E-Receipt

Acknowledgement No. : AF22013495

Receipt No : 107*2022017845
Payment Date : 26 Jan 2022 4:48:45PM
Pay Mode : WEB FPX - ZURICH@Corporate Web

CHRISTINA A/P MUT MARTHIN

NO33 TASEK MUTIARA 3, PUSAT PERDAGANGAN
TASEK MUTIARA IPOH
IPOH
31400 IPOH

Application/Policy No : 6200114053
Applicant Name : CHRISTINA A/P MUT MARTHIN
Insured Name : CHRISTEVEN ANTHONY

Payment Description Due Date Amount (RM)

Premium 23 Jan 2022 RM 170.00

Next Due Date / Tarikh Seterusnya : 23 Feb 2022

Payable / Dibayar : 002Y08M

Agent : S S SEBASTIAN

Terms & Conditions:

(1) The company, by reason of this payment incurs no obligation toward the Proposed Life Assured
until the new application, application of reinstatement, repayment or endorsement of the
insurance policy is received and approved by the Company, subject to provisions and conditions
in the policy contracts or any other requirements stipulated by the Company.
(2) This receipt is only valid and acceptable subject to the negotiable instrument presented being
honoured by our banker.

Interim Coverage for New Application

Payment equivalent to the first premium received by the Company under the application will be treated
as deposit until the application is approved. When we receive the application form with the deposit, we
will provide interim coverage to the Proposed Life Assured , subject to the following conditions:

a) We will provide accidental death cover to the Proposed Life Assured equivalent to the proposed
basic sum assured (but shall not exceed RM500,000 per life, at any one point of time, or
whichever is lower). This cover shall only be given if the proposal is acceptable by the Company
on standard rates.
b) Interim coverage commences and is effective for 90 days from the date of this receipt (inclusive).
c) If the application for coverage is not accepted as stated in Terms and Conditions (1), or the
applicant applying for coverage requests for cancellation, no coverage will take effect and the
payment will be returned.

This is computer generated document. No signature required.

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