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WZ | eS) TakaFULMalaysia ae Syarikat Takaful Malaysia Keluarga Berhad jrsewiorwea\rs10eece |W tekalubmataysia.com.mny ea OFA! 4, aan Sultan Suliman, 80000 Kuala Lut, F e0s2oroza7 PO, Box 11483, 50746 Kuala Luopur E cou@iakafu-mnaiysia.commy oon ; Pauanui A201 ys we ee edt MFT Ppa nnn Flo sn ty cer atta yo toy eb eto Sat ai ya ara ua i er snes gn acces che) a Deco gre) (apa) ana peg Meat deem e | ‘nbsp chal i mun nes rn, wilt eno cng Wo Ths yl ou Sal corse ete ecard gal oven uaa Skee | ‘reais ower qos nti te sos rato a ue po pel ss ra Hepes hy eagle pal aryl | Pesan Daan usa aco ap ues ko al dns as dewey esa) a paps cate ws sean ae a Je Rea a zm eGo ‘1 St allt Pasa Kan 208 and nana a ig wy a Ba Ct des Tat Kage a ep. x a a ste ta tit atl i ha ea er eta ena absent saa ce rs ks sus) Sy) ae ae sd ees net es lt tay enn ta sg use vat gh lass eee sal ua aN eo ‘rss hartge ct aga aa gro uss rs ys es mea nen manu parse sy bl pena ne A shia ers pears acon aon esa sept pr aba sav laura eager 9) utes ep aat mit nae ets enn el ia Earp a cai haga pes jan 9 v 3 | Maa ce) hr} inca e/a er LE at ener ons a ae Lope cay er eas ees cn fone i ae Taf ergo Gael ethap (Sei beringol Abate Pema Betas tweubee MyXaa/Pasport) l T I ‘Height (Tinggi fem} T ier [Oe ie isp 4 [Pease complete ti form in fallin GHPTAL LETTERS and arose [x ]the Lewes as appropri, il baglaplan Dora in sponutne Gagan HUTUF BESAR dn pangtah [Jade kesh yg brksaan. ca ae Saree et ag Nm aa anTioANS OF PROPOSED PARTOANTPEASON TOBE COVED T BNAGIOTD BUTA-UTPSERTA YANG DIOR OVORANG Ye ARAN DnDDNG) a = — Ta | east olole|-[ola]-[ sah 17 a ay an TA Tr SG a lo | amen ry nen a Pee tay eg eg ec it esas | TA aaN TPE (LEASE SELEDT a ONE) OFTHE FOULOWNG) BAHAGIN A JENS PLA (SRA PL SALAH SATU OARIPADA ERI) | pietgaae a tre Ts ga Busnes rl Leer ual (LT) YY bane ae | Ty Wal [aitiryth | [AH [m|a fo T (sgeitaous | lal | LL | + baa 7] vo] vet || F\etace compet lr ta non omie chet Rotok [IE] tt cmunte part sh reaccetd [To art sling ent th tah cat cia cot [IE] te. otra dey un co sear Totes emai / th than th nerlok Eck Eviak Co wer (mos ae arttncce) Tanai iin) Hel many ans tea ey eer i ther ttasz Teta om ras oes esta ston LL] “tl yi of eli / om tu at maton Opteron een rast / Prado penggannotinian Ls ve - CO) wy ree 7 Gnas [FA ua totes Pea Perempuan © [heidootasane — [Zf mstm ism [_] Non sim uta a 3 [eaty? |] ayn Rar a Wo aeons [J ese ona [dan na Wagnenes | omerss tain, [jonas ain | ossnaton? | Pete | Ba fas as ibrar Palen pmwty SANE, CAINE PN 13 | ireiqerianend| BAN Com PANAD NAST ie of uses Bidang Perkin ‘aie tac funatitsnay (LN OA TUK Lumbar PLO! 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Bibi lo in " [ERaEnet {| i aART GRANTEE /BANAGAN G: PEVERII PENBERIAN Bank Name / Nama Bank: kane eAcyar meeGone PART FAVILY TAMAFLL PLAN DETAILS /BAWAGIAN D BUTIR-DUTINPELAW TAKAPUL KELUARGA Bank tect No.1 Me tan Gant [ POO 6 OS FOF 7 a tat Parone Payment Mate Care Basaran “peo Faring ois Pion A rand Oba! non Fane Ts yah ‘sane amie Cameo Komen feng Aout uni Pain Tx of Coverage TompohPerinungan element pt anpoh Pagan rw 1] 4/8] of of of-D|o] |2{o} vex nun + 2 Cs Fs (ones tains Sam Cover domi Perchgon Prat Rte ada Netngen “afl Goren Gruman Tat ew Hoje] ae]-[4]2] [_]#]-[olol« ow | ‘ype of Applicant denis Parton Single Appi Peron Trgat [1] nt Apa /Pancon Brana ‘All aplean(s] dtts / Bub Pomaton Borsa 7 a Wn ad Gage Prantge Prats Pardon eusve | No/ ik 77s erin feo a won pyro drs hes pa Hn Dol pas, a, coda tutes oy dinneettucaraleesbhelerauioy gute dene tyicemeiemecsoe tr dose |_| seer dan ene este yar oss pres eye pata eam sous Vari deca a Setar tecpetat pm ear toro ges on ms node ota hse a a tly sre sec ter stn sites‘ pm AOS HD con ea dena sy cb plyysical defects or deformity or health impairments not mentionad here? / Maton carogson ta bee mene ots tpt, ugg ont ab ca etna dy daa al teenth neta ett poague atch oot rer eo raped ns a (ea ata oops eb pel Set a s,s on a, oe, | ett ely aon pect nears agen peda sr gp ae es at ada Wt taco eps peg cer one eee ea Se ope eee oe tems aap a ns nase onan ia aa et 1 favo eon oben uns tang mol tea aan ape