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    irqim

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    ‘REA Afin General insurance Berhad iss0000) Ground Floor Wisma Bousteas 71 Jalan Raja Cholan 50200 Kuala Lumpur ‘ ‘B (603) 21708282 %_ (603) 2031 7282 2 customerservice@ava.commy 1B wwwnwaxa.commy Proposal Form SmartStudent Care Date: 4. Pursuant o Paragraph Sof Schedule 9 ofthe Financia Services At 2013, You are applying fr this Insurance whol for purposes unrelated to Yur tade, business or profesin, You haves uty take reazonable cre not to makes margpresetationnsrawering the questions ths Proposal orm You most Answer the questors ths Proposal Frm uly and accurately Faire to fae reasonable core ansting he questions may rsultin avoidance of Your contac of insurance, refusal or eduction of Your claims), change of {erm or termination af Your conver of masrance. ‘Theabove duty of asclosoe sal contre ut the tne Your contract of insurances entered ita, varied o enced with Us Inston to anweing the cuestons mis Proposal Farm, tow are required to discese any ether mater that You know tobe relevant to Our decision in acceaing the ss and determing heats ane tems tbe apple. ‘ovalsa Rave a dy tel Us mmeiatd fat any ume ater our contract of insurance has bee entered int, varied renewed wth Us any ofthe information Even in his Proposal ormis insecurate or has changed. 2, Thepersonal data (Personal Data" submitted by and collected from you may be used by Us andor any company within the AXA Group of Companies andor any ofits assocatec companies, mith or outside Malaysia, for purposes related fo our incurance business or dieet marketing. In connection with ths we may close your information (inluging your Personal Dat] to"any of the aforementoned companies. We may also ciclase your information {including yout Personal Data to any other thie pares (which inclode third party service provers, reinsurers, claim adjutes/investigatr, related Indust associations, regulators, statutory bacies, government authortes anc any person wna is under a duty of confidentiality andor who nas undertaken te responsibilty t keep Such data confidental) Acomplete st four ciclosures to rd parties canbe ound inthe Data Privacy Nelice In our website ‘We wil cease to use the Personal Data # you request Us todo so. For further details on how to exercee your rigs, pleae refer tothe "Data Privacy Notice” in Section or our ebste at wi.axa.com my, 23, Premium charged for this Policy exclude applicable tax(es) that would be imposed in the future and fram ime to time, We wll be entitled to recover rom You any tangs that We are required by aw i cole. |. DETAILS OF PARENTS/LEGAL GUARDIAN Name” as per NRICPassport alin aderess Postcode’ NRICIPassport No: Nationality Gender: Mate/ Female Occupation Email el. No. House! Tel No. (Mobi Te. No. (Offi Relationship with student: Prvateuse: Eves No Collective Agreement/SOCSO/Workmen Compensation Agreement: C]ves_ No DETAILS OF STUDENT Name* (a per NRICPassport Nlc/Bith Certicate/Passpor No Gender": Male Female Nationality Date bir ees standardFoem Name ofschool/educational institution: Period of ineurance: From To C. PAYMENT METHOD |wish to pay my premium of RM (inclusive ofall tax (Total Amount Due") Py: Ci cash Ci cheque tease cross the cheque and made payable to‘AXAAlfn Genera Insurance Berhad’) Bank ‘cheque. ‘Amount (RM) i oniine transfer (cits Bank virtual account) 98] - [37 Di credit/ oebit card Not: For onine transfer, cree ane debit card payment, please contact your AXA Servicing Representative, Automatic Renewal ‘The Palcy, subject the terms and conditions, payment of Total Amount Ove, willbe automaticaly renewed unless natice afnon-enewalis given by youn wrting othe Company before the Policy's anniversary date Piease charg the Total Amount bue to my debitjeredit card above D. DECLARATION \yWehereby declare hat the above answers and statements are tue, and that we have withheld no information whatever regarsing this application \yWeunderstand that it is myfour duty to take reasonable