CONFIRMATION AND AGREEMENT BY LIFE TO BE ASSURED/PROPOSER

OF ELECTRONICALLY SUBMITTED PROPOSAL

[to be attached and form part of the Proposal for Assurance together with all other forms/qualifications that have been submitted to the Company
electronically in applying for a life policy]

Proposal No. Policy No.

AGENT'S/ THE FAR'S/ OFFICER'S DECLARATION

I hereby declare that I have sighted the original NRIC/Passport/Birth Certificate of the Life to be Assured and the Proposer and verified the
identity(ies) of the Life to be Assured and the Proposer through the use of such NRIC/Passport/Birth Certificate. In case of the Proposer being
a corporate customer (including company and business), I have sighted the original/certified true copy of its certificate of
incorporation/registration, identification documents of its directors/shareholders/partners and of person authorised to represent the corporate
customer, and verified their identities through the use of such documents.

I further declare that I have adhered to the requirements of the Proper Sales Advice Checklist and have disclosed all required information and
advice to the Proposer. I have also explained and given the Proposer the full set of Company's approved Sales Illustration and Product
Disclosure Sheet relevant to the proposed products. I hereby confirm that I had clicked on the agent's confirmation box in the electronic
"Confirmation Note From the Soliciting Agent". By so doing I understand that I had confirmed that the party/parties to the proposed policy
had/have fully understood the contents of the E-Form(s) together with the statements made and answers given by him/them to the questions
therein and that he/they had duly indicated his/their agreement to submit the duly completed E-Forms to the Company for processing.

I declare that the information provided to me in the Customer Fact Find Form is confidential and will only be used in the process of
recommending suitable insurance products and shall not be used for any other purposes.

The analysis/advice in Customer Fact Find Form is based on the facts furnished in the Form. I have taken reasonable steps to ensure that the
advice is suitable for the client, having regard to the facts disclosed in this Form and other relevant facts, which are made available to me. I
have also explained to the client about the features of the product recommended and have given sufficient information to enable the client to
make an informed decision.

I hereby certify and witness the following signature(s) was/were made in my presence and that to my own personal knowledge it is the
signature(s) of the Life to be Assured/Proposer/Credit Card Holder.

LEADER'S VALIDATION (only applicable for year 1 agent)

Based on the information provided by the Client, I agree with the recommendations / product advice given.

CREDIT CARD HOLDER'S DECLARATION

I have read and fully understand the information and authorization contained in the electronic Easi Pay Service Form. I agree that the
authorization is governed by the Terms & Conditions specified in the electronic Easi Pay Service Form. In addition, I must inform Great Eastern
Life Assurance (M) Berhad in writing of the cancellation of the authorization at least thirty (30) days before the next premium due date. The
authorization shall remain binding upon me until Great Eastern Life Assurance (M) Berhad's receipt of my written notification to cancel the
authorization.

Great Eastern Life Assurance (Malaysia) Berhad (93745-A) NBZ-FCOEF-V09-072013 FPMS

(A member of Great Eastern Holdings Limited)
Head Office: Menara Great Eastern 303 Jalan Ampang 50450 Kuala Lumpur
Customer Service Careline (603) 4259 8333 Agent Service Careline (603) 4259 8111 Fax (603) 4259 8198
E-mail wecare-my@greateasternlife.com Website www.greateasternlife.com
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 Proposal No. Policy No.

PROPOSER'S/LIFE TO BE ASSURED'S DECLARATION

I/We confirm and agree that I/we had made all the statements and given all the answers in the electronic proposal for assurance and any other
accompanying electronic and/or hard copy form(s) or questionnaires submitted and that they are true and authentic as transmitted to the
Company; and their contents therein shall form the basis of the contract between myself/ourselves and the Company. I/We understand that
the Company, believing them to be such, will rely and act on them as the basis of the insurance. The Company may void the policy (if issued)
if there is any non-disclosure, misrepresentation, misstatement, inaccuracy or omission.

I/We confirm that I/we have given the agent undersigned no other information in connection with this electronic proposal for assurance, except
that contained in the electronic proposal for assurance and/or hard copy form(s) or questionnaires submitted. I/We also confirm that save for
sales brochures, sales illustrations and documents duly authorized by the Company, the undersigned agent had not given me/us any
document or information to induce me/us to enter into a contract of assurance with your Company.

I/We further agree that the insurance applied herein shall not take effect and no cover whatsoever will be provided by the Company until a
policy is issued to me/us on the said electronic proposal for assurance and/or electronic forms and/or questionnaires and the first premium has
actually been paid and received in full by the Company during the lifetime and good health of the Life to be Assured/Proposer and I/we
understand that I/we will always reserve the right to return the policy document to the Company for cancellation within 15 days of delivery to
me/us.

I/We hereby authorize any doctor, medical practitioner, physician, hospital, laboratory, surgeon, nurse, medical staff, clinic, insurance
company, organization or institution, that has any records or knowledge of me/us or my/our health, to disclose to the Company or its
representative any information about me/us, my/our health, medical history and any hospitalization, advice, treatment, disease or ailment, and
I/we authorize the Company and its representative to give and release any such information to any party to process this application and for the
administration, analysis or processing of claim. A photocopy of this authorization shall be effective and valid as the original.

I/We confirm that the agent undersigned has provided me/us with a copy of the completed Customer Fact Find Form. In relation to the extent
of the disclosure of my/our information in the Customer Fact Find Form, I/we confirm that I/we had selected

Option 1 I/We wish to disclose all information requested for in this Form.
Option 2 I/We wish to disclose partial information requested for in this Form.
Option 3 I/We wish to receive product information only and do not wish to disclose any information requested for in this Form.
as set out in the Customer Fact Find Form.

Instruction: Please use thick dark BLUE color pen to avoid being taken as non-original document.

Signature of Proposer (Owner) Signature of Life to be Assured

(If other than Life to be Assured)

Name Name
New NRIC/BC/Passport No.

Signature of Credit Card Holder Signature of Agent Signature of Leader *

Name
Name Name
A/C No. Rank

Date / /
Day Month Year

* For applications of the Agent's own life or his immediate family members, the Agent's immediate Officer or GSM or the Company's Executive or Head of
Business Development/Administration Manager/Head should countersign,verify and confirm the information to be correct at Signature of Leader.

NBZ-FCOEF-V09-072013 FPMS

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