spss eps WoT sass rho ae sre ony ate otoconia as Se rete aelal monet ao panda Sn nant yin Sage psi 2 pea nt reps oe mie apa ees BB a aso dein sar |e eu ba ioe, Taian ig Ta i ps na Srl hime tenes rane tse west) Z ao ee oar at els dl ay bag ata di dl en png (ss sg png oe mem i neta aah ja ora os tng, PS | ‘anna 7 | or ons oat en, i oven ahah or TNS wa Ow | | orany other takaful operator or insurancs company ever decined, pastponed or accoptad at special rates? Merit ral crf penis at nso sss lad itr, sna erate rg sano nr oyna ee Soa ars, agin do Sin ig a a [ra o/s a S| {8 Havoyos ever had any sod ofthe breast or fenae reproduce organs or menstel order, abnormal pap smears) or any corptcton of pregnancy? / Peat ands mengelsm! aangoosn pay dar alu onan reprocut wena, ganaguan hal, pap smear Hosk nara sau kompiassemase mengendingtesatr? 1 Arayourow progrant? yes, how mary months? ‘Asta ands sang mangancng? ay, bapa bulan? Way anata Guatons 1 6 Yo, lke picid dls below Cor ac eoneiion a lows, a avanantopava salon (ng Sah “hi ryataan sear larpern ‘vara e bawah int sept tent * Gieslon mbar Nomar Seat + ype at canaon a dat ot eacertence Jos keadan don ht beh * Name and acess ofeach door Rospitl/ Nan da lana sen dor / asp * burt of ess in ané te of cay appropa/ empob cat eceeran da tipi ara mana tesesstn * ure af ts one, eae, ros and reason forest / ons an yang eeu, kh annua soba sab ln anon Mosh) Buln 7] Breton ATT a UTTIazneaoet Page Muka Surat 6 A:.: a ‘PART Fs HOMINATION DECLARATION / BAHAGIAN F: PENGAKUAN PENARAAN. OTE /wOTA ‘You ae adie to somite raion who natural yrson anders tat he nana of hs Fant Taka Pianta you have prt. By vot eaten 142 ane ancl ‘Serves he 2013, you ray esr ha aaflbnes toa person or designate te naivoss orc th tal anes sa banefiary under condone iba or desigate the ning ta eee {atafl bert as an aut You shad ra tine to tne ex ithe pation ceed reais rent you oe stator, ander or ook Ets nl Your nanan she te wessed bys peso ler thts noma Miset and wo is tsound ind and has atrad age of dhinn (16) year. Ade cst unk menamatan pane dn asta png ‘nha Pn Teka lat yg tah an seri Menu Seay 142, Ata Pekan Kevangan sum 2012 anda Ble anata hk mata fl apads saoang para sea menelapian pra ota msc man tka sesagal beef Bawah ta ryt tay melpn een stk main Mela! etapa sarang wae Anda hrc sasa fs samas mami aa ads penmien yaeg dat mash ess pads aden ksus aad rant alu mena a ara i fg esl, Penaan ads bere aan lth aesorang sl dad nun tu send yang bran was ta ence ums pan bis (18th, {hay autos the Company tay ny attr lnc of my ay tote Garam ha barf ly te Comesny he eve a | stl ister a etal and PerantDisably, sue tothe ns nt conn th caifieate tas proved un the, he alae ay, myname a css my death The Capa is day Achat ro al labs made under Unwoethcate pon cyanate are | Baavasanya derps saya cimderan Saka os membsyar apt bak teragaat amucuan sje ape Paina Pande dads ant ang ebayer lh Sasa ka say mental dita mera Hig Ura Pe en Hat, teak eps yr syaat di porte dl st dan meng ean undang- ‘dang; baal manta, haa alan ajar pads pena yarg dharani saya sg, Syria ab tas cso Vb cts i stot leas av nah bar, | sreoynorinae the ellwing peso tobe the nominee ofthe cbove proposal. aya dasa in menamatan dvi yang bei sabaga panama baglcadaaga It ass roi toro of th Nin Typ bl: / i pana i) pat lh ata ens Peano yang borhan, § Senatisiary ueder Conditional Hbah | Henetsia of bawah Hibah Borsyarat Executor! Wash s ‘owes radu] af al ete ol [elalal ol [elt ol falafel tim) i oon (43) 10] 4 ]- [o> ES] | | tg Dasara GaN) 7 Super [pasoracr oon? [a tAlaB ‘Sama address as Proposed Participant? if No, please state. / Alamat sama dengan Peseria yang Dicadangkan? Jika Tidak, sila nyatakan, | 7 vse [mos ri ess jaenat Lg Pastaede? Posted ‘PART @ ENROL WENT FOR PAVOUT/ REFUND VIA E-PAYMET/ BAVAGIAY @ PENGAPTARAM UNTUN PEMBAVARANWAYAAAN BALIK MELALUIE-PENBAYARAN Pinas op fk partir a ure Bendy ab made vi et Cal (ePayan/ Vay matngtaplan Dagan i supaya seria Baran ballPeayaran pada ria aka dating boleh aaa scare Kent Ts e-Pambayara cout ol Wane Nana Porargg Alun (tb th Pssae ob Gove | Masih Car arg Aa Acai oH, Maun Bankr inl O ak yo exo pe save Savrg/Sianan Cane