Takaful myClick Term

E-CERTIFICATE NO. | NO. E-SIJIL: [D202302250000013]

E-CERTIFICATE INFORMATION PAGE ("e-CIP") When contacting us, please be ready to quote this number.
HALAMAN MAKLUMAT E-SIJIL Ketika menghubungi kami, sila kemukakan nombor ini.

Details of Participant | Maklumat Terperinci Peserta

Full Name RAJA AHMAD BAZLI BIN RAJA Date of Birth 01/11/1994
Nama Penuh SHAHRUM Tarikh Lahir
Identification Number 941101-10-6213 Age Next Birthday at Entry (years) 29
Nombor Pengenalan Umur Hari Lahir Akan Datang Pada
Kemasukan (tahun)
Address NO 8 JALAN SENTOSA 10, TAMAN Gender MALE
Alamat DESA SENTOSA, DUSUN TUA, 43100 Jantina
HULU LANGAT, SELANGOR

Details of Person Covered | Maklumat Terperinci Orang yang Dilindungi

Full Name RAJA AHMAD BAZLI BIN RAJA Date of Birth 01/11/1994
Nama Penuh SHAHRUM Tarikh Lahir
Identification Number 941101-10-6213 Age Next Birthday at Entry (years) 29
Nombor Pengenalan Umur Hari Lahir Akan Datang Pada
Kemasukan (tahun)
Address NO 8 JALAN SENTOSA 10, TAMAN Gender MALE
Alamat DESA SENTOSA, DUSUN TUA, 43100 Jantina
HULU LANGAT, SELANGOR

Details of Takaful | Maklumat Terperinci Takaful

Contribution Mode MONTHLY Occupation Loading (Death / Total NIL
Mod Caruman & Permanent Disability)
Loading atas Pekerjaan (Kematian /
Total Amount Payable RM24.00 Keilatan Menyeluruh & Kekal)
Jumlah Bayaran
Final Contribution Due Date 28/01/2074 Health Loading | Loading atas Kesihatan:
Tarikh Caruman Akhir Dibayar Death / Total & Permanent
Expiry Date 28/02/2074 Disability NIL
Tarikh Tamat Kematian / Keilatan Menyeluruh
& Kekal
Critical Illness (CI)
Penyakit Kritikal (CI) NIL

Sum Covered Effective Date Standard Contribution Extra Contribution

Jumlah Dilindungi Tarikh Kuat Kuasa Caruman Standard Caruman Tambahan
Death / Total & RM100,000 01/03/2023 RM17.17 NIL
Permanent Disability
Kematian / Keilatan
Menyeluruh & Kekal
Critical Illness (CI) RM100,000 01/03/2023 RM6.83 NIL
Penyakit Kritikal (CI) CI (Advance Payout) CI (Advance Payout)

The contribu ons are not guaranteed and may vary based on the contribu on in effect for the a ained age of the person covered at
certificate anniversary.
Caruman adalah dak dijamin dan mungkin berlainan berdasarkan kadar caruman mengikut umur tercapai orang yang dilindungi pada
ulang tahun sijil.

CIP/MCT/V04/02-2022
 Takaful myClick Term
E-CERTIFICATE NO. | NO. E-SIJIL: [D202302250000013]
E-CERTIFICATE INFORMATION PAGE ("e-CIP") When contacting us, please be ready to quote this number.
HALAMAN MAKLUMAT E-SIJIL Ketika menghubungi kami, sila kemukakan nombor ini.

Important Note | Nota Penting:

This e-Cer ficate Informa on Page is issued to the Par cipant in considera on of the contribu ons payments and shall take effect on
the Effec ve Date. As part of your e-Cer ficate, please refer to the Cer ficate Wording available in
h ps://stmkb.online/Term_cert for the full terms and condi ons of this product.
Halaman Maklumat e-Sijil ini dikeluarkan kepada Peserta dengan per mbangan ke atas pembayaran caruman dan akan berkuat
kuasa pada Tarikh Kuat Kuasa. Sebagai sebahagian daripada e-Sijil anda, sila rujuk pada Sijil yang boleh didapa di
h ps://stmkb.online/Term_cert bagi semua terma dan syarat penuh untuk produk ini.

Authorised Signatory Issue Date 01/03/2023

Penandatangan yang Sah Tarikh Dikeluarkan

Nor Azman bin Zainal

Group Chief Executive Officer
Ketua Pegawai Eksekutif Kumpulan

THIS PLAN IS UNDERWRITTEN BY / PELAN INI DIUNDERAIT OLEH: SYARIKAT TAKAFUL MALAYSIA KELUARGA BERHAD [198401019089 (131646-K)]

CIP/MCT/V04/02-2022
 Takaful myClick Term
E-CERTIFICATE NO. | NO. E-SIJIL: [D202302250000013]
HEALTH QUESTIONNAIRE When contacting us, please be ready to quote this number.
SOAL SELIDIK KESIHATAN Ketika menghubungi kami, sila kemukakan nombor ini.

I confirm that each statement in relation to this application is true and complete and I have not withheld any
other information which might influence the acceptance of this proposal by Takaful Malaysia.
I further authorize Takaful Malaysia to obtain the health and medical information of the person covered for the
purpose of claims administration.

