CONFIRMATION AND AGREEMENT BY LIFE TO BE ASSURED/PROPOSER OF

ELECTRONICALLY SUBMITTED PROPOSAL (NON-FACE-TO-FACE SALES)

This form is to be signed and completed by Life to be Assured, Proposer, Agent and Leader (where applicable) and will form part of the Proposal for
Assurance with all other forms/qualifications that have been submitted to the Company.

Proposal No. Policy No. 1 0 6 3 6 3 0 4 8 0

SECTION 1: AGENT'S OR FINANCIAL ADVISOR'S DECLARATION

I hereby declare that I have verified the identity(ies) of the Life to be Assured and the Proposer through the use of such NRIC/Passport/Birth
Certificate.

I further declare that I have adhered to the requirements of the Proper Sales Advice Checklist and have disclosed all required information and
advice to the Proposer. I have also explained and given the Proposer the full set of the Company's approved Sales Illustration and Product
Disclosure Sheet relevant to the proposed products and have not provided the Proposer any unauthorised document or information to induce the
Proposer to enter into a contract of assurance with the Company.

I hereby confirm that I had clicked on the agent's confirmation box in the electronic "Confirmation Note from the Soliciting Agent". By so doing I
understand that I had confirmed that the party/parties to the proposed policy had/have fully understood the contents of the E-Form(s) together with
the statements made and answers given by him/them to the questions therein and that he/they had duly indicated his/their agreement to submit the
duly completed E-Forms to the Company for processing.

I declare that the information provided to me in the Customer Fact Find Form is confidential and will only be used in the process of recommending
suitable insurance products and shall not be used for any other purposes.

The analysis/advice in Customer Fact Find Form is based on the facts furnished in the Form. I have taken reasonable steps to ensure that the
advice is suitable for the client, having regard to the facts disclosed in this Form and other relevant facts, which are made available to me. I have
also explained to the client about the features of the product recommended and have given sufficient information to enable the client to make an
informed decision.

I hereby certify and witness the following signature(s) was/were made in my presence and that to my own personal knowledge it is the signature(s)
of the Life to be Assured/Proposer.

I hereby declare that I have deleted all customer personal data from my own personal devices.

SECTION 2: AGENCY LEADER'S VALIDATION (Only applicable for year 1 agent)

Based on the information provided by the Client, I agree with the recommendations/product advice given.

SECTION 3: POLICY OWNER’S DECLARATION FOR DIRECT CREDIT FACILITY

I have read and fully understand the information and authorisation contained in the electronic Direct Credit Facility Form.

I agree that the instruction is governed by the terms and conditions and Authorization specified in the electronic Direct Credit Facility Form.

SECTION 4: LIFE TO BE ASSURED'S / PROPOSER'S DECLARATION ON NON-FACE-TO-FACE SALES

I/We confirm that during the course of the agent’s remote/non face-to-face sales presentation to me:

a) the agent has explained the product features, and its terms and conditions, including limitations and exclusions;

b) the agent has explained the contents of the electronic proposal for assurance to my/our satisfaction, including the contents of the Personal
Data Protection Notice incorporated therein; and

c) I/We have authorised the agent to key in and/or enter on my/our behalf the statements, answers, and/or information into the electronic
proposal for assurance and I/We acknowledge that this was done by the agent on my/our behalf during the course of the agent’s remote/non
face-to-face sales presentation. I/We have read verified and checked all the statements, answers and/or information in the electronic proposal
for assurance and confirm them to be true, correct and accurate.
FPMS

I/We agree that all information given in the proposal form together with any documents, I/we provide or will provide will form the basis of the
contract of insurance and any temporary insurance, and I/We agree that I/We will be legally bound by the information given in the proposal form
once this confirmation form is signed.
NBZ-FCOEF-V15-052021 (NFTF)

SECTION 5: LIFE TO BE ASSURED'S / PROPOSER'S DECLARATION

I/We confirm and agree that I/we had made all the statements and given all the answers in the electronic proposal for assurance and any other
accompanying electronic and/or hard copy form(s) or questionnaires or cover photos or documents submitted and that they are true and authentic
as transmitted to the Company; and their contents therein shall form the basis of the contract between myself/ourselves and the Company. I/We
understand that the Company, believing them to be such, will rely and act on them as the basis of the insurance. The Company may void the policy
(if issued) if there is any non-disclosure, misrepresentation, misstatement, inaccuracy or omission.

