GREAT EASTERN TAKAFUL BERHAD (916257-H)

Certificate Owner’s Servicing Agent Form

Completed application form to be submitted to the Agency Administration Department

A. Certificate Owner’s Details

Name:
NRIC No: Address

Details of certificates numbers & name (s) of current servicing agent(s)

How do you currently pay your contribution? Cash/cheque GIRO/Bank Deduction Credit Card
** Certificate owners are duly advised to use the convenience of GIRO or Credit Card as the mode of contribution payment and if
cheques are handed to your servicing agent please ensure that it is crossed account payee cheque made to the Operator and not the
agent’s name. You are advised not to pay cash to your servicing agent to remit to the Operator but to pay at the appointed banks
having contribution collection facilities for the Operator.

B. Agent Servicing Request & Status

I am satisfied with the level and standard of services currently provided by my servicing agent
and would like him/her to continue servicing me.

I do not object to my current servicing agent / Immediate Officer requesting that my certificate/certificates be
serviced by AC No.

I am not satisfied with my current servicing agent

and would like to request that my certificate or certificates be serviced by
please state your dissatisfaction

Certificate Owner’s Signature Date

C. Current Servicing Agent’s Details

Name:
AC No. Branch

I agree to the certificate owner’s request to transfer the servicing agent to

AC No.

I do not agree to the request and seek the opportunity to provide the following actions to provide a better service
to the certificate owner

My Immediate Officer has requested that I service these certificates and the certificate owner has indicated
above that he/she wants me to service him/her.

Agent’s Signature Agent’s Immediate Officer’s Signature

AAD/CertOwnerSrv_Tkf/v1.2/122014