Date : 16 Nov 2021

AZALINA BINTI ESSA

NO 4B LOT 3739 LORONG ABDULLAH
KAMPUNG JALAN KEBUN SEKSYEN 31,
40400 SHAH ALAM

Dear Sir/Madam

RE: APPLICATION NO. : A210539409

PERSON COVERED'S NAME : AZALINA BINTI ESSA
PARTICIPANT'S NAME : AZALINA BINTI ESSA

We thank you for your application for a family Takaful Coverage with our Company. For the consideration of issuing
you a certificate, we require additional tests/reports/investigations/forms as indicated in the attached Outstanding
Requirement Advice.

Please be advised that any initial/subsequent contribution paid shall be deemed invalid null and void and the
Company shall not be liable in any manner whatsoever for any claims made there from unless and until the
requirements indicate in the attached Outstanding Requirement Advice have been attended to, application has been
duly approved and certificate contract has been duly issued.

By copy of this letter, we are also requesting our agent to assist you in this matter.

Thank you.

ZURICH TAKAFUL MALAYSIA BERHAD

ztmb.underwriting@zurich.com.my

From Family Underwriting

(Computer generated advice - no signature is required)
cc - CONSULTANT : GA13-01-T70425W FAIQAH HUDA BINTI JUSOH
C.M.C : AT02-05-T40303P ZAMRI BIN YAHYA

eCOPY
 Outstanding Requirement Advice

Application No. : A210539409 Date :16 Nov 2021

Person Covered's Name : AZALINA BINTI ESSA
Applicant's Name : AZALINA BINTI ESSA

Please accomplish the requirement(s) indicated below for assessment of the above numbered application:

1)Large Amount Questionnaire

2)Auto Debit is required.

Kindly register via E Mandate (current/savings account )
3)Covid-19 Exposure Questionnaire

4)Income Tax Return (last 3 years)

5)Company Audited Accounts (past 3 years)

Remarks :
NOTE: Further medical requirement needed upon financial part is justifiable.

eCOPY
 SOALSELIDIK JUMLAH YANG BESAR
LARGE AMOUNT QUESTIONNAIRE

(Maklumat yang disediakan dalam borang soal selidik ini adalah bahan untuk penilaian permohonan takaful)
(Information provided in this questionnaire is material of the application of takaful)
Tandakan (√) pada kotak yang berkenaan / Tick (√) where appropriate

Nama Pemohon _____________________________________________________________ No. Cadangan ___________________________

Applicant’s Name Application No.

1) Orang yang Dilindungi _____________________________________________________________________________

Person Covered

2) Jumlah perlindungan yang dipohon RM

Amount of coverage applied for RM

3) Tujuan perlindungan Takaful

Purpose of Takaful coverage

4) Kelas Takaful yang dipohon Takaful Peribadi Takaful Perniagaan

Classification of Takaful applied for Personal Takaful business Takaful

5) Cara langganan Menerusi Ejen Pertanyaan Permohonan Lain-lain

Method of solicitation solicited by Agent Applicant Enquiry Others

(BAGI PERMOHONAN TAKAFUL PERIBADI, JAWAB SOALAN 6 HINGGA 17 ; BAGI TAKAFUL PERNIAGAAN, ISI SELURUH BORANG
SOAL SELIDIK) / WHERE APPLICATION FOR PERSONAL TAKAFUL, ANSWER ALSO QUESTION 6 TO 17; IF FOR BUSINESS TAKAFUL,
THE WHOLE OF THE QUESTIONNAIRE IS TO BE COMPLETED.

6) Butir-butir takaful yang terkini berkuatkuasa atau yang dipohon secara serentak untuk pemohon Takaful atau anggota keluarganya. /
Details of takaful presently in-force solicited simultaneously on Takaful applicant and family members.

Jumlah (Termasuk Hubungan dengan

Orang Yang
Syarikat No. Sijil Tempoh Rider) Tarikh Dikeluarkan Pemohon Takaful
Dilindungi
Company Certificate No. (Amount incl. Term Date Issued Relationship to
Person Covered
Riders) Takaful Applicant
i)

ii)

iii)

7) Butir-butir kediaman
Residence details
Jenis (contoh banglo, teres, dsb) _________________________________________________________________
Type (e.g. bungalow, terrace, ect)

Kelas kawasan (atasan, pertengahan, dsb)_______________________________________________________________

Class of area (Upper, Middle, etc)

Pemilikan (sama ada dimiliki/disewa, ________________________________________________________________

Disediakan oleh syarikat,disediakan
oleh ibu bapa atau lain-lain)
Ownership (whether owned/rented,
provide by Company, provided by parent or other)

Jika disewa atau disediakan oleh syarikat:_______________________________________________________________

If rented or provided by company
Nilai sewaan bualanan
Equivalent monthly rental

Jika dimiliki: tarikh dibeli ___________________________________ nilai pembelian ____________

If owned date purchased purchase value

Nilai semasa (anggaran) __________________________ baki gadaian dsb ____________

Current Value (approximate) mortgage outstanding etc

8) Gaya Hidup Keluarga

Family Lifestyle

Status Perkahwinan _______________________________ Bilangan Anak ____________________________

Marital Status No. Of Children

Di mana Anak-anak bersekolah _______________________ Bil. Pembantu Rumah __________________________

Where children schooling No. Of Servants
INTERNAL USE ONLY
TP103_1_L Page 1 of 4
 Kereta digunakan oleh Pemohon _____________________________________________________________________
Cars used by Applicant
Jenama _______________________________________ Model ____________________________________
Brand Model
Tahun dibuat ____________________________________ Tarikh Pembelian ______________________________
Year Made Purchase Date

Pemilikan (Sendiri atau Syarikat) ____________________________________________________________

Ownership (Self or Company)

Kereta digunakan oleh Pasangan ____________________________________________________________

Cars used by Spouse

Jenama _______________________________________ Model ____________________________________

Brand Model

Tahun dibuat ____________________________________ Tarikh Pembelian ______________________________

Year Made Purchase Date

Pemilikan (Pasangan atau lain) ____________________________________________________________

Ownership (Spouse’s or otherwise)

9) Pemilikan Hartanah (selain yang dinyatakan dalam No.7)

Property Ownership (other than listed in No. 7)
Pemilikan (sama
ada dimikili oleh
Anggaran Nilai Pendapatan Pemohon atau
Baki Gadaian
Jenis Lokasi Semasa Sewa Diterima Pasangan)
Mortgage
Description Location Approx. Current Rental Income Ownership
Outstanding
Value Received etc. (whether owned
by Applicant o
Spouse)

10) Bank Pemohon

Applicant’s Banker
Baki dalam Aset Lain, contoh
Nama Alamat Balance In Barang Kemas
Name Address Akaun Simpanan Akaun Semasa Other Assets e.g.
Deposit A/C Current A/C Jewellery

11) Butir-butir tanggungan belum berbayar selain gadaian yang dinyatakan dalam (7) dan (9) di atas (contohnya, hutang pinjaman, cukai perlu
dibayar, overdraf, dan sebagainya)
Details of outstanding liabilities other than mortgage indicated in (7) and (9) above (e.g loans owing, taxes, dues, bank overdrafts etc.)

_________________________________________________________________________________________________

_________________________________________________________________________________________________

12) Anggaran jumlah nilai harta bersih (jumlah aset dimiliki oleh pemohon tolak jumlah tanggungan). Nyatakan bagaimana angka ini dihitung.
Approximate total nett worth (total assets owned by applicant minus total liabilities). Indicate how this figure was calculated.
_________________________________________________________________________________________________

13) Pendapatan
Income
Tahun lalu 20___ Tahun Sebelum 20__
Past Year 20 ___ Previous Year 20__

Pendapatan daripada pekerjaan (kasar) _______________ ________________

Employment income (gross)

Nilai faedah-faedah yang disediakan oleh Syarikat (nyatakan) ________________ _________________

Value of benefits in kind provided by Company (specify)

Pendapatan lain (contoh; dividen, faedah atas deposit tetap) ________________ _________________
Other income e.g. dividends, interest on fixed deposit etc.

Pendapatan daripada perniagaan ________________ _________________

Income from business
INTERNAL USE ONLY Page 2 of 4
 14) Butir-butir pekerjaan
Job details

Perniagaan dalam perniagaan jenis ini _________________________________________________________

Experience in this type of business

Pemilikan (pemilik atau rakan kongsi atau pekerja)_________________________________________________________

Ownership (owner or partner or employee)

Tarikh menyertai _________________ Jawatan sekarang _________________________

Date joined Current job title

Tahap tanggungjawab __________________________________________________________

Degree of responsibilities

Sebarang kelayakan profesional ___________________________________________________________

Any professional qualification

15) Jika pemilik atau rakan kongsi perniagaan

If owner or business partner

Peratusan pemilikan __________ Tarikh perniagaan dimulakan atau dibeli __________________

Percentage owned Date started or business bought on

Jenis kegiatan Syarikat ____________________________________________________________

Type of Company activities

Perolehan tahun lalu dan tahun sebelum 20 __________________________________________________________

Turnover for last year and previous year

Untung (selepas cukai) tahun lalu dan tahun sebelumnya 20 _________________________________________________

Profits (after tax) for last year and previous year

Aset bersih (jika diketahui) ____________________________________________________________

Nett assets (if known)

Sebarang kontrak atau projek khas dalam tangan yang menguntungkan perniagaan dan sebarang maklumat lain mengenai perniagaan.
Any special business contracts or project currently successful and any other information regarding the business.

Peringatan: Jika lebih daripada satu perniagaan, berikan butir-butir mengenainya setiap satu.
Reminder : If more than one business, give details of each.
Nota: Salinan akaun perniagaan yang telah diaudit bagi tahun lalu dan tahun sebelumnya perlu dikemukan.
Note: A copy of audited accounts of the business for last year and previous year to be submitted.

16) Jika Takaful adalah untuk melindungi pinjaman ___________________________________________________________

If Takaful is to cover a loan

a) Berikan nama institusi peminjam ___________________________________________________________

State name of financial institution

b) Nyatakan jumlah pinjaman ____________________________________________________________

State amount of loan

c) Tempoh pembayaran balik ____________________________________________________________

Period of repayment

d) Kadar keuntungan/faedah ____________________________________________________________

Profit/Interest rate

17) Sebarang maklumat lain berkaitan kedudukan kewangan pemohon?

Any other pertinent information on applicant’s finances?

_________________________________________________________________________________________________

SOALAN-SOALAN BERIKUT PERLU DIJAWAB JIKA PERMOHONAN ADALAH UNTUK TAKAFUL PERNIAGAAN.
FOLLOWING QUESTIONS NEED TO BE ANSWERED IF APPLICATION IS FOR BUSINESS TAKAFUL.

18) a) Apakah jenis perniagaan Syarikat Pemohon?

In what type of business is the Applicant involved?

_________________________________________________________________________________________________

b) Sudah berapa lamakah perniagaan ini beroperasi?

How long has this business been operate?

_________________________________________________________________________________________________
c) Sudah berapa lamakah pemohon menyertai Syarikat ini?
How long the applicant joined