Takaful/Insurance history
Has any of your certificate/policy or proposal for family takaful or life or critical illness No
insurance ever been declined or postponed?

Height and weight

What is your height? 170cm

What is your current weight? 83kg

Lifestyle
Have you smoked tobacco or any other substance in the last 12 months? No

Medical history
In last 5 years have you ever had any of the following conditions or symptoms: No
• High blood pressure, high cholesterol, chest pain, heart attack, stroke or any No
condition affecting your heart or circulation
• Diabetes, raised blood sugar, sugar in urine, any condition affecting your pancreas, No
thyroid or hormones
• Cancer, leukaemia, tumour, cyst, lump, growth or lymphoma No
• Asthma, bronchitis, tuberculosis or any condition affecting your lungs or breathing No
• Hepatitis, liver cirrhosis, elevated liver enzymes, or any condition affecting your No
liver, stomach, intestines, anus or digestion
• Blood or protein in urine, kidney failure or any condition affecting your kidney or No
genital urinary functions
• Fits or seizure, epilepsy, recurrent headache, brain injury, paralysis, mental disorder No
or any condition affecting your nervous system
• Arthritis, gout, rheumatism or any condition affecting your spine, joints, bones, No
muscles or tendons
• Anaemia or any blood disorder No
• Any condition affecting your eyes, ears, nose, mouth or throat requiring a doctor's No
consultation (excluding common flu or red eye as a minor eye infection)

Hospitalisation history
Other than disclosures you have already made, in last 5 years have you: No
• undergone surgery or been hospitalised more than 14 days; or

CIP/MCT/V03/02-2021
 Takaful myClick Term
E-CERTIFICATE NO. | NO. E-SIJIL: [D202302250000013]
HEALTH QUESTIONNAIRE When contacting us, please be ready to quote this number.
SOAL SELIDIK KESIHATAN Ketika menghubungi kami, sila kemukakan nombor ini.

• been under any kind of medication, treatment or counselling lasting more than 30
days; or
• been advised to go through any medical investigation, scan or test?

Family history
Do you have 2 or more family members (natural parents, brothers and sisters) who have No
suffered from cancer, heart attack or angina, stroke, diabetes, polycystic kidney disease,
or any other hereditary disease before the age of 55?

CIP/MCT/V03/02-2021
 Takaful myClick Term
E-CERTIFICATE NO. | NO. E-SIJIL: [D202302250000013]
PROPOSAL DETAILS When contacting us, please be ready to quote this number.
BUTIRAN CADANGAN Ketika menghubungi kami, sila kemukakan nombor ini.

Participant's Declaration and Authorisation

Aqad & Confirmation of Understanding
I agree with the Aqad ("Par cipa on Agreement") and I agree to par cipate in Takaful myClick Term. I understand that it is
my duty to take reasonable care not to make any misrepresenta on in applying for this plan. The contribu ons will be
automatically deducted from the card that I have authorized on a monthly basis.
Aqad
a. I agree to pay the contribu on based on Tabarru' ("Dona on") into the Group Family Takaful Account (GFTA) for mutual
assistance payment of claim benefits.
b. I authorize Syarikat Takaful Malaysia Keluarga Berhad ("Takaful Malaysia") based on Wakalah ("Contract of Agency") to
manage the GFTA and in return, Takaful Malaysia will receive 45% of the contribu on as a Wakalah fee for the services
rendered.
c. I also agree that any surplus arising from the GFTA will be kept in the GFTA and if the GFTA is in deficit, a Qard ("Interest-
free Loan") will be provided by Takaful Malaysia to the GFTA.

I am aware that:
a. The plan pays benefit in the event of death, Total and Permanent Disability (TPD) or critical illness, where applicable;
b. The plan does not provide coverage under certain condi ons such as: (1) suicide within the first year; (2) TPD which has
existed prior to or on the effective date; or (3) TPD due to attempted suicide;
c. I have 15 days from the date of delivery of the e-Cer ficate to cancel the plan and I can obtain a refund of total
contribution paid; and
d. I can nominate an executor or beneficiary(ies) under conditional hibah. I shall refer to the nomination guide here.

I have read and understood the Product Disclosure Sheet and I shall refer to the Cer ficate Wording for the full list of
exclusions, terms and condi ons.
Note: To make a claim, please refer to the claims guide. For any other enquiries, Takaful Malaysia's Customer Service can be
reached at 1-300 88 252 385 or csu@takaful-malaysia.com.my.

Personal Data Protection Act (PDPA) 2010

I have read and understood the Privacy No ce made available in Takaful Malaysia's website and I hereby consent for Takaful
Malaysia and its appointed third party service providers to process my personal informa on for my cer ficate applica on, claims
and related services in the manner set out in the said Privacy No ce.

Marketing Consent
I hereby consent and authorise Takaful Malaysia and its appointed third par es to share and use my personal informa on for
marke ng and promo on of its products and services. If I wish to amend the marke ng consent, I may opt in or opt out by
comple ng the Endorsement Form.

Full Name : RAJA AHMAD BAZLI BIN RAJA SHAHRUM

Identification Number : 941101-10-6213
Date : 25 February 2023

CIP/MCT/V04/02-2022