COVER NOTE

STAMP DUTY PAID

Participant Cover Note No. : 82715829-01

Account No. : V0028518
MOH ROSLI BIN ISHAK Agent Name : NINDIAWAN ENTERPRISE
F 82 KAMPUNG RANTAU PANJANG
KOTA KUALA MUDA Product Type : Private Car - Private Use
KOTA KUALA MUDA Period of Takaful from 29/06/2021 To 28/06/2022 (both Dates
08500 KEDAH Inclusive). Any subsequent period for which the Participant shall pay
and the Takaful Operator shall agree to accept a renewal contribution..

NRIC No : 700903-02-5469 Business Reg No : Sum Covered RM 8000.00

Business/Occupation : Others Other ID No : Gross Contribution RM 548.45
Vehicle Information Less: No Claim Discount RM 301.65
55.00%
JPJ Document No :
______
Vehicle Reg No : BGQ8452 Log Book No : NIL
RM 246.80
Make : PROTON
Add : Service Tax 6.00 % RM 14.81
Model : PROTON WAJA NA
Stamp Duty RM 10.00
Engine No : 4G18PKH5042 Cover Type : Comprehensive
Chassis No : PL1CF1SNR3F126468 Vehicle Type : Private Car
TOTAL AMOUNT DUE RM 271.61
Year of : 2002 License Type : Normal Vehicle
Manufacture
Cubic Capacity : 1584 Use For : Private Use
Excess All Claims RM 0.00
Seating Capacity : 5
Financial Interest : NIL
Authorised Driver
1 MOH ROSLI BIN ISHAK 700903-02-5469
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 : 22-06-2021/04:25 PM For and on behalf of

Issue At : K2 Etiqa General Takaful Berhad
Issue By : v0028518
 Invoice No: ETBG2021UWFL01155621
Date: 22/06/2021

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: V0028518

MOH ROSLI BIN ISHAK
F 82 KAMPUNG RANTAU PANJANG
KOTA KUALA MUDA
KOTA KUALA MUDA
08500 KEDAH

Description Total (RM)

Type of Certificate: Private Car - Private Use
Certificate Number: 82715829-01
Period of Takaful: 29/06/2021 to 28/06/2022

Contribution 246.80
Total (Excluding SST) 246.80
SST payable @ 6.00% 14.81
Stamp Duty 10.00

Total Amount Payable 271.61

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