Seas uk are 7 a Bu (Barkin iO an a lysis ‘Terms end Candtons /Trma-tarma dan syaratsyarat 4. The ePagmant iy ot potable fr bark accounts mated in Malena ¢-Ponbayaan anya ble gust ba kun bank sane Slept asi 2, Thee-Pamsn adit int coal ak aco of artaants Gerla Overs Bete ark ofthe Caran, omudhanePortayaan haya ic dena ar atau bank Peseta eile pena pra, ‘Paar Certte Owner benetaay regula fish 2 spy oe tank passk oan sateen ad he etn Dosen! (0) sx as een Ca), Passat No, tar czumenaton a as wea open the ath accu vena pergoses Paseo S/ zen pet mesgarkatan ssa ut ipa Sank ta ja an lohaen png epert fs erent, passpr, aly dug pala sens mut hn Bg pepesaan, 4, Bert ten lb inetd event ent Dagar he nk sae! ker are payer wlan onoue f easton tse aah so ensure tt pyri made a ‘depen Bak ol san Satan ont angeebin 1 pereine rad romber alan Bu yang bain dos vans pba hay ableton slay ter egestan dotune psu oi Sash unt mamasion ake party dat pads panna ang sh sha 5, Paar One beret esos tant in wel treaty ay changes inh eur curr, Tents sa ta fc on thd of cat byte Company. Pasta Pah Senet Oranggnglvad tsk manana gin spur sea Glas dbkuran yang basa selina terdaatselrang prs at nombres, Paral ala cat ec ed onrnae eh Sarat 5. taco ott bank pssbokrtnkstuent ial rod te Paranal Cana lds cnts al acne poi is om as vad aac, esis but inganan bank at para tank és hema Paso / Po Si iangep rsgesstan Ohaus Ou-buaa a an brag a adalat 7. ie ev of ania inate aco dlls rv by he Patt Cartel rere payment eng reed nt tr pay an ace, he ayer made eas ti ama el aya or Relud (Surendo Part Wide Chin arealton iss ane Comgany sl ened andl char ral xing and re abies, 0 ares nian to suc Rens / Sets Paral Whiovl Ors (Cancolaon tas. etary uli yong ara oot Puce Paik Sp ik sab ih op, ‘renal panbaan Kus edly sa Dank pat aga pmtayaan elt bas cing pmeayaan pana Dea Baan Bk / Staten /Pegenan Soatvgan/ Tian Petar ainsi Sanat ae kan etargunganc as sea ati, atyaan npr pata masa hl anu pad as hcanyarg tekan dng ara) ‘Bale Sean Pagan Sobran nba / Pantanal‘PART: PROVISIONS OF INTERIM ACCIDENTAL COVER / BANA GIAN W = PERUMTUKAN PERLINDUNGAN SEMENTARA AKldAT KEMALANGAN. ‘Only eplieable for Taal myMergage /* Hanya lepakl sno Takata myNertoage ‘pone Companys approval your pletion Tlf mAletoge, an ein cove etn ul ier (Rertaer redo 2s “tein Comal begat ta he Proposed sae tebe Conzed sto hkl ams ad contin: Abie Sart mats pemohran Takata myBMareg and peuchegansanena fai teat aia kemalagan tun drat eg ptnungn somes’ akan eran leas Cag yng Dolan ang alan Ding! tka framed sats brut 1. This ita Gove sal aft a dal fhe aero Ait 0") or Ofer of Gna cepa (Lwin she le, ody he Company nage of | Foy Taku Popa and ect Fn) Peladyn Sonoma sa Brake eta Sal Pam i Srl Prerian Sree, an-nena Yong teks, Yor) tara oh Sart orkeaan Brag Casa dn Aas Teak Kar ik 2 Theat otis tin Cove stb eterno by Fe Congay a nde be LOA cr LA duh Prong Semartar ml tata eh yaa seeing cyan hd Surat Parris ta Srl Presa Berta The Grapany sant able apy an Dt unde tis ner Gover for dt dl: Sarat alo barangunaawa nk manda ebay mt ol eva Pelchngan Samanta boi ema abet ape ‘31 Silat sie or e-edinuy, lese risn,buh eban una ata zara an Sedan ot sen ata ra aa ek rs la ‘32 dyes x dns innate wich so resign nada cae o/ obrang psa la abe sem yar ula a dats aba i 239 ius orgs or aha peryltosasn ds eave | | Paton or wig ra aren rts pro cement an fa oa rate: o/ peje dl aaa nk sebagai salar yng bata Borba gran alu mecugaseg au mean dln stags pranian alpaca aan {45 Mayor maa snes tinea eh order var owe er ras for warn peratins rsallon pub ore of petite eleean fast teat sens erga semana aaa tts errs aaa bo operas pepe aay pan alana 2b {46 The Prepased Fess lt Comte eainganylaw aay esa proved by Kn. saburg plan undng andy Ol Orang yang edo yg aan Didnt sang ang dows. | 4 Thr const cand a oo hc elt ont cst loin! Prig Sort isla rian dn an ian kay ot ay be as ot da {UT Two to ha cae Trt ast aa ei at 4.2 The dts ren tote appeain of! Th pentane pamahoran; au 43 Tatas ey ate th LOR and UK oT tl al a Surat Pannen dan Srl Pnainan Borja ty 44 Tres nods sic (6) dys lowing ne ates dit LOR an LOA. Ha yang ata rts na pul ar (36) tah rab Soa Fseinaan dn Sur