HEAD OFFICE/ Syarikat Takaful Malaysia Keluarga Berhad [198401019089 (131646-K)]

IBU PEJABAT: 14th Floor, Annexe Block, Menara Takaful Malaysia,

No 4, Jalan Sultan Sulaiman, 50000 Kuala Lumpur,
P.O. Box 11483, 50746 Kuala Lumpur

COVID-19 QUESTIONNAIRE (TO BE COMPLETED BY THE APPLICANT)

BORANG SOAL SELIDIK COVID-19 (DIISI OLEH PEMOHON)

Name of Person to be Covered:

Nama Orang yang akan Dilindungi: _____________________________________________________________________________

NRIC No of Person to be Covered: Proposal No:

No. Kad Pengenalan Orang yang akan Dilindungi: _______________________ No. Cadangan: _____________________

Please provide the following details / Sila berikan butiran berikut:

Part I : To be completed by the Applicant / Diisi oleh Pemohon

1 Do you currently have or have you had any of the following symptoms in the past 30 days?
Adakah anda sedang mengalami atau pernah mengalami simptom yang dinyatakan di bawah dalam tempoh 30 hari?
Symptoms / Simptom Please tick (√) if Yes /
Sila tandakan (√) jika Ya
i. High temperature / Fever / Suhu Tinggi / Demam
ii. Sore throat / Sakit tekak
iii. Dry Cough / Batuk Kering
iv. Nasal congestion / Hidung tersumbat
v. Myalgia (generalized body ache) or Arthralgia (pain in joint areas) /
Myalgia (sakit badan secara umum) atau Arthralgia (sakit di bahagian sendi)
vi. Headache / Pening kepala
vii. Shortness of breath or breathing difficulties / Sesak nafas atau kesukaran bernafas
viii. Fatigue / Keletihan
ix. Gastro-intestinal symptoms such as nausea, vomiting and / or diarrhoea /
Simptom gastro-intenstinal seperti loya, muntah dan / atau cirit- birit
x. Dysgeusia (distortion of the sense of taste) / Dysgeusia (gangguan rasa)
xi. Anosmia (loss of the sense of smell) / Anosmia (hilang deria bau)

If yes, please provide further details, i.e. dates, duration, treatment, results of investigations (if any), name and address of
treating doctor / clinic / hospital.
Jika Ya, sila berikan butiran lengkap termasuk tarikh, tempoh, rawatan, keputusan ujian (jika ada), nama dan alamat
doktor / klinik / hospital yang dikunjungi untuk rawatan.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

2 Have you been tested for COVID-19?

Pernahkan anda menjalani ujian saringan COVID-19? Yes / Ya No / Tidak

If yes, please state the date of the test done:

Jika Ya, sila nyatakan tarikh ujian saringan dijalankan: ______________________________

Result of the test / Keputusan ujian saringan: Positive / Positif Negative / Negatif

Have you made a complete recovery with no sequelae?

Adakah anda telah pulih sepenuhnya tanpa gejala berulang? Yes / Ya No / Tidak

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3 Within the past 30 days have you had any contact with someone confirmed as infected with the virus?
Dalam tempoh 30 hari ini pernahkah anda berhubung dengan individu yang dijangkiti virus tersebut?

Yes / Ya No / Tidak
If yes, please specify the date and provide information / Jika ya, sila nyatakan tarikh dan berikan maklumat:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

4 Have you been issued any notice or directive to self-quarantine or stay at home (excluding as part of the altered employment
arrangement)?
Pernahkah anda mendapat notis atau arahan untuk kuarantin secara sukarela atau duduk di rumah (kecuali arahan majikan)?

Yes / Ya No / Tidak
If yes, please specify the date and provide information / Jika ya, sila nyatakan tarikh dan berikan maklumat:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

5 Are you currently residing outside your country of residence or have you returned to your country of residence within the
last 4 weeks?
Adakah anda kini menetap di luar daripada negara yang didiami atau telah kembali ke negara yang didiami dalam tempoh 4
minggu yang lalu?
Yes / Ya No / Tidak

If yes, please provide information: Country/City/Departure Date/Arrival Date/Planned Return Date.

Jika ya, sila nyatakan maklumat berikut: Negara/Bandar/Tarikh Ketibaan/Tarikh Keberangkatan/Tarikh Dijangka Pulang.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

6 In the next three months, do you intend to travel outside your country of residence?
Dalam tempoh tiga bulan dari sekarang, adakah anda mempunyai perancangan untuk keluar dari negara yang didiami?

