COVER NOTE

STAMP DUTY PAID

Participant Cover Note No. : 85904209

Account No. : V0006230
INTAN LIANA BINTI ZAINUDDIN Agent Name : RUKIAH BINTI ISMAIL
LORONG CAKERA PURNAMA 12/2, FASA 3, SEKS
BANDAR PUNCAK ALAM Product Type : Motor Cycle Private
42300 SELANGOR Period of Takaful from 20/03/2023 To 19/03/2024 (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 : 820402-08-5048 Business Reg No : Sum Covered RM 6000.00

Business/Occupation : Others Other ID No : Gross Contribution RM 284.83
Vehicle Information Less: No Claim Discount RM 71.21
25.00%
JPJ Document No :
______
Vehicle Reg No : VDT2482 Log Book No : NIL
RM 213.62
Make : HONDA
Add : Service Tax 6.00 % RM 12.82
Model : HONDA VARIO NA
Stamp Duty RM 10.00
Engine No : KF29E8062560 Cover Type : Comprehensive
Chassis No : PMKKF3770KB014823 Vehicle Type : Motor Cycle
TOTAL AMOUNT DUE RM 236.44
Year of : 2020 License Type : Normal Cycle
Manufacture
Cubic Capacity : 149 Use For : Private Use
Excess Damage Claims RM 100.00
Seating Capacity : 2 Rider Type : All Riders
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 : 20-03-2023/05:12 PM For and on behalf of

Issue At : Y4 Etiqa General Takaful Berhad
Issue By : v0006230
 Invoice No: ETBG2023UWFL00751805
Date: 20/03/2023

INVOICE

ETIQA GENERAL TAKAFUL BERHAD (201701025031)

LEVEL 19 TOWER C
DATARAN MAYBANK
NO 1 JALAN MAAROF
59000 KUALA LUMPUR
(SST Reg No: W10-1808-31012539)

To Account Number: V0006230

INTAN LIANA BINTI ZAINUDDIN
LORONG CAKERA PURNAMA 12/2, FASA 3, SEKS
BANDAR PUNCAK ALAM
42300 SELANGOR

Description Total (RM)

Type of Certificate: Motor Cycle Private
Certificate Number: 85904209
Period of Takaful: 20/03/2023 to 19/03/2024

Contribution 213.62
Total (Excluding SST) 213.62
SST payable @ 6.00% 12.82
Stamp Duty 10.00

Total Amount Payable 236.44

This is a computer generated document. Therefore, no signature is required