Pent brs, For ect of doa, Acie” nears a sen, uterus an pai eal tha acu al anette pie wich wi indepecny of 8 te cass be fol cause o boi ij. Ba! meng agua, "emaga beter ean ttt yang bay srr th, i dengan, a aga ur eis pads as ag en hn taal ng atest, ang enka mej sat satya sab bg cede argo a branng pads ap sub it [PART AAD Av DECLARATION By PROPOSED raRTciANT/PERSON TO BE COVERED RHIAN T:AOAD DAN PENGARLAN OLEH PENERTA YANG DGADAGRAWORANG| VAN AKA DILINDUNG 1. av aa ait ype contractual uy of dolore at ust eres acne axe ot omar iste gs abe arswefetrnaten obs answairg ay queso oad bythe ‘amyany Sa sot maki bara ad evap enefaan pra kta arg par sje ent sacar wir ape ek munber gambar yang sth cao antes ep ‘mult sarace mason ang cnt ch pa Sy 2 Ihave ead nd under th cones is Fay Tall Pops ad Oeesaon For cg lasing nd sts trea ave fly and actly nso lla ees ‘nts andl Taka rool and Ouran er ane usta ase ty be Corp ay ft aly re neers th ques. | Soa merbaca dn mean ‘au et andongas yang ld! a alan Soran Caga dar Aun Te! Kay mss sia aan Sn ac party danny da 3h suc nua son es ‘dln Brag Cangan dn Abu ela Korg ng kgip dan pl easok oan a yang yan cl ak Sar, iz ad, ska seb mombses aca da mst ats yng yatta, ‘8. lunesta tthe Tl coer at comsaec nl Fan Tt Prepasl and Doran Fr os bon oy acraptd ana Taka Cate nda cone has oo 8. ‘Sayama alia perdongan Tal akan er Kuso ohne rng Caegon dar Ak Talat Aas ctr scr man Sf Titel menatanpraaan pornduoan heaton 4 hey decree bes my tno an bese, tae aes ale ae togehr wl fer Soeur suet cametnnarewn a te an compet. Sj dngan “nvm, ena paris Kgs a, ben seme ena ds dn dodanie jay asa etude petnonay i ta tar den gap. 5 under leet Compa ofay changes tomy eh conden ort Persen ob Gore ain a of is alo lr oh sane hace Sou canes ‘is apt, hareby al ne Compre Gul any cred nea expan rom ry arr. dar margala alan mamaktadan lad Sara fogs papa ‘peta tap ako eioen aya st ana rig Jang ainda ar ks seb earan Seana sya mambaaanpemonoran i, Pear ener‘ pata Sarat nt ea amuse partatan ag ch data ce yaa aos arama any SO ey canst and atin te Company sek md oman xn ny dc, chic hosp or rs th has ears cinoma ote and medial soy. rewea autores ay aren, stoner aut tas reer ar loge fy ah aaa rye ast 2st as nono my eer b ase 2 ea man od of rtd esc, ode ah Caer) terpenes suchieematn. A scopy ffs ashe sl be etal nt el she eral Th | en tes arto en art ue Ws er, other a wh he Copy oe cine at ate dae ae Li | Instance Asc yay aa scar, Gmeanr etry Ahoy aby to any oer sian ean, tel pear auhosed Wis pares wows ‘eer su an ft purpose rdsrtghtrepaymanose, | ay mantras Spas mate-mane nea sts ar i yg ray sean eda | [artnet ean dn srl pean sre alaska cra ata rng slpa dr any abt aad as btu eae” Sec jny Bra ars mend eat Sara tr wml bol. Salea flip! be ia sat eras dasa ata Shara ‘erat mengginlan mkt sb hay op tn semahonn ss porate ti cela dengan Sra be mspenian ssn ke ate tan Jag ah at pendcaarg pat tatopad Pest urs at eta Val, maroans Pk eras Kk sas Pi al al 39 U-Pb oped an ‘ararraSpengw tetany aa kopade mar pl aga ran erg ata eer aa teat agai pagoraraahnss pasar Reps 7. ery can dart nt caf apf: th wl er, ha ol ade ay sere te rere Your Sls Ox wih cbse na tes na slept ears have gen ls Fry Taf Paez an Desa Fr, ey conto an cert Sab ar as et maha aera Go at 3M itt ray ono gst isa el oe ad Desa era axe ja cgm engender savers | _manaton periagan ttl sy ek amb sabarg kan vay pcan haps Papal ants any mana ang cana aa aya aah bres Sagan ‘run yng aera cha ee Cadre dn a 1 agai Sgn dagen image cn rege ea Pen and i mena ae pa heya aa ‘Saag member siya dtm ahr bat et orate at ay Can an Fan I aga scr a ea Et en 4 agosto priciatn in is product and ay th cau nah Paar Account PA | ao ors eda tthe Pat’ Spal Aart "A" ase onahr’ hr ‘nants be dese am tPA sadn oth pce ab rae. Sas brat rtakmanyer prea dn mambo carsales AP, Soest tk mene cn aun Ki Pesta (ANP) bras bar'yangaauneya akan dick dyad AP ag ka tara any aula. 5. agen autora te Carpany asd an waa to manos hs PA ad PSA nd, th Congr wirocae 4% often a Wah e/a Dera umn mamba Ksa ope yaa ards a tgs AP AN eas Gaia, Shaan rar 4% denna aaa yr ake 10, Lallow te Compary tte 10% tessa prof afsig fa tha®A ea patomancs nea ba nh Sas manbaraan Sis one metrins 10% ce eundagan paar AP bagel isn pastas brssuan ath 1. Ls aya that ary sul arstog trom th PSA Wt be tte FSA anh PA In el, neres-es an ie prvles by heCompy to he PSA Delonge! See ‘est Eta sarang an ads ANP an sear cl dla AXP dla AMP mga des, pan ys Gad an Aer bh Sart eae ANP keds 2. 