COVER NOTE

STAMP DUTY PAID

Participant Cover Note No. : 86504856

Account No. : V0026644
KHAIRULNIZAM BIN RUSLI Agent Name : ANANDAN A/L PATTAPAN
194 B JALAN CENDANA 4
TAMAN SERI CENDANA Product Type : Private Car - Private Use
SUNGAI PETANI Period of Takaful from 15/10/2023 To 14/10/2024 (both Dates
08000 KEDAH Inclusive). Any subsequent period for which the Participant shall pay
and the Takaful Operator shall agree to accept a renewal contribution..

NRIC No : 830310-08-5779 Business Reg No : Sum Covered RM 17300.00

Business/Occupation : Businessman / Other ID No : Gross Contribution RM 695.76
Businesswomen Less: No Claim Discount RM 382.67
Vehicle Information 55.00%
JPJ Document No : ______
Vehicle Reg No : PKM8997 Log Book No : NIL RM 313.09
Make : PROTON Add : Service Tax 6.00 % RM 18.79
Model : PROTON EXORA BOLD EXECUTIVE Stamp Duty RM 10.00
Engine No : S4PHRV0022 Cover Type : Comprehensive
Chassis No : PL1FZ6YDRCF081577 Vehicle Type : Private Car TOTAL AMOUNT DUE RM 341.88
Year of : 2012 License Type : Normal Vehicle
Manufacture
Cubic Capacity : 1597 Use For : Private Use Excess All Claims RM 0.00
Seating Capacity : 7
Financial Interest : NIL
Authorised Driver
1 KHAIRULNIZAM BIN RUSLI 830310-08-5779
2 ANY AUTHORISED DRIVER -

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 : 12-10-2023/09:33 AM For and on behalf of

Issue At : R1 Etiqa General Takaful Berhad
Issue By : v0026644
 Invoice No: ETBG2023UWFL02460193
Date: 12/10/2023

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: V0026644

KHAIRULNIZAM BIN RUSLI
194 B JALAN CENDANA 4
TAMAN SERI CENDANA
SUNGAI PETANI
08000 KEDAH

Description Total (RM)

Type of Certificate: Private Car - Private Use
Certificate Number: 86504856
Period of Takaful: 15/10/2023 to 14/10/2024

Contribution 313.09
Total (Excluding SST) 313.09
SST payable @ 6.00% 18.79
Stamp Duty 10.00

Total Amount Payable 341.88

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