a-

Policy No.
,rj,:. F*J*r
I o t 5 q o I 1 3
x'AGENT'S/THEFAR'sloFFlcER'SDECLARATloN...
I hereby declare that I have sighted the original "NRIC I Passpofi / Birth Certificate ot the Life Assured and the Policy Owner and veritied the
identity(ies) of the Life Assured and the Policy Owner tlrrough the use ol such .NRIC I Passport / Birth Certificate.
I further decla"e that I have disclosed all required informalion and advice to the Policy Owner. I have also explained and given the Policy Owner the
full set ol Company's Product Disclosure Sheet relevant to the proposed products.

g4ryt8o1
Signature of I the FAR / Oflicer A/C No
.Ejen i WPK i Pegawai
Tandatangan

Chn* htat Y/'0"1

Name ll signed by FAB, please state the name ol FAR's FA
!:r., )-'t-^..1-t^,1--,,.. ^:,.,, tntDW cil: nt-il:L=r r:.'r= Fr'

Xl. CONSENT TO FEQUEST FOR ALTERATIONS gtrS$lv$€Et{ H#.sr*S Pg#$iSide}ffAFl ##itu'd f.i##E;*;\r
.Trustee(s) Nominee(s) Parent
I / We, the / / of the nominee(s) / Conditional Assignee, hereby irrevocably and unconditionally give my i our consent
to the Policy Owner for the amendment(s) requested.
I / We further agree that we shall hold the Company harmless in respect of any and all consequences and things which may arise as a result of its
compiiance with the Policy Ownefs instruction to any of the above deeds and acts.

:'

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Signature of .Trustee / Nominee I Parent
*
Signalure of -Trustee / Nominee / Parent
f Y
Signature of Witness+
of Nominee I Conditional Assignee of Nominee / Corditional Assignee Iandaianoan Sa*sl+
7a n Calarig an P e fi eg ang A, rnat-t ah :' T and ata*g an Pe,elagang fi-lT ala h i
Penama i lbu bapa Pena*a.t Peter;:r;a Penama lbt; bapa Penaina . Pe::erit;a
Se,a/r Hak Bersyara! Serah Hak Bersyarat
6,an chal4- |/te/l.g tltei Therq ?hotg, r',:i:;a: * NAi Sff-- YUU
Name,!.r;r:,i: Name : Name

NRrc No.: 6q93I' -3!-9tqe NRiC No. 97oQo8- o*' 6+t* NRIC No. r lsaltt@DfiL
Na. KP Na. KP No.KP

Tel No. iHlP)

ot* ,+g 6al3 Tel No. {H/P) op-r$q E6B fel No. (HlP)
x 0il tos+0730
iio. Tei i?,j:'t:!:ili /Vo. Iel {Bimbit} ltic.'lei r*!::ir:i!;
*Please delete whichever not
applicable Ngte; The Witness must be at least 18 years
' c..... . ,- . ! .r^ej.rJll
' ,n,',!:C,9
^,. ol age and cannot be a named Nominee or
Truslee.
NoIa: S*i:si fiesi.r,'€ir j:erunrr lS aaJl.,n 8e
t!es dtn b:*ar. Poia"',a.;!;r Fe':.€Edt)E
.;tflanal, ya$g iel8li dllantik.

i,lote: lf the policy is eonditionally assigned, consent is required from the conditional assignee. lf you are a non-Muslim and your cunent nominee(s)
is / are your spouse, child or parent (if you have no spouse or child living at the time ol nomination), then youf policy is deemed to be a tust policy.
Therefore, consenl is required from the trustee(s) of the policy. lf there ls no trustee appointed, (a) the nominee r,vho is competent to eontract, or (b)
where the nominee is incompetent to contract, the parent of the incompetent nominee (other than the policy owne0, or where there is no surviving
parent, the public trustee shall be the trustee of the policy.
Nqta-: Jika palisi riiserah hak secara bersyarat, &ebenarar daripada pene*ma se."ai hak bersyaral iip*riukan. iika a*da frukan lsiarn dan penama
i i
senasa anda adaiah suarni / isten, anak atau ibt) bapa {jika anda iidak {neffipur}yai suami isteri atau anak serrasa aftda niefibuat penamaan),
iraka polisi entia dianggap s*lsatsa! paiis! amanah. Ole* selraly itu, k*b#,"r*raa rilperiLtka* tiaripada -t*megang amanai: pcliri. Sekirart),a iiada
pene$ang arnenal; clila*lil<, {ai p*ratna yarig iayak akan dilantik alau {b} sekiranya tiada perana yar;g i*yak uni:.tk diia*tik. ibu i bapa penana
be*e:';aan iseiain daripada pemillk polisii atau seklra*ya tiada ibu / bapa yang nasih llidup, paneg\ng an:ana* awar* akan Cilantik sebagai
pemegar}g en}anah p* I isi.

Pase t1 ol 13 0617770065