12 Weaimart of Sl Peyment Anau / Bayar unk Aun Kel! ‘vby ares tat wr an arcu ue and payable ma ety are 2 tr wxrndsetty/terizalentlin ht ta be mde er tn byway of eore pant cach oma lore ateto men cud a ate Rl ays Ton FTO 0) and abo. Foray aout es tan Rng Maja Ten (AMTDOD) Se Company wa dre a char 7 Saga og bron ohana mt searang asa yng at par dn yang atan ya apata saa eaaKaaa Dalsuranaagparanatn Stoning an tar ‘merannaan sean dads cua penbeyre bkntk bea abut aan nan dbus! stanya aaa ai att aya da yag lan bar Dunia Raat Mast Sept (TO. au bi, Un eaang aru yang frag ode Rng li Seu (AM G2), ya an mancermaanys uu ar! aaa, Hh ive tors RIT @UTTNa2nd2ne: Page /Muta Sua 46 A= : = TS aby aenonolge bute ao crank oa a xplaod te acrtaWarmaon on tw lr res ol he peu vada omy slater, 2nd acopy prone ascoaue shea ior guon fo meby the abs alesbark aft Says daa hl mamer pagan Data poanaoanavangan bank i? rusian ion! ass yang mpl cd ong rn aah le Kean aa ca alan Ba tarp rod harap sje 08 papa fa aHangs ane 14. Pesanal Daa Protstn Ae (PPR) 2010/ Ata Porntungan Data Pra (APD 2010 Ihave red en underened he Prva ten made ala he Cons wee twa ays comm aI hay cost rte Company adie sppalis te pny ann aro gress my partes formalin frm eee append rete eros he mars a out tel rary Hotes) Sea bh mbes a Imunahams te Prva yng teat dalam tan Wo Sart wets al.com. dn dengan] emsearan Shara de pega penn lak katie yg rt maprocs matt part sya vtkaratonan Si tunves dan gedaan natn dag cea yang yaar aa Nts Pras sat ‘Msatig Coxsn!/PaztauenPomssaran [PA heey coset an ators the Cerny andi apis tpt osha ané us my personal information er maretg and prmation fs paduts an soca. 11 "ih rand th rng corso, sy ot a pl 0 2) camling te Endrorat Form. xanga buses dan mam ase lpade Sart! dpa Iola 5a aa un ekonge Sn margunaan altura antalya bg tan pasa sea roa roa ean pariralanya Seiatya saa gi ahah parsayha amusaay, iy bch mor untuk arena at macalkdogan meng! any Erdrsann Ne ‘Siged at! Dtanaetngen ot Siri of Fp ato Ga a ‘iar ota aang esa Dn eras | ee ‘Dea customers, Repade pelergpa-peleggan, ‘spray ntl fx peraor ta (Pivaoy Nate" isued to allcustaros of Sarat Talal Molsia eluaga Bara (wich nls lisse, lated ander aencatas coraniseabtvaly 2st coro equ) ("ampany, wa", “us or“our, pursuant the stauory racloias oth Prcoal Data Proacton At 2010 PDPA')./ ets priv nt ota riba (ais Piva) cbelan pads semua pelarggn Sara oat lysis Kola Bard (ermasuk sr subst saat eran canta | ‘yr erslutu soar abet dara kontks mamorvsan) (yar, eo aay am’) slras dongn olga! salto lbauah Ata Parndurgan Data Parad 2010 (POPR‘. | ‘Your persona ta ies, ut snot Ete nary parsenalinfoaton aut you eancerin your name, 2, gener, arcs, NRIC mbar, phone nurber and eral adress, marta, caddis, pie or ntl a a motel conan (Peso Da). ‘Data pera anda tomas tap tala kepada, paps maior penbad mengnaiandsmengena naa, alana uu, anna, alam naibor kad pnganelen,nomtor too ‘sin eel and, sto partaatan, slashed, keshaan fll ata mene at headzan prvtatn (“Data orb) ‘uring you couse of deals wth as, wo wl clot nd process your personal ata torvatous purposes, cuding to consanicale wt you, prove products and eres ta ou, ‘smile ané ge eet a your camera ansactons wis, spond a your enulles of compl roid you wt iveraten andor ups on reduc, services anor Tashetna promotions (deena set market, ss xpos nse a casey you) ler us and sold tn ares and aber purposes request aerate anata ‘ur bine unt a8 laa aperato as stot in he Company Pray ator onthe wets (alec fered tas "Purposes ‘Somasa an berrasan dengan aka akan mengumpul dan manproses dla perbad anda unk pags ten tarmasukBorkoruiasl dengan and, menyedakn prod de” ‘ata pehmean tsp ar, nad a rambar dasa tad ansak keri anda brsaa ar. mba atm bas terhacppertanyae ta aun ands, mente ‘ant matt tek mgr produ pekhidnatan date promas! pemasaran (lemasuk pean secarebngsung, meahanaaianpeipscvan