COVER N OTE

STAMP DUTY PAID

Participant Cover Note No. : 84995245

Account No. : V0032759
SATIYAVARAN A/L K LETCHUMAN AN Agent Name : SETIA TEGUH CETERA
N O 2 JALAN MEGAH 11 TAMAN MEGAH SERVICES
SUN GAI JELOK KAJAN G
KAJAN G Product Type : Motor Cycle Private
43000 SELAN GOR Period of Takaful from 29/06/2022 To 28/06/2023 (both Dates
Inclusive). Any subsequent period for which the Participant shall pay
and the Takaful Operator shall agree to accept a renewal contribution..

NRIC No : 971103-01-7043 Business Reg No : Sum Covered RM 3000.00

Business/Occupation : Administrator Other ID No : Gross Contribution RM 177.64
Vehicle Information Less: No Claim Discount RM 0.00
JPJ Document N o : 0.00%
Vehicle Reg N o : BPS4538 Log Book No : N IL ______
Make : MODEN AS RM 177.64
Model : MODEN AS DIN AMIK AS120C Add : Service Tax 6.00 % RM 10.66
Engine N o : AS120CEL48730 Cover Type : Comprehensive Stamp Duty RM 10.00

Chassis N o : PMN AS120CHML47518 Vehicle Type : Motor Cycle

Year of : 2018 License Type : N ormal Cycle TOTAL AMOUN T DUE RM 198.30
Manufacture
Cubic Capacity : 118 Use For : Private Use
Seating Capacity : 2 Rider Type : Single Rider Excess Damage Claims RM 100.00
Financial Interest : N IL

IMPORTAN T N OTICE - APPLICABLE TO ALL CON SUMER 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 : 29-06-2022/12:12 PM For and on behalf of

Issue At : B3 Etiqa General Takaful Berhad
Issue By : v0032759b
 Invoice No: ETBG2022UWFL01620052
Date: 29/06/2022

IN VOICE

ETIQA GEN ERAL TAKAFUL BERHAD (201701025031)

LEVEL 19 TOWER C
DATARAN MAYBAN K
N O 1 JALAN MAAROF
59000 KUALA LUMPUR
(SST Reg N o: W10-1808-31012539)

To Account Number: V0032759

SATIYAVARAN A/L K LETCHUMANAN
NO 2 JALAN MEGAH 11 TAMAN MEGAH
SUNGAI JELOK KAJANG
KAJANG
43000 SELANGOR

Description Total (RM)

Type of Certificate: Motor Cycle Private
Certificate Number: 84995245
Period of Takaful: 29/06/2022 to 28/06/2023

Contribution 177.64
Total (Excluding SST) 177.64
SST payable @ 6.00% 10.66
Stamp Duty 10.00

Total Amount Payable 198.30

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