ENDORSEMENT CONFIRMATION SLIP

BRANCH : IBU PEJABAT

BROKER / AGENT : 10-204-GCA02842
TYPE OF ENDORSEMENT :
ISSUE DATE : 29/03/2018

INSURED DETAILS
PARTICIPANT NAME : MOHD SUFIAN BIN TOKIMAN
NRIC / PASSPORT NO / BUSINESS REG. NO : 850623-01-5841
ADDRESS : 6862
JALAN SRI PUTRI 12/3
TAMAN PUTRI
KULAI
81000 JOHOR
CONTACT NO. :

COVERAGE
CERTIFICATE NO. : VPP-V1242309-10-AGT-18
REFERENCE NO. :
ENDORSEMENT NO. : 002
MAIN CLASS : MOTOR
SUB CLASS : PRIVATE CAR
SUM COVERED : RM
PERIOD OF COVER : 15/03/2018 TO 14/03/2019
ENDORSEMENT EFFECTIVE DATE : 26/03/2018
RISK DETAILS : JJL4112
HP OWNERSHIP : -

CONTRIBUTION
GROSS CONTRIBUTION : RM 0.00
DISCOUNT : RM 0.00
NET CONTRIBUTION : RM 0.00
GST (0.00%) : RM 0.00
STAMP DUTY : RM 0.00
TOTAL TAKAFUL CONTRIBUTION : RM 0.00

ISSUED BY : ROSLIN @ ROZLINA BINTI RAJAB

ENDORSEMENT DESCRIPTION
WITH EFFECT FROM 26/03/2018, THE PARTICIPANT'S NAME IS
AMENDED AS MOHD SUFIAN BIN TOKIMAN.

THIS CONFIRMATION SLIP IS ISSUED PENDING ISSUANCE OF TAKAFUL CERTIFICATE.

This is a computer generated document. No signature is required.