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CONFIDENTIAL

RECORDS Ref. No.: ISSD

Revision: 02
TITLE : i-SMART APPLICATION FORM (AGENT)
Effective Date: 01-06-2016

DESCRIPTION OF REQUEST

New i-Smart Request Re-send i-SMART Enrolment E-mail

Others _________________________

PLATFORM DEVICE TYPE

IOS Others _________________________

AGENT INFORMATION

Agent Name as Per NRIC :__________________________________________________

Agent Code :__________________________________________________

Agent Email Address :__________________________________________________

Agent Hand phone No. :__________________________________________________

REMARKS

_____________________________________________________________________________

_____________________________________________________________________________

Agent Signature

Name: Date: Signature:

FOR TIB USE ONLY (Redmine

Login/User Id Date Done By Reference Number

Note:
Please e-mail completed form to ismarthelpdesk@takaful-ikhlas.com.my
For any inquiries please call i-SMART helpdesk at 03-2723 9595 (Press 3)

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