COVER NOTE

STAMP DUTY PAID

Participant Cover Note No. :-

Account No. : V0032442
MUHAMMAD AKMAL BIN NAZARUDIN Agent Name : ZULAIHA BINTI BAKAR
NO 2 JALAN SENTOSA 15
TAMAN DESA SENTOSA Product Type : Motor Cycle Private
DUSUN TUA Period of Takaful from 21/01/2023 To 20/01/2024 (both Dates
HULU LANGAT Inclusive). Any subsequent period for which the Participant shall pay
43100 SELANGOR and the Takaful Operator shall agree to accept a renewal contribution..

NRIC No : 990419-01-7473 Business Reg No : Sum Covered RM 3800.00

Business/Occupation : Student Other ID No : Gross Contribution RM 263.65
Vehicle Information Less: No Claim Discount RM 65.91
25.00%
JPJ Document No :
Special Perils (Flood, Storm, RM 10.00
Vehicle Reg No : TBV3722 Log Book No : NIL Tempest, Hurricane, Landslide,
Make : YAMAHA Landslip, Typhoon & All
related perils
Model : YAMAHA 135LC NA
______
Engine No : G399E-588526 Cover Type : Comprehensive
RM 207.74
Chassis No : PMYUG0420H0089446 Vehicle Type : Motor Cycle
Add : Service Tax 6.00 % RM 12.46
Year of : 2017 License Type : Normal Cycle
Manufacture Stamp Duty RM 10.00
Cubic Capacity : 135 Use For : Private Use
Seating Capacity : 2 Rider Type : All Riders TOTAL AMOUNT DUE RM 230.20
Financial Interest : NIL

Excess Damage Claims RM 100.00

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 : /12:57 PM For and on behalf of

Issue At : Y4 Etiqa General Takaful Berhad
Issue By : v0032442