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    Borang Takaful Warga Pendidik2015 PDF

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    Hamdan Lutfiwafihamzi

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    Borang Takaful Warga Pendidik2015 PDF

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    Hamdan Lutfiwafihamzi
    20 views8 pages

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    Borang Takaful Warga Pendidik2015 (1).pdf

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    20 views8 pages

    Borang Takaful Warga Pendidik2015 PDF

    Uploaded by

    Hamdan Lutfiwafihamzi

    Copyright:

    © All Rights Reserved
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    eTiQa “eee” “Takaful 'BORANG PERMOHONAN TAKAFUL MUTIARA PLUS BERKELOMPOKI GROUP MUTIARA PLUS TAKAFUL MEMBER APPLICATION FORM ‘Tanggungjewab Pendedahar/ Duty fo Disclose : Anda dikehendak! menerangkan dengan penuh dan benar segala butir yang anda ‘ahu atau harus tahu di delem boreng permohonan ini, borang perubatan atau borang soal selcik dan/atau apa-apa penyataan, ‘skiranya ada, jka tidak Sj yang dikeluarkan boleh dianggap tidak sah. Bukti tentang umur diperlukan sebelum apa-ape bayarsh ‘manfaat dibuat. You ae fo cleclose i tho application form, medal ferm er ether quostionnsires andlor statement, Hany, fuly and fal, al the facts which you know or ought fo know, othorwise the Cerliicale ised hereundlsr may be void. Proof of age is reguited before any Deument of nett is mage Notis Penting! important Notice 4 Kami menasinatkan anda untuk mengkajl brosur, helalan pendedshan produk dan lustrasijualan. Anda boleh mendapatkannya daripada ejen keml yang juga boleh memberitahu anda maklumat tentang manfaat sil dan tanggunglawab peserta di bawah sift ini. We would advise you to study our brochure, product dleclosue chest and sales usiraion. You can obtain them from aur agent who ‘can also give you information regerding the Cericale Benefis and dite ofthe Partspants under the Coricte. 2 Pengambilan masa secara amnya untuk mengeluarkan Sil Takatul kepada Orang Dilindungl/ Peserta adalah dalam masa tiga ;puluh (80) hari selepas permohonan diluluskan dengan sumbangan sepeauhnya diterima ‘The genoral tne for fsuance ofthe Tekaful Certicate to tne Persan Covered / Participants within thity (30) days ar the apeccval vith ul contnbution received. ‘Untuk Ani] Staf Sahajal For Member” Sta Only 1 Permononen Baru/ New Aoplcton ‘Sumbangan Bulanen! Monthly Conrbuton Rw 1 Penambshen Sumbangan/ Contribution Incase Daripada Fom RM___kel to RM_ No. Sift Asal/ Original Certifeate Nor ‘Pemegang Sifjil Induki: | SaaeEaEE eee eee Master Contct Holder Nama Pomohion (Hurut Besar Name of Apolcant (Capital Lees): A No.Kad PongonalanPasport: CITT TT LITT T1111} Kewargenegaraan Naonalty tdentteaton Card Passport No ‘Tarat Perkahwinan/Martal Status: ToratPendiaikan(pin salah satu): [Pendidikan RendaW Botow Secaidary []Pendhken Menengah! Secondary Eascaton Lave! (base select one} Diploma [_lNazan dan ke atas! BachearDagres and above, Kelayakan Profesional Professional Qalitcsion ‘Agamal Religion ‘Bangsa/ Race ‘Atamat Surat-Menyurat (dengan Poskody Nailing Aatoss (wih Poseede) ‘Alamat Kediaman (dengan Poskod {tka berbeza dengan Alamat Surat- ‘Menyuraty Rosidontal ross (with Poscade).f diferent iro Mating Across) Tarikh Lair! [ Borat: kg, Tinggi om Jantinal: Date of Birth Weight Height sx MF No, Telefon (R) / Phone no (H) OTTTITTTTTi No, Stat Staff No: Cocoon) No, Telefon (PY! Phare No (0) OOOTTTTTT) No. Gap OOOO) Baloo No Telaon (Py Holo coo Pekeuan! Nava Majkan! Ccnspooon Name of Enver Jenis Pekerjan,jka bekerja sendie/ Notre of Susiness, i sel-omployed. Popo tote Poorer hs ENS UE BE 4 ‘Nama Banke’! Bank Name" No. Akaun Bank'/ Bank Account No* * Seberang bayaran, jika ada, akan dikredikan Repada akaun bark yang diberikan. Sile pastikan butran akaunt bank dlberikan ‘adatan tepat / Any Bonelis paymentésurendorhefund of contibution, any, may be crected ino the bank account provided. Pease fersure that account otal are accurate fia pastikan skaun tereebut adalah Kepunyaan Peserta/Pleaso ensure thatthe account belongs tothe Participant ‘Sumber KewangarY Kekayaan (sila tandakan mana-mana yang borkanaan) Source of Funds/ Wealth (piease tek where apcabie) ‘Simpanani Sevngs Pewarlsand Inurince Pinjamany Loan Pelaburan! Investment ‘Keuntungan Syarkat! Company Profit Laindain’ Others Gai KomnisyerVSalary/ Commission Ponjualan Sahaml Share Sales, Tujuan Transaksi bagi produk ini, sis tandakan mana-mana yang berkenaan/ Purpose of Transaction fortis product, lease Bok where applicable ‘Simpanani Savings Petaburany investment rsaraani Rtement Pertindungan’ Protection Penuldthan! Education Lainlain! thora: ———_————— ‘Untuk Ani Keluarga (Jika memohon untuk dlindungil For Members Spouse and Child (also applying (o be covered) ‘Nama Suamil ister (Muruf Besar Name of Hustand/ vite (Capt Lottors) CLLELEIT Ee TIT tr tt tt rt rt rr rt TTI TI rrr rir No. Kad PengenalaniPespord: (TT TTTTTI ITI TIT] Keworganegaraan! Nationality ‘dontfcaton Cara! Passpart No Pokersat Nama Majkand Cccupstion Name Empoyer ena Pterjaan ka bekera con Natur of Business, seltepoyed: ‘Tarikh Lahird CECT tera: tg Tinggi__em Sumbangan Butanany RIM _ Dai fin Weght — Hoght Ment Carton Santina vo »o LEP” Petamtanan Sunbangan ser MOF Conte nrese No. Telefon (HPV Motil No Coo) Daipaal From Fst__el oF Nama Anak 1 Muru Besa Nae of dt (Caplets): CLOILLLT Ti rr tri tir rt tr rrr rir it rit tir) Pokerlean! No, ad PongensionPacperds § CCD TET TTT TT) Ccoupaton etiteation Gur Passport No ‘Tarik Lahird : CLEC) eer kg Tinggi: em — Sumbangan Bulanan/ RN. Date o itn velght Heat ~~ Many Cotton Santina: uo eo ‘Perfambahan Sumbangani Ser moe ‘Conttion erese. Kowarganegarea!Natnaty Daipaal Fo Fa elo Fot Nama Anak 2 un Besar Name of hil 2 (Cal Lote): I I Pokeroan! No.KadPengenalanPaspow:§ (TTT TTT TTT TIT} ‘vapaon Henicaton Card Paseprt No Feneuatie = CCCI aera ng” Tingle Sumbangen Butonan! RM Date of bith wage Hoon en Contbuton santa! a (of ectambanan Sumbengant Ser ‘Contruton rose Kouarg Darpada om RM Kot REA Nama Anak 3 Hurt Besar Name of hid 9 (Capal tors): [ TIL LL T11 CH Pokorjaany No. Ked PengonatanPaspory: CTT TTT TTT TIT IT) Soa feentnaton Cora Pascpot NO ‘Tarik bah ‘cm Sumbangan Bulananl RM Date o Btn Went Hight ‘Mently Contibution santnal vo ro 1 Pertambanan Sumbangan! ‘Sox wu oF ‘Contribution increase Kewarganegaraani Notional Deripadal From RIM kel fo RM__ Page 2088 ‘Pengakuan Kesihatan (Jka Melebini Had Porlindungan Percumal/ Health Declaration Exceed Free Cover Li) Pomohon! Pasangan! Anak‘! Anak2/ Anak 4, Pemahkah mans-mana_permohonan anda bagi polis! Insurans hhayat/siil Takaful Keluarga, kemalangan atau hilang upaya termasuk semasa pembaharuan atau pemulihan sijl takafulpolis! insurans hayat, dtolak, dtanggunkan, dni atau ‘atau tortakiuk pada forma khusus atau masih dalam pertimbangan? Has any of your spoicaton for ie poeytamty Taka, accident or

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