yang alterna capac pik ‘anis) yang dtewaran ch Ram dor pik koa ang tephra ua ian fan yang Lam pers untuk eangerdatan an mengealanpegaan kar sebazel pagendal afl ‘Sapotinara yng tra dla Nous Piva aya acaet l aran web (scara Kosi ck saps “Tosa Tan) We wil ot doe ay of your errata to any ted party tout your consent exon to the Campa group of ampale (nlc acute sl ts subir, reed anor ssid carga clestaly asthe contest reques), our rfesscralaviers, virdos, suppor, agen, contactors, sence providers, business pater, ensure pao, banks andor franca nstuors, wihh er uti Nasi wer nozesay fre Purposes mentioned above, to ary party who unetakes to Kp your pesoal dee arfdontal to ary persone se ott ut Pray No, ro worm wo ara crrpod er oquirad unr latoesslos to, ‘Ka ik alan mendedkan apaapsdta pital ad hapadamana-mara pak kala lana hberaran ands cual kepade sara seritcam tapos Sarit (lrmasok ‘sama subir yank beratan data Sara ersekuty kam! esas sow mana koteskmemaukan), pons proeslona on, vendor pomdeka kontator ponbalal prose, ratan korg polygon, hsuans sama, gorge lala somula bank dandy Ista! kewarga, dalam ato ar Masa, a per, api Tanja {ang set dais, hgada maa-mara lak yang bern} untuk meryimpan dats paral and sacar sul, epsds manasa pha epertmina ang tetra dtm Mots Pinas ar, ala seas ape dl bana undang-andarg It ngassary or et calect and process you persona eat. you do nt prove us wth our persona tao o et conan to tis Pvacy Note, wa ll not be alta tect provide posi anlar sees oyu or procs eur pero data any he Purpose. Weare commited oerung tht our erseral ea redex YOUnaNe INE Tigh rogues for ase to, reqs for 3 copy of are ree oust cre, your gerenaldate hd hy Us. You lo nave he ge 2 ay tne to request sto tithe processing nd ate your personal dala er ecampl, equating us tn sp sending yu ary earketng and prometoal strats cr eantacng you or mare purpose), sunt a GU ih ra on ay auto eampters andor xcepions te ole, use and dls your personal data. am pers mergupa! can menyimpan dla prbal anda Setar ande eae mambaran dita paadl anda kopada km, za Ha bers cengn Hos Prva am nunghin. ‘ak dapat merhan prod dna peindratan scaa ti apa anda ata nirass dt porta anda bap) Tjuin-Tyan yan sed tas Kn akan mvmasttan da partad anda asimpan dengan slsmat Anda mempuyal hak nk rma akses pada manda sana, mangemastin atau marperbtukan data paribal anda yang dsinpan ‘kam Ada juga memuryal Pa ux mera Kad manghadan pmorosean en pangpunean cha paras ands pada le-a mass (onahny,mamint ka berentan inghantaan an sta promasl pad anca uu van amas). Wudegaman pon tam mempurya na unc agontng kepada mara-merapangezsatan dal mengumpo ngguna ean monde paral anda. prong you porsoral data to us yu conser us roessng your gesorl dats accordance wlth ths Pivacy Mois, and you cot a personal dla provided by yous ‘curate and compete, and at soe of ts risang ar au o ts, You al promely update us ne evant o ary change to our personal dat Dengan merbertan des pera and epade ka, ard tessa untuk tar memross Gala peel and sepetinana arg tetra dala Nts rvs i, oun anda mengsahtan aaa semua data pita yang dbertan oleh ana adh bet dn gta, dan isd ct pal yang mena aiu yong bet dkemeskian. And mest, dgan sega mengemastin data prt anda sean ferdpat paps eruban ec lapel yar arabe kepada ‘When you ge ste persorl dt of hr party in respect fa group eal carat or 2 cafe akon for anothar parson and ther tht pry, such asa nominee (bane ‘meezan aa person ceed whore th ersonal ta nat deny colectd,acanenl i dacmed to he ben gue oyu ta doe the td pars inde personal atu ‘nab anda emberan kam maki perled pak ee yg pes sls mpuen taal eta staf yang aooton mengesl orang ln dan pha ata, separd ‘sabagelPonamaan (beni atau was) atu ora yang lidung yang man data prado am scara tsk argsng, kam menganggip ps ands tlh bert Yabenaran ‘itr mendedtan maliomst pal pak kets pads kl ‘Wa resarve the mgt toupee and aan tl Privy Nate or aur Gerpany Privacy Nec artnet tne We may change ar unde pans fs Pray Hoc arr to mani our eampianes th appicabl aw and elton of foouing an update our neal rates. We wld ths by udaing the wording in tis Fam Taal Propose and Darton Ferrand updating the verson of hs Fri