care nt to make a misrepresentation in answering the questionsin this Proposal Form and ie heveby declare that we have fully and accurately answered the questions above imme hereby consent to have AXA Afin General Insurance Berhad andjor any company within the AXA Group of Companies andjor any ofits assocated ‘companies within or utsice Malaysia, process my/our Personal ata forthe purposes and tothe extent stated inthe Data Privacy Notice, Cire woutd tke to receive special offers, promotions, surveys and information related to the insurance products, events and services of AXA Affin General Insurance Berhac andj any company within the AXA Group of Companies and/or any afits associated companies Name ofparentlega guardian signature E. DECLARATION BY INTERMEDIARY/INSURER Ue hereby confirm that we have sighted the original copy ofthe NRIC/Passport and verified the identity ofthe Proposer, Signatur of termedian/nsure: pate Name Agency Code Note: Please attach a copy of the Propose'sNRIC/Passport where the premium is more than RM5O,000, F. PERSONAL DATA POLICY ‘Your privacy s important to us, AXA AFFIN General Insurance eehad "AXA AFFIN"), and we are committe to ensure that your personal data under our care Is safe and Secured, The following paragraphs wil provide you with a better understanding of how we collet, process, Use, retain, secure, endeavour ‘maintain accuracy and how you could access your personal data, Collection of Personal Data Inorder to proces the purchase ofan insurance policy and to perform policy services it isnecessary fer you to provide us with obligatory personal data such 2syourname, dentication number, birthdate, address, phone number, information on yourhealth or medical conition, nancial, familial and nen-anilial information ee, Your personal data is captured inthe application form and other relevant forms as and when you transact or when you require changes or amendments to your personal detail Your persona data once provided by you would be input into our information system or processing safekeeping and forthe performance of our obligations in relation o your policy. Processing and Use of Personal Data We process your personal cats forthe following purposes 1, forthe performance of contracts between AKAAFFIN and you; 2. forthe performance of our functions 3, forthe performance of our due diligence process to conduct background checks to validate and confirm the information provided by your for compliance with all applicable lavs, rules, regulations, guidelines andjor other legal or regulatory requirement, as well 3s requirements of the fpovernment, (aw enforcement agencies, and any authorities to whom we are Subject to, oF any orders a the Cour; foritgatng, defending or responding accordingly to an actual or potential lawsuit or queries involving regulatory and non-reulatary bodies; {or generally protecting our rights and property 38 well as ensuring the technical competence and functioning of ou systems tammonitor and detect any fraudulent activities in the insurance industry: for marketing (nluding direct marketing) ofinsurance products; te conduct market research, understand and analyse customer behaviour location, references and demographics for us to cffer you other products and services as well as cary out special offers and marketing programmes which may be relevant to your preferences and profle; and 10. any other purposes which are elated tothe aforesaid. Allpersonal data requested by uss obligatory unless stated otherwise. you do not provide us with suchinformation, wemay nate able to provide you with insurance coverage orto respond to any claims, Disclosure of Personal Oata \Wemay disclose your personal data fr the abovementioned purposes tthe following partes including those within and ouside Malaysia ‘our associated and elated companies and aflites ("AXA Group"); any agents, service providers, contractors or third parties who provide any services tothe companies within the AXA Group: any person whe has a duty f confidentiality tous for example, external auditors, medical