COVER NOTE

STAMP DUTY PAID

Participant Cover Note No. : 83355006-01

Account No. : V0027494
NUR SEIRA BINTI SARMAN Agent Name : NANDY BIN MD SABERI
LOT 3243, KG TG BANGKONG
ULU BENDUL Product Type : Private Car - Private Use
TERACHI Period of Takaful from 14/02/2022 To 13/02/2023 (both Dates
TANJONG IPOH Inclusive). Any subsequent period for which the Participant shall pay
71500 NEGERI SEMBILAN and the Takaful Operator shall agree to accept a renewal contribution..

NRIC No : 871111-14-6496 Business Reg No : Sum Covered RM 16000.00

Business/Occupation : Administrator Other ID No : Gross Contribution RM 841.56
Vehicle Information Less: No Claim Discount RM 252.47
30.00%
JPJ Document No :
Windscreen (RM1,500.00) RM 225.00
Vehicle Reg No : WVY4645 Log Book No : NIL
______
Make : FORD
RM 814.09
Model : FORD FIESTA LX Ti-VCT
Add : Service Tax 6.00 % RM 48.85
Engine No : TSJABS57467 Cover Type : Comprehensive
Stamp Duty RM 10.00
Chassis No : MNBAXXARJABS57467 Vehicle Type : Private Car
Year of : 2011 License Type : Normal Vehicle
Manufacture TOTAL AMOUNT DUE RM 872.94
Cubic Capacity : 1596 Use For : Private Use
Seating Capacity : 5
Excess All Claims RM 0.00
Financial Interest : NIL
Authorised Driver
1 NUR SEIRA BINTI SARMAN 871111-14-6496
2 ANY AUTHORISED DRIVER -

IMPORTANT NOTICE - APPLICABLE TO ALL CONSUMER PRODUCTS

(Takaful wholly for purposes unrelated to your trade, business or profession)
Where You have applied for this Takaful wholly for purposes unrelated to Your trade, business or profession, You had a duty to take reasonable
care not to make a misrepresentation in answering the questions in the Application Form (or when You applied for this Takaful) i.e. You should
have answered the questions fully and accurately. Failure to have taken reasonable care in answering the questions may result in avoidance of
Your contract of Takaful, refusal or reduction of Your claim(s), change of terms or termination of Your contract of Takaful in accordance with the
remedies in Schedule 9 of the Islamic Financial Services Act 2013. You were also required to disclose any other matter that You knew to be
relevant to our decision in accepting the risks and determining the rates and terms to be applied.

You also have a duty to tell Us immediately if at any time after Your contract of Takaful has been entered into, varied or renewed with Us any of
the information given in the Application Form (or when You applied for this Takaful) is inaccurate or has changed.

Issue Date : 24-01-2022/05:43 PM For and on behalf of

Issue At : B1 Etiqa General Takaful Berhad
Issue By : v0027494
 Invoice No: ETBG2022UWFL00232622
Date: 24/01/2022

INVOICE

ETIQA GENERAL TAKAFUL BERHAD (201701025031)

LEVEL 19 TOWER C
DATARAN MAYBANK
NO 1 JALAN MAAROF
59000 KUALA LUMPUR
(SST Reg No: W10-1808-31012539)

To Account Number: V0027494

NUR SEIRA BINTI SARMAN
LOT 3243, KG TG BANGKONG
ULU BENDUL
TERACHI
TANJONG IPOH
71500 NEGERI SEMBILAN

Description Total (RM)

Type of Certificate: Private Car - Private Use
Certificate Number: 83355006-01
Period of Takaful: 14/02/2022 to 13/02/2023

Contribution 814.09
Total (Excluding SST) 814.09
SST payable @ 6.00% 48.85
Stamp Duty 10.00

Total Amount Payable 872.94

This is a computer generated document. Therefore, no signature is required