Taal Proposal a Declan Form, abou, plese be ona; you wil ot ncsssany be tty nes of sucha chage.Tarfoe, ‘lao encure hal you regulary check the Carpary Piva Hoos you aa uly aaa ofan changus outs. ‘ami daeak unt margeckn dan minds Nos Pras atau Hots Prive! Syria a Gar somaca ke amas, Kail akan manind aay agersstn bhapin dapat Now Prva untuk mangetatan dsr penturan kan kepada undang-undag den saat ~ saat ata meal rast dalam aaln alan, Ker atan mlaalan conga care | mangeastinpetataan cl ola Borang Cadangan dan Alan afl Keuarga dan morgsmastn vr Borang Cacagan din Aso Talat Ketarg in, walupun dept sie ama ‘arhatan bane anda tak mesa arta alumna seearangsing meparal persian il Cl fu ke pastian anda rap menyamak Ao Prnas! Syria supaya anda ‘atu dengan sabarang pautahan dan kaso. “te Peay Hobo lobe a0 tagethar wth he Carpary Pray toe whic is avalablon cu west a natty com my. 7 ots Prva nedakin ca besame-saa dengan ots Pia yank ang doth cap ran wad aml state cn.a[PA 4 DEGLARATION BY SALES OFFICERANK STAFF / wANAGIAL./:PENGANUAN PFGAWAI UALANKANTTANGAN BANK "hy dec ha a umztion oxtd nhs Fry a Pepa are Desa Form sh lyon gh the PropeadParearPesn obe Cnet an | Nae ‘ot wield ay informa on ch natn hacen of Es apt, Saya degen manga faa aa ange ang ana tn Brag ads dan ‘Alaa at ear sa ong ear lpads oy ch Psera yang DcaeagaDang ary aan Cdn dn ae as naneneuryan faanguketeagen yg beh ‘anprgua poretnaan patos 2. ery ety that ta ao ignte as mae ry esc a hl to mrs oa th sgn te Propocn Parr eson be Caered uce isFamyTtl Props an Detar Fam estionad 5 abe. Sadr i engin dco ttn 2 aba pa saan st yen sy aaa Wat sa) Pesala yang DeatnghavOan ag akan dg aaah Soran adagyn da Akan Tlf Kea yng eta aes hive sna thc Matinasspt ad vie ted othe above pro, Seat maa dengon end olan as Madspedan mene baba stan seu ash _Repunyaan Peseta yang Dieaangkan/Orang yang akan Dindungisapert nama a tas, “s Date /Tarikh So: O2|/| 49) /|>I]0| 317 Soh Signature of Sales Otfioor Bank Stat / Wits fal Stamp of Fa ution? Tandstngan Papo stain akiangan Bak Saki Cop Ras ns Kevan ene Aaa a ANIM. pn Yh NEP BS Nya No | Mo, tka Stati Code Kod Pens; WA at 5 Mobile No./o, tt Bima : OLA-HBB7PO O mal Ena) NevEt lO lovee yh Corse ‘anc Gotetune ota Canon = ‘in: bsvtsonilas ne joai on fa Egham dan ee ageb Hh Hp EA ra she ‘a: Satan eters ara Yr os ie enn aes Dag aa aes gyre ae asa Hh net: RIT 6 LITIS 20042001 Page /Mula Swat 6takafubimalaysia.comamy SS TakaruLmalaysia ar tea ornices — Syatikat Takaful Malaysia Keluargs Berhad nwerorsoun ree5¥) TBUPEIABAE 14th Floor, Annexe Block, Menara Takafl Malaysia, F cueniati-maaysincom ny 1 Name of Person to be Covered: | Noma Orang yang akon Diincungh AO 2ANSO) _ NNRIC No of Person to be Covered: ‘No. Kod Pengenalan Orang yang akan Ditindungi: 26190 6-02-8214 No. Cadangan: Piease provide the following details / Silo berikan butiran bert: Tianna 7 No4,Jalan Sultan Sulaiman, 50000 Kuala Lumpur, P.O. Bow 11483, 50786 Kuala Lumpur COVID-19 QUESTIONNAIRE (TO BE COMPLETED BY THE APPLICANT) BORANG SOAL SELIDIK COVID-19 (DIISI OLEH PEMOHON) BR Ata Proposal No: Do you currently have or have you had any ofthe following symptoms in the past 30 days? Adakah anda sedang mengalami atau pernah mengalam simptom yang dinyotakan di bawah dalam tempoh 30 hari? z peer | Symptoms /Simptom lease ck () ites / : : ‘Sila tandakian (¥) Jka Yo. i._High temperature/ Fever / Suhu Tinggi / Demarm i, Sore throat / Sokittekak li_Dry Cough / Batuk Kering iu_Nasal eangestion / Hidung tersumbat \s Myalgia (generalized body ache) or Arthralgi (pain in joint areas) / Myaigia(sakit badan secora umum) atau Arthralglo(sakit di bohagion send) vi. Headache / Pening kepala vii, Shortness of breath or breathing difficulties / Sesak nafas atau kesukaran bernafas vill, Fatigue / Keietihan ix, Gastro-intestinal symptoms such as nausea, vomiting and/or diarthoea / Simptom gastro-intenstinal seperti loya, muntah dan/atau ciri- birt Xe Dysgeusia (distortion of the sense of taste) / Dysgeusia (gangguan rasa) xi,_Anosmia (loss of the sense of smell) / Anosmia (hilang deria bau) if yes, please provide further detalls, Le, dates, duration, treatment, results of investigations (if any}, name