Yes / Ya No / Tidak

If yes, please provide information: Country/City/Date of Travel/Intended Duration.

Jika ya, sila nyatakan maklumat berikut: Negara/Bandar/Tarikh Perjalanan/Tempoh Masa Perjalanan.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

Part II : To be completed by the Applicant if confirmed positive for COVID-19 / Diisi oleh Pemohon sekiranya disahkan positif COVID-19
1 Please specify the types of symptoms encountered (e.g. of symptoms limited to flu - dry cough or fever (loss of sense of smell)
and/or ageusia (loss of sense of taste), dyspnea, hypoxia, or >50% lung involvement on imaging, pneumonia, acute respiratory
distress syndrome (ARDS), shock, cardiomyopathy, arrhythmia or multi-organ dysfunction).
Sila nyatakan jenis simptom yang dihadapi (contoh simptom terhad kepada selesema-batuk kering atau demam (hilang deria
bau) dan/atau ageusia (gangguan rasa), dispnea, hipoksia, atau >50% penglibatan paru-paru pada imbasan, pneumonia,
simptom gangguan pernafasan, kejutan, kardiomiopati, aritmia atau kegagalan fungsi organ-organ).
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

2 Type of treatment received.

Jenis rawatan yang diterima.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

3 Advice or health management plan given.

Nasihat atau pelan pengurusan kesihatan yang diberikan.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

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 4 Have you ever been treated in the Intensive Care Unit (ICU) and/or required ventilator support? Please provide the details.
Pernahkah anda dirawat di Unit Rawatan Rapi (ICU) dan/atau memerlukan sokongan ventilator? Sila berikan maklumat.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

5 Type of treatment received.

Jenis rawatan yang diterima.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

6 Date of recovery.
Tarikh pemulihan.
_______________________________________________________________________________________________________

7 Date of the repeated COVID-19 test and the test result (if not available, please provide the reason).
Tarikh ulangan ujian saringan dan keputusan Covid-19 (jika tiada, sila berikan sebab).
_______________________________________________________________________________________________________

8 Please elaborate if any complication arises, residual and/or side-effects of treatment.

Sila jelaskan sekiranya terdapat sebarang komplikasi dan/atau kesan sampingan rawatan.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

9 Do you have any co-morbidities risk such as: chronic respiratory conditions, chronic kidney diseases, overweight, hypertension,
diabetes mellitus, cardiovascular diseases, haematological cancer or cancer with chemotherapy within the last 2 years, HIV,
immunocompromised illness, solid organ or bone marrow transplantations or any medical condition where there is a long-term
use of immunosuppressive treatments?
Adakah anda mengalami risiko penyakit seperti: masalah pernafasan kronik, penyakit ginjal kronik, berat badan berlebihan,
hipertensi, kencing manis, penyakit kardiovaskular, kanser haematologi atau kanser dengan kemoterapi dalam masa 2 tahun
ini, HIV, penyakit imunokompromi, pemindahan organ atau sumsum tulang atau sebarang masalah kesihatan yang memerlukan
penggunaan perubatan/rawatan imunosupresif jangka panjang?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

10 Are you still on a regular follow up? Please specify the last follow up date.
Adakah anda masih menerima sebarang rawatan susulan? Sila nyatakan tarikh rawatan susulan terakhir.
_______________________________________________________________________________________________________

11 Name and address of the attending doctor.

Nama dan alamat doktor yang merawat anda.
_______________________________________________________________________________________________________

12 Please attach a copy of all the laboratory lab results.

Sila lampirkan salinan keputusan makmal yang sedia ada.
_______________________________________________________________________________________________________

I hereby declare that the above particulars and answers I have given are to the best of my knowledge, true and that I have not withheld
any material information that may influence the assessment or acceptance of the proposal. l agree that this form will constitute part
of my proposal for family takaful and that failure to disclose any material fact known to me may invalidate the contract.

Saya dengan ini mengaku bahawa kenyataan dan jawapan yang saya berikan adalah sepanjang pengetahuan saya adalah benar dan
saya tidak menyembunyikan sebarang maklumat yang boleh mempengaruhi penilaian atau penerimaan cadangan ini. Saya bersetuju
yang borang ini akan menjadi sebahagian daripada cadangan takaful keluarga saya dan kegagalan untuk mengemukakan sebarang
maklumat yang saya ketahui boleh menyebabkan perjanjian ini terbatal.

______________________________________________ ______________________________ _____________________

Name / Nama Signature / Tandatangan Date / Tarikh

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