practitones, tastes, insurance companies, and actuaries {government agencies, statutory bodes, and other authors; cur business partners and strategic aliances; ‘ur assignees or potential assignees, acquirers or potential acquirers and successos-nttles and “any other parties in espect of whom you have consented ta the disclosure of your personal data, ‘Access and Change Requests We take all reasonable steps to ensure tha the personal data provide by you or your authorised party is accurate, complete, not misleading and kept upstosdate consistent withthe purpose for which the personal data was collected and further processed Please contact us or request to speak to our Privacy Oficer at 03-2170 8282 Ifyou would like to access to or amend or correct your personal data that is inaccurate, incomplete, misleading or natup-todate, You could also fax or email us by using the deta stated below. We will use reasonable efforts £2 accommodate the access and make the changes a soon as practically possible. A fee may be charged fortis purpose. We may request verification of your identity before allowing such access or making such changes and any other details tohelpus adress your request or concers appropriately New Product and Services [part of our continuous efor to promote awareness and greater understanding on our new products and services for your beni, we wl om tin time contact or send you information on the said new products or service. Inquires and complaints Fou need te contact us or if you have any inquiries or complaints (such a limiting the processing of certain information, including the withdrawal of please writetousat: _AXAAFFIN GENERAL INSURANCE BERHAD Customer Service Department Ground Floor, Wisma Boustesd, T1Jslan Rajachulan, ‘50200 Kuala Lumpue “Tel: 603-2170 8282 or Fax: 603.2021 1282 or Email: Untuk manyimpan data trcobut sult, Sonara longkap perdedahan kam kopada pinakketga boleh dapat Nats Prvas Dat a lama” wob kam Kam akan berhert) manggunakan Data Peribad jka anda meminta Kami untuk berouat demkian. Untuk maklumat lant tertang cara untuk melaksanaken hak anda, sla rujux Hepa "Nats Prvas Dat’ dalam Sahagan F atau laman Web kal wir. axa com. 3. Premium yang dkenakan untuk Pols ni tdaktermasu cal terpkal yang bole dkenkan pada masa hadapan dan car masa ke seas, Kan berhak Umuk mamperloh daripada Anda sebrang cutal.cukal yang peru dibayarc Dawah peruntukar undangancang ‘A. BUTIRAN IBUBAPA/PENJAGA Nama" (sepert pada KP}Pasport) Alama Poskod No KP/Pasport Warganegae" Janta": Lela Perempuan Pekeraan Emel No. Tel. (Rumab No. Tl (Bibi No. Tel. (Pejabat Pertalian dengan pelaar: ogunaan Persendvian: C]veL] Tidak ParjanianKoleatt/SOCSO/Perjaniin Pampasan Pekar: Ow Otieak B. BUTIRAN PELAJAR pert pada K/Paspor No. KP/Pasportsijl ahi Janina’ Leak’ Perempuan Warganegara ures Darah Tingkat Namo sekolahfnaits pengalian Temnch maurante pai PTT Hines (C. KAEDAH BAVARAN aya ingin membayar premium at (termasuk semua cual ("Jumish Amaun Yang Peru Dibayar") dengan: C] Tunai C1 cek(Silapalanghan cok dan bayaran kepada ‘AKA Alin General Insurance Berhad’) Bank No Cal Jamiah (RM A Pemindahan dalam Tolan tkaun Mayo cine Bans) [38] -[ 7s] kd wredit/oenit Nota: Untuk pemindahan dalam tli, perbayaran kad kredit dan debit sla hubungl wak AKA anda, Pembaharuan otematik Pols ini tereakluk kepada terma dan syrat, pembayaran Jumlah Amaun Yang Perl Dibayar, akan éiperbaharuisecara otomaik melainkan jk natis untuk tidak memperoanarunya dlverkan secarabertulis oleh anda kepada Syarkatsebelum tare ulangtahun Pol C7 Sita kenakan bayaran Jumlah Amaun Yang Peru Dibayar ke atas kad debit/kredit saya dl atas. D. DEKLARASI ‘aya/Kami dengan ni mengisyiharkan bahawa semua Kenyataan yang terandung di tas adalah benar, dan says/kamicidak menyembunyikansebarang kenyataanberaatan permohonan in ‘aya/Kamimemahami bahawa [a adalah kewsj/pansaya/kam untuk mengambillangkah yang munasabah untuktidsksalah nyate dalam menjawab Ssoalansoalan dalam Borang Cadangan Il dan saya/kami dengan ini mengisyinarkan banawasaya/kam telah menjawab soalan dl stas dengan lenghap. 