TAKAFUL BENEFITS APPLICATION FORM

A. DETAILS OF CERTIFICATE OWNER

Certificate No :

Certificate Owner Name :

NRIC No : Others ID :

New Address : House/Office Tel. No :

Handphone No :

E-Mail :

Bank Name : Bank Account No :

Note: A copy of bank account book / bank statement showing account no, name and IC no of the owner must be enclosed.

B. DETAILS OF PERSON COVERED (If Different From Certificate Owner)

Name of Person Covered :

NRIC No : Others ID :

C. REQUEST INFORMATION
Please mark (X) whichever applicable:

1. Partial Withdrawal From Accumulated Participant Account Amount Requested : RM

(Each withdrawal requested will reduce the Accumulated Participant Accounts on maturity) /

2. Intellectual Award / Academic Excellence Award

UPSR PMR SPM STPM

3. Hajj / Umrah / Child Allowance (Applicable for Mabrur Plan Only)

D. DECLARATION
I / We, hereby agree that this application shall be subject to the terms and conditions of the certificate contract provisions.

SIGNATURE OF CERTIFICATE OWNER SIGNATURE OF ASSIGNEE

Name : Name :
NRIC No. : NRIC No. :
Date : Date :

E. FOR ETIQA/BANK BRANCH USE ONLY

Staff Signature ; : Date :

Name & PF No : : Branch Stamp :

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