PERSONAL

HEALTH
DECLARATION
FORI\4
BORANC
PENGESAHAN INDIVIDU
KESIHATAN
PleaseuseBLOCKLETTERS/Tick
/ appropriate box.
SilogunokonHURUF / di kotokyongsesuoi.
BESAR/Tondl

Nameof Company
B S M A R T S Y S T E IM S O L U T I O N S S D N B H D
NomoSyorikot

Nameof Insured/Employee
M O H A M M A D R A D Z I B I N A D I M A R
NomoPihokDtinsuronskonf
Kokitangan

NRIC/Passport
No.
No.KP/Posport
8 0 0 6 2 8 -t]]-[T]]]
7 1 5 0 8 3 . Cender
Jontino
l\4ale
rl-l Leloki l-l
u
Female
Perempuon

Dateof Birth
Tarikh
Lahi m-m-[I-n]
2 8 0 6 1 9 8 0 Height
Tinggi l-T-f-].'
1 6 4 Weight :
Berot ll-[-lon
6 7

Occupation
T E C H N I C A L S U P P O R T E N G I N E E R
Pekerjoon

l-_l Yes
of consultation, namesandresults.
diagnosis I lYo
AdokohondapernohmendopotnosihotdoktorotosseboronqsebobkesihotonotoumenjoIoniujiondoroh,sinoron-X,ECGdonIoin.|ainpemeriksoon
ini?liko "Y0",siloberikonbution dontorikhberjumpodoktor,diagnosis
dolommoso5 tahunkebelokongon donkeputuson. [--l No
PEMERIKSAAN BUAH PINGGANG. JALANI PEMBEDAHAN PEMASANGAN CAPD t______J
ilooK

N a m ea n da d d r e sosf C l i n i c :
NomodonolomotKinik
HUKM

Yes
l--l t Y
lf "Yes",
please
givenames,
dates,results,
recovery andanyrelevant
status details. I o
Pernohkohandodirowototoudiberitohubohowoondamenghidopipenyokitjontung,tekonondoroh
untukmenjoloni
dondinosihotkan seborong
DARAH TINGGI, DIABETIS DAN ESRF (DIALISIS)
Jiko"Y0",silosebutkon
pembedohon? stztuspemulihon
nomo,torikh,keputuson, danbutiranlainyongberkenoon.
I);*
1 FEBRUARI 2021

3. Hasyourapplicationformedicalorlifeinsuranceeverbeendeclined,postponed,ratedormodified?lf"Yes",pleasegivefullpaniculars: T-l Yes

Pernohkoh permohonon
seborong peruboton
ondobogiinsurons otouhoyotditolak,ditundo,
dipurotokon Jika"Y0",siloberikonbutironlengkop:
atoudipindo? I lYo

TH*

andvalidastheoriginal.
shallbeaseffective
authorization
Kesemuopengokuandiotosodolohbenordonlengkapmen
danbertindokberdosorkonnya'Seterusnya,soyomengizinkonkepodomona-monopokorperuboton
soyountukmengemukokon
kesthoton kepodoPenonggu
yongosol.
terusberkuztkuosadonsoh seperti

lnsured's/Employee'sSignature:
Tondotangon Pihok Diinsuro nskonf Kokitongon:
Date
t0nKn ul-uI-l-lrl-l
1 4 0 7 2 0 2 1

beforesubmitting
it iscompleted to Allianz Insurance
Ceneral (lValaysia)
Company to avoidanydelayin processing.
Berhad

lengkopdonsempurno dihontorkeAllionzbagimengelokkon
sebelum seborong
kelewoton
memprosesnyo.

bearing(NRICNo. an *employee/agent
of AllianzCeneralInsurance
Company (Malaysia) Berhad
hereby thattheProposer's
certib/ NRIC/Business
original Registration for
Certificate wasverified bymeat thepointof sales.
andauthenticated I furtherconfirm
thattherelevant weresighted
documents andtheInsured
andverified isnotsuspected of financing
of moneylaundering of terrorism

Soyo (No. KP: *kokitongon/ejen

AllionzCenerollnsuronceCompony(Moloysio)Berhoddenganini
)
bohowoNomborKadPengenolon/Sijil
mengesohkan asolpemohon
Perniogoon
Pendoftoron yongbernomo ketulenonnyo
telohdisohkon ketikourusniogo
dija|onkon'Soyojugomenqesohkondokumen.dokumenyangrelevonte|ohdiso