1 sayaykami dengan ni bersetuj untuk membenarkan AXA Afin General Insurance Berhad dan/atau mana-mana syarkat dalam Kumpulan Syarkat AXA dan/atau mana-mana syarkatbersekatunya, cl dalam atau diluar Malaysia, memproses Data Peibadl saya/kam’ untuk tujuan dan setakat mana yang inyatakan dalam NotisPrivasi Data, 1 sayaykam’ ingin menerima tawaran Generalinsurance Berhad dan/atau ime, promosi injauan dan maklumat yang berkaitan dengan produk, acara dan perkhidmatan AXA Ain emana syarikatéalam xumpulan Syarkat AXA danjatau manaemana syrikat bersekutunya "Noma bubapa/penjoga Tandatangan: Noe: Tare E, DEKLARASI OLEH PENGANTARA/PENGINSURANS. ‘Saya/Kamimengesahkan bahawa saya/kamitelah melinat KP/Pasport yang asa dan memeriksa identi pencadang, ‘Tandatangan Pengantara/Penginsurans: Tare Nama: Kod Agensi Nota: Sila lapitkan slinan KP Pasport pencadang sekranya premium lebih daripada RM F. DASAR DATA PERIBADI rivasi anda penting kepada kami, AXAAFFIN Genera nsurance Berhad ("AXA Ain"), dan kam komited sepenuhnya untuk memastkan data peribadi anda «i bawah jagoan kam adalah selamat dan terjamin,Perenggan-perenggan berkutnya akan member anda pemahaman yang lebih bak mengenal cara kam\ ‘mengumpu, memproses, menggunakan, menyimpan, menjamin, berusaha untuk mengekalkanketepatan seta cara ana boleh mengakses data peribad ans Pengumpulan Data Peribadi ‘Untuk memproses pembelian pols insurans dan melaksanakan perkhiématan polis, anda perlu member kami data perbadl yang wall clberkan seperti rama, nambor kad pengenala, tar lah, alamat, nombor telefon, maklumat berkaitan dengan keshatan atau keadaan mental anda, makivmat bersaitan cengan kewangen, keluarga dan oukan keluarga dl Data peribac ancadirekockan di dalam borang cadangan dan dekumen-dokumen lain yang, berkenaan apabila ands berurusniaga atay apabila anda memerlukan penskaran atay perubahan Ke atas maklumat perbadi anda. Data peribad! yang cisediakan oleh anda akan dimasuklan ke dalam sistem maklumat kam untuk proses, disimpan dan untukpelaksansan keualipan kam beraitan dengan pols anda, Pemprosesan dan Penggunaan Data Peribadi Kami memproses data petibad anda untuk wujuan-tujuan berkut 4. untuk pelakssnaan perjanjar-perjanan cl antara AKAAFFIN can ands; 2. untuk pelaksanaan fungs-fungsi kom 3. untuk pelaksandan proses usaha wajar kami untuk mengendalikan semakan latar belakang untuk menyahkan dan mengesahkan maklumat yang, dlsediakan oleh anda; 4. untukmematuh semusundang-undang, keedah, peraturan, gat panduan dan/otau Keperluan undang-undang atau kawalaturyang terpakol, dan jugs untuk keperluan kerajaan, agens! penguatkvasaan undangeundang, dan apa-apa pihak berkuasa yang kami Certaklk kepada, atau apa-apa perntah Mahkamahy 5. untuk tjuan lias), merbele atau membalas sewajarnya kepada tindakan undang-undang sebenar atau berpotensl atau pertanyaon yangmelbatkan tbadan pengatur dan badan bukan pengatur Ssecara umumaya untuk melindunghalchak dan hartatanah kami dan jugs untuk memastkan kecekapan tekikal dan perfungsian sstem kami; untuk memantau dan mengesan apa-2p3aktvt penipuan dalam industinsurans; untuk perasaran(termasuk perasaranlangsung) produkinsurans untuk mengendalizan penyeliikan pasaran, memahami dan menganalisstingkeh aku, lokasi, phan dan demograf elanggan kami agar kami dapat renawarkan kepada anda produk dan perzhidmatan lain dan juga melaksanakan taworankhas dan program pemasaran yang mungkin elevan kepada pithan dan profil anda; dan 10. apa-apa tujuan lain yang berkaltan dengan tjuan yang dnyatakan datas, ‘Semua data peripad yang diminta oleh kami adalah wall kecualidnyatakan sebaiknya.Sekranya anda tidak menyediskan kepada kami maklumat yang, bberkenaan, kami mungkin tidak dapat menyeeiakan anda dengan perindungan insurans atau membalas kepada apa-apa tunttan, enzahiran Data Peribadt Kami mungkin menzahirkan data perbad! ana untuk tjuan-tjuan yang dinyatakan cl atas kepada pihakephhak berkut(termasuk di dalam dan di lar Malaysia 1. syarkat-syarkat bersekutu dan syarkat-

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