and address of ‘weating doctor / clinic / hospital. Jika Yo, sta berikan butiran lengkap termasuk tarikh, tempoh, sawatan, keputusan wjian (jika ada}, nama dan olamat doktor / Klinik / hospital yang dikunjungi umtuk rawatan. Have you been tested for COVID-19? Pernahkon anda menjalani ujian saringan COVID-197 Yes/¥a NofTidat [7 I yes, please state the date of the test done: Jka Ya, sila ryatakan tarith yjian saringan dljelankan: Positive / Positif Negative / Negatif| ] Result ofthe test / Keputusan ujfon saringan Have you made @ complete recovery with no sequelae? Adokah anda telah pulth sepenuhaya tanpa gejala berulang? Yes/¥a No/Tidak|3 | within the past 30 days have you had any contact with someone confirmad as infected with the virus? Dalam tempoh 30 har’ ini pernahkah anda berhubung dengan individu yang aljanghiti virus tersebut? Yes/¥o [ No/Tidok| If yes, please provide information Jka yo, sila berikan maklumat: 4, | Have you been issued any notice or directive to self-quarantine or stay at home (excluding as part of the altered employment arrangement)? Pernahkah onda mendapat notis atau arahan untuk kuarantin secara sukarela atau duduk di rumah (kecualiarahan eajikan)? vesyra[__] NofTidak |v I yes, please provide information /ika ya, sila berikan moklumat: S| Are you currently residing outside your country of residence or have you returned to your country of residence within the last 4 weeks? ‘Adakah anda kini menetap di uar daripada negara yang didiam atau telah kembal ke negara yang didiami dalam tempoh 4 ‘minggu yang alu? Yes/to | No/Tidak [ Ifyes, please provide information: Country / City / Departure Date / Arrived Date / Planned return date, ka yo, silo nyatakan maklumat berikut: Negara / Bondar / Waktu Ketibaan / Waktu Keberangketan /Tarikh dijangka pulang. 6 | Inthe next three months, do you intend to travel outside your country of residence? Dalam tempoh tiga bulan dari sekarang, adakah anda mempunyai perancangan untuk keluar dari negara yang didianni? Yes/Ya NofTidak[ 7 If yes, please provide information: Country City / Date of Travel / Intended Duration. Jka yo, sila nyatakan makluenat berikut: Negara / Bandar /Tarikh perjalanan / Tempoh masa perjafanan. thereby declare that the above particulars and answers Ihave given are to the best of my knowledge, true and that | have not withheld any material Information that may influence the assessment or acceptance of the proposal. | agree that this form will constitute part ‘of my proposal for family takaful end that fallure to disclose any material fact known to me may invalidate the contract, (Saya dengan ini mengoku bahawa kenyataan dan jawapan yang diberikan sepanjang pengetahuan saya adalah benar dan soya tidak ‘menyembunyikan sebarang moklumat yang boleh mempengaruhi penilaian atay penerimaan cadangan inl. Saya bersetuju bohawa orang iné akan menjadi sebuhagian daripada cadangan takaful kelvarga saya dan kegagalan untuk mendedahkan sebarang fakta ppenting yong diketahul oleh saya boleh menyebabkan kontrak terbata). AdrLWwA Siu AHmao Oe, iz _rtpolae% Name / Nama Signature / Tandatangan Date / Tarikh‘takatumalaysiacommy 0008252305, ih TakaruLinalaysia ‘yaa ay bod seem arcs nae tence a atae ifiieatecient le PO. Box T1485, 50748 Kea Lumpur JUOTATION ‘quoraOn sue BATE 7 Sapam 2022 voraion ex DATE seatarh 2002 pum Tatar monToAse vert of eth a Tota an Parana iby (PO) oes during tha harig pre. Acer personage oho “onto pod alba payable oh Tata Operatarawatih os forthe sone ranee AMANCIALINSTTUTON / GRANTEE 2 ERASAREARARVAT MALAYSI BERD saan no. reopens coor ree ‘aa my Argo sng entation nda fy taka plan hat prose pteton coverage in he nano nate 2008 PNANCING PERIOD VERE) Ey ree pion (EAs) a news Imma suvt coveneD (ut) 2oaassaa Penton 0 COVERAGE EARS] » NertaKaeuL coNTRBUTON [at) ‘COMMISSION /ADLANISTRATION F(R) TOTALTAXAFUL CONTRIBUTION INCUISNE OF akauan ae cn + sep overteup to tained age cy foe (65) yao net thy en. 2 mcLsive ans the etal Toefl Contributions fsncedite the seg Amat > wo Fe 3.58 A 3,525.74) ofthe cotton of hh cat of Cmmison/ AS fee -30% 440886) and Olber Expenses 225 2asnas,Keerti salinan asal 761006-02-5214-02-01 (2474087) Tou eee ae