COVER NOTE

STAMP DUTY PAID

Participant Cover Note No. :-

Account No. : V0035817
ROSILAWATI BINTI ABDUL MANAF Agent Name : MUHD FAIZAL BIN MUHD
BAHAGIAN SIASATAN JENAYAH (URJ) ARIFFIN
IBU PEJABAT POLIS DAERAH
KAMPAR Product Type : Motor Cycle Private
31900 PERAK Period of Takaful from 22/02/2023 To 21/02/2024 (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 : 790316-03-5146 Business Reg No : Sum Covered RM 1000.00

Business/Occupation : Businessman / Other ID No : Gross Contribution RM 131.74
Businesswomen Less: No Claim Discount RM 32.94
Vehicle Information 25.00%
JPJ Document No : Basic PA (Death-Limit RM 18.65
RM8000)
Vehicle Reg No : AED8204 Log Book No : NIL
______
Make : YAMAHA
RM 117.45
Model : YAMAHA SRX NA
Add : Service Tax 6.00 % RM 7.05
Engine No : 5AL2305484M Cover Type : Third Party Fire And
Theft Stamp Duty RM 10.00
Chassis No : YYK2305484 Vehicle Type : Motor Cycle
Year of : 2000 License Type : Normal Cycle TOTAL AMOUNT DUE RM 134.50
Manufacture
Cubic Capacity : 102 Use For : Private Use
Seating Capacity : 2 Rider Type : All Riders Excess Damage Claims RM 100.00
Financial Interest : NIL

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 : /05:00 PM For and on behalf of

Issue At : N1 Etiqa General Takaful Berhad
Issue By : v0035817