charges incurred is caused directly or indirectly, wholly or
partly, by any one of the following occurrences:
· Pre-existing illnesses;
· Specified Illnesses occurring within the waiting period;
· Any disabilities, medical or physical conditions and its signs and symptoms occurring within the waiting period, except for injuries due to accidents;
· Circumcision, eye examination, refractive surgery or surgical procedure for visual impairments due to astigmatism, farsightedness or nearsightedness
(Radial Keratotomy or Lasik), glasses or contact lenses, High-intensity Focused Ultrasound (HIFU), rhizolysis, robotics surgery that aided surgical
procedure and the use or acquisition of external prosthetic appliances or devices such as artificial limbs, hearing aids, implanted pacemakers and
prescriptions thereof;
· Dental conditions including dental treatment or oral surgery except as necessitated by injuries due to accidents to sound natural teeth occurring during
the period of insurance;
· Private nursing, rest cures or sanitaria care, illegal drugs, intoxication, sterilisation, venereal disease and its sequelae, Acquired Immune Deficiency
Syndrome (AIDS) or AIDS Related Complex (ARC) and Human Immunodeficiency Virus (HIV) related Diseases, and any communicable diseases
requiring quarantine by law (except for death during Hospitalisation in Isolation Ward covered in the respective benefit in this Policy);
· Any treatments or surgical operation for congenital conditions or deformities including hereditary conditions;
· Pregnancy, pregnancy related condition or its complications, child birth (including surgical delivery), miscarriage, abortion and prenatal or postnatal
care and surgical, mechanical or chemical contraceptive methods of birth control or treatment pertaining to infertility, erectile dysfunction and tests
or treatment related to impotence or sterilisation;
· Hospitalisation primarily for investigatory purposes, diagnosis, X-ray examinations, general physical or medical examinations that are not related
whether directly or indirectly to treatment or diagnosis of a covered disability, any treatments which is not medically necessary, tests and
investigations done for the purpose of excluding diagnosis other than the final diagnosis in which final treatment is rendered, any preventive
treatments, preventive medicines or examinations carried out by a physician, and any treatments specifically for weight reduction or gain or bariatric
surgery;
· Suicide, attempted suicide or intentionally self-inflicted injury while sane or insane;
· War or any act of war, declared or undeclared, criminal or terrorist activities, active duty in any armed forces, direct participation in strikes, riots,
civil commotion or insurrection;
· Biological or chemical contamination, ionising radiation or contamination by radioactivity from any nuclear fuel or nuclear waste from process of
nuclear fission or from any nuclear weapons material;
· Expenses incurred for donation of any body parts or organs by the Insured and costs of acquisition of the organ including all costs incurred by the
donor during organ transplant and its complications;
· Investigation and treatment of sleep and snoring disorders, hormone replacement therapy, placenta/serum therapy, chelation therapy and alternative
therapy such as treatment, medical service or supplies, including but not limited to acupressure reflexology, bone setting, herbalist treatment,
traditional and complementary medicine (unless otherwise specified), supplementary medicine, vitamin, nutritional herb, massage or aroma therapy
or other alternative treatment;
· Care or treatment for which payment is not required or to the extent which is payable by any other insurance or indemnity covering the Insured and
disabilities arising out of duties of employment or profession that is covered under a workman's compensation insurance contract;
· Psychotic, mental or nervous disorders (including any neuroses and their physiological or psychosomatic manifestations) and any other conditions
classified under the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV Codes) as published by American Psychiatric Association;
· Costs/expenses of services of a non-medical nature, such as television, telephones, telex services, radios or similar facilities, admission kit/pack and
other ineligible non-medical items;
· Sickness or injury arising from racing of any kind (except foot racing), hazardous sports such as but not limited to skydiving, water skiing,
underwater activities requiring breathing apparatus, winter sports, professional sports and illegal activities;
· Private flying other than as a fare-paying passenger in any commercial scheduled airlines licensed to carry passengers over established routes;
· Expenses incurred for sex changes;
· Any treatments directed towards developmental delays and/or learning disabilities of an Insured;
· Any treatments which only offers temporary relief of symptoms on any long-term illnesses and diseases rather than dealing with the underlying
medical condition;
· Any diagnostic tests, procedures, blood tests, investigations or screenings that are not directly related to the final diagnosis and treatment for the
covered disability; or

AXA AFFIN Life Insurance Berhad 200601003992 (723739-W)

8th Floor, Chulan Tower, No.3 Jalan Conlay, 50450 Kuala Lumpur. Telephone : +603 2117 6688. Fax : +603 2117 3698
Proposed Insured : Rafidah (Non-Smoker) Date: 28/06/2021
Prepared by : KUSMAADIKAWIRA BIN SUPARMANTO Ver 7.14.0 Page 7 of 9
 AXA Medic Essential – Smart
PRODUCT DISCLOSURE SHEET
· Cosmetic/aesthetic/plastic surgery or treatment, or treatment which relates to or is needed because of previous cosmetic treatment. However, We will
pay for the reconstructive surgery if:
(a) it is carried out to restore function or appearance after an accident or following surgery for a medical condition, provided that the Insured has
been continuously covered under this Policy since before the occurrence of accident or surgery;
(b) it is done at a medically appropriate stage after the accident or surgery; and
(c) We agree, in writing, to the cost of the treatment before it is done.

Note: This list is non-exhaustive. Please refer to the Policy Contract for the full list of exclusions under Your Policy.

7. Can I cancel my coverage under this plan?

You may cancel Your Policy by giving a written notice to AXA AFFIN Life Insurance Berhad. Upon cancellation, You are entitled to a partial refund of
the premium provided that You have not made a claim on the plan.

8. What do I need to do if there are changes to my contact details?

Please contact AXA AFFIN Life Insurance Berhad if there are any changes in Your contact details to ensure that all correspondences reach You in a
timely manner.

9. Where can I get further information?

Should You require additional information about medical and health insurance, please refer to the insuranceinfo booklet on 'Medical and Health
Insurance', available at all Our branches or You can obtain a copy from Your insurance agent or visit www.insuranceinfo.com.my.

If You have any enquiries, please contact Us at:

AXA AFFIN Life Insurance Berhad
Ground Floor, Chulan Tower
No.3 Jalan Conlay
50450 Kuala Lumpur
Tel: 1 300 88 1616
Fax: 03 2117 6768
E-mail: customer.care@axa-life.com.my

10. Other types of Medical and Health Insurance Cover available.

Please ask AXA AFFIN Life Insurance Berhad for other similar types of plans offered.

IMPORTANT NOTE:
YOU SHOULD SATISFY YOURSELF THAT THIS PLAN WILL BEST SERVE YOUR NEEDS. YOU SHOULD READ AND UNDERSTAND
THE INSURANCE POLICY AND DISCUSS WITH THE AGENT OR CONTACT AXA AFFIN LIFE INSURANCE BERHAD DIRECTLY FOR
MORE INFORMATION.

This insurance plan is underwritten by AXA AFFIN Life Insurance Berhad 200601003992 (723739-W), a company licensed under the Financial Services
Act 2013 and regulated by Bank Negara Malaysia.

The information provided in this disclosure sheet is valid as at 28/06/2021

AXA AFFIN Life Insurance Berhad 200601003992 (723739-W)

8th Floor, Chulan Tower, No.3 Jalan Conlay, 50450 Kuala Lumpur. Telephone : +603 2117 6688. Fax : +603 2117 3698
Proposed Insured : Rafidah (Non-Smoker) Date: 28/06/2021
Prepared by : KUSMAADIKAWIRA BIN SUPARMANTO Ver 7.14.0 Page 8 of 9
 SERVICE GUIDE FOR LIFE INSURANCE
What Services can you expect from our Agent?
Our Company offers life insurance products through our agency force, bank partners, online channel, etc. If you intend to purchase a life
insurance product from our agents, you can enjoy these value-added services.

1. Before you buy a policy

Deal only with registered agents

· You can check the status of the agent via the Life Insurance Association of Malaysia’s (LIAM) website or via Short Message Service
(SMS).
· Visit http://www.liam.org.my/index.php/customer-zone/know-your-agent for more details.

Assist you in Choosing the Right Insurance Plan

· Go through with you the Customer Fact Find form to understand your insurance needs and financial goals.
· Recommend suitable insurance plan after assessing your needs.

Explain Product Features

· Explain the product features, benefits payable, exclusions, premiums and charges.
· Provide Product Disclosure Sheet to assist you in making informed decision and to facilitate product comparison.

2. When you Decide to Buy a Policy

Assist you with the Policy Application

· Explain the importance of answering the questions in the proposal form fully and accurately.
· Submit your application for underwriting after you have signed the proposal form and made the premium payment.
· Arrange for medical examination with one of our panel clinics, if required.
· Provide information on making a nomination or appointment of a trustee to ensure policy moneys are received by your beneficiaries in
the event of death.

Explain the Policy Terms and Conditions

· Your policy document will be delivered to you (by hand or via post) within 14 days from the last document received.
· Go through the policy terms and conditions with you to ensure that this is the right plan that you have purchased.

3. During the term of the policy

Continuous Policy Servicing

· Assist in renewal of policy.
· Provide continuous service e.g. policy modifications, change of address and frequency of premium payments. If the agent has left the
Company, we shall appoint a new agent to service you.

Assist you in making a Claim

· Guide you through the standard procedures on how to file an insurance claim.

Customer Website
Please visit our Customer Website at www.axa.com.my for more information.

If you are not satisfied with the services of our agent, or require additional support from our Company, you may contact us at 1300 88 1616.

AXA AFFIN Life Insurance Berhad 200601003992 (723739-W)

8th Floor, Chulan Tower, No.3 Jalan Conlay, 50450 Kuala Lumpur. Telephone : +603 2117 6688. Fax : +603 2117 3698
Proposed Insured : Rafidah (Non-Smoker) Date: 28/06/2021
Prepared by : KUSMAADIKAWIRA BIN SUPARMANTO Ver 7.14.0 Page 9 of 9