['To be attached to Medical Report | Date: 15-July-2016 To: The Medical Examiner From: Underwriting Section, New Business Department, Operations Dear Doctor Proposal Number -—«;-—« 80906989 Name of Person Covered: KAMARULHELMY BIN TALIB 900527055029 ‘Name of Participant KAMARULHELMY BIN TALIB 900527085029 [Name of Joint Participant Subject ! Modical Requirement(s) for Family Takaful Application ‘We seek your assistance to conduct the following examination(s) for the above named 1 ‘Medical Examination (In addition to normal medical examination, Dr to pay attention to build, history of leg surgery in 2003, history of pulmonary embolism in 2011 and history of aceident in 2012. Dr to provide details of treatment, current condition, and any limitation, Current ROM? Result of SLRT? Any evidence of pulmonary heart disease or pulmonary hypertension as a result of emboli Important Note: Where Medical Examination is requested, only a clinical assessment is required (unless mentioned otherwise in the above request) If any additional tests are conducted, kindly obtain the additional payment from the applicant, Please complete the below Medical Chit and forward to us together with the reports (except blood and urine test results where the lab will forward to us directly) for reimbursement. ‘Thank you. Date : Clinic's Code Clinic's Name: Doctor's Nam ‘The following examination(s)/test(s) has/have been performed on the above-named:- Clinic Stamp Charges (RM) Medical Examination Resting ECG ‘Service Charge (drawing blood) Service Charge (collect urine specimen) Others Total [ 62701001 | Prudential BSN Takaful Rerhad (740651-I) Level 8A Menara Prudential, 10 lan Sultan mail, $0250 Kes Lumpur, ‘Malaysin P.© Box 10928, 50700 Kuala Lumpur Tel (603) 2078 1188 Fax (603) 2072 6188 ww. fen com Cut here ~ PADENTIAL BSN Date [Doctor's Copy ] Proposal Number 80906989 [Name of Person Covered: KAMARULHELMY BIN TALIB 900527055029 "Name of Parielpant KAMARULHELMY BIN TALIB 900527055029 ‘Name of Joint Participant Subject ‘Medical Requirement(s) for Family Takaful Application Charges (RM) ‘Medical Examination Resting ECG. Service Charge (drawing blood) Service Charge (collect urine specimen) TotalPRUDENTIAL BSN TAKAFUL NEW BUSINESS REQUIREMENT FORM TO: MD ALANIN HATKAL B MOHAMAD ZULKARNA (MH180218)DATE : 15-07-2016 (C/O KERTEH REF: NBA/owffab FROM : OPERATIONS PROPOSAL NO: 80906989 Please refer to the following requirements/remark :~ KANARULHELMY BIN TALIB 1. Accident Questionnaire by Person Covered with regards to accident in 2012 2. Medical examination by appointed Dr. on person proposed due to health (In addition to normal medical examination, Dr to pay attention to build, history of leg surgery in 2003, history of pulmonary enboli: 2011 and history of accident in 2012. Dr to provide details of treatment, current condition, and any limitation. Current ROM? Result Of SLRT? Any evidence of pulmonary heart disease or pulmonary hypertension as a result of emboli? We encourage the doctor and client treated to be the same gender. Please submit requirement (s) by 15/08/2016. Thie ie a computer generated document which does not require a signatureACCIDENT QUESTIONNAIRE (To be completed by The Person Covered) ‘SOALSELIDIK KEMALANGAN (Untuk diisi oleh Orang Dilindungi) Proposal Number/Nombor cadangan 80906989 Name/Nama KAMARULHELMY BIN TALIB ‘New NRIC No/Nombor KP Baru ‘What was the cause of the injury e.g, motor vehicle accident, ete? Please give full details and dates Apakah punca yang menyebabkan kecederaan, contohnya kemalangan kenderaan, dan sebagainya? Sila berikan butiran penuh dan tarikh. Cause/Punca : Date/Tarikh Details Butiranpenui, What were the injuries sustained2/Apakah kecederaan yang dialami? If cerebral concussion was sustained, how long were you unconscious?iJika anda mengalami hentakan di kepala, berapa lamakah anda tidak sedarkan divi? How long?/Berapa lama? ‘Were you admitted to a hospital? If'so, how long were you admitted and where?Adakah anda telah dimasukkan ke hospital? Jika ya, berapa lamakah anda dimasukkan dan ai mana’? L JNolTidak [ Tyesva; How long?/Berapa lama? Hospital/Hospital Were any investigation done e.g. X-ray, sean, BCG ete? IFso, please state nature of test done, results and dates? Adakah ‘pemeriksaan telah dilakukan, comohnya sinar-s, imbasan, ECG dan sebagainya? Jika ya.sila nyatakan jenis wjian yang dilakukan, Reputusan dan tarikhnya. [ WNolridak [ Wvesva; TypesJenis Date/Tarikh ResuluKepurusan ‘Was any operation performed? If'so, pleas give full details e.g. when, what, te?/Adakah sebarang pembedahan telah dilakukan? Jika ya, sila berikan butiran penuh contohnya, bila, apa dan sebagainya? T No!Tidak [ Wes'Va: ‘Type of operation/Jenis pembedahan Date/Tarith [60301002] ‘Was any metal implant inserted?/Adakah sebarang jenis implan besi dimasukkan?Declaration/Pengakuan: 1 declare that the answers I have given are, to the best of my knowledge, true and that Thave not withheld any material, information that may influence the assessment or acceptance of this proposal. I agree that this form will constitute part of my proposal for life assurance and that failure to disclose any material facts known to me may invalidate the contract. ‘Saya mengaku bahawa jawapan yang telah saya berikan adalah, sepanjang pengetahuan saya, benar dan saya tidak menyembunyikan sebarang maklumal penting yang mungkin akan mempengaruhi penilaian atau penerimaan cadangan insurans ini. Saya bersetuju bahawa borang int akan menjadi sebahagian dari borang cadangan untuk insurans havat dan kegagatan untick mendedahkan sebarang maklumat penting yang saya ketahui berkenmungkinan membatalkan kontrak insurans tersebut Signed by/Ditandatangani oleh : Date/ariki: tement of Witness/Kenvataan Saksi Thereby certify the above signature was made in my presence and that to my own personal knowledge i is the signature of the applicant under the proposal mentioned as above. Saya dengan ini mengesahkan bahawa tandatangan di atas dibuat di hadapan seya dan setakat yang saya ketabui tandatangan {ersebut adalah tandatangan Orang yang Dilindungi seperti yang disebut di tas Signature of Witness) Tandatangan Saksi Date/Tarith