I/We confirm that I/we have given the agent undersigned no other information in connection with this electronic proposal for assurance, except that
contained in the electronic proposal for assurance and/or hard copy form(s) or questionnaires submitted. I/We also confirm that save for sales
brochures, sales illustrations and documents duly authorized by the Company, the undersigned agent had not given me/us any document or
information to induce me/us to enter into a contract of assurance with your Company.

GREAT EASTERN LIFE ASSURANCE (MALAYSIA) BERHAD (93745-A)

Head Office Menara Great Eastern 303 Jalan Ampang 50450 Kuala Lumpur
Tel: +603 4259 8888 Fax: +603 4259 8000
E-mail: wecare-my@greateasternlife.com Website: greateasternlife.com Page 1 of 2 2208161820
 Proposal No. Policy No. 1 0 6 3 6 3 0 4 8 0
Instruction: Please use DARK BLUE color pen to avoid being taken as non-original document.
SECTION 5: LIFE TO BE ASSURED'S / PROPOSER'S DECLARATION
I/We hereby confirm that the signature(s) on this form is/are made under my/our hand and I/we agree for it to be used for the purpose of verification
in all my/our future transactions with the Company.

I/We further agree that the insurance applied herein shall not take effect and no cover whatsoever will be provided by the Company until a policy is
issued to me/us on the said electronic proposal for assurance and/or electronic forms and/or questionnaires and the first premium has actually
been paid and received in full by the Company during the lifetime and good health of the Life to be Assured/Proposer.

I understand that the policy document ("e-Policy Contract") will be issued to me through my account in e-Connect. In this connection, I further
confirm that the email address and mobile telephone number given in this electronic proposal for insurance are correct and I agree to activate
my account in e-Connect in the event I do not have an existing account. I understand that the delivery and acknowledgement of receipt of the
e-Policy Contract will be completed through e-Connect. I also acknowledge that my right to return the e-Policy Contract to the Company for
cancellation will expire 75 days from the date the e-Policy Contract is made available in e-Connect. If the Proposer is a corporate customer
(including company and business): I/We understand that a physical copy of the Policy Document will be issued to me/us, and that I/we have the
right to return the Policy Document to the Company for cancellation within 15 days of its delivery to me/us.

I/We hereby authorize any doctor, medical practitioner, physician, hospital, laboratory, surgeon, nurse, medical staff, clinic, insurance company,
organization or institution, that has any records or knowledge of me/us or my/our health, to disclose to the Company or its representative any
information about me/us, my/our health, medical history and any hospitalization, advice, treatment, disease or ailment, and I/we authorize the
Company and its representative to give and release any such information to any party to process this application and for the administration,
analysis or processing of claim. A photocopy of this authorization shall be effective and valid as the original.

I/We confirm that the agent undersigned has provided me/us with a copy of the completed Customer Fact Find Form. In relation to the extent of the
disclosure of my/our information in the Customer Fact Find Form, I/we confirm that I/we had selected the following option as set out in the
Customer Fact Find Form:

Option 1 I/We wish to disclose all information requested for in this Form.

Option 2 / I/We wish to disclose partial information requested for in this Form.

Option 3 I/We wish to receive product information only and do not wish to disclose any information requested for in this Form.

SECTION 6: SIGNATURE SECTION

X X
Signature of Proposer (Owner - if other than Life to be Assured) Signature of Life to be Assured

Name Name LIEW ZHI XUAN

New NRIC / Passport No. New NRIC / Passport No.

981026086672

X X
Signature of Agent / Financial Advisor Signature of Agency Leader
(For year ONE Agent ONLY)

Name
OH WAN PING Name GUN KER YANG
6809259 6407584
IAC No. IAC No.

Rank UM

Date 2 6 / 10 / 2 0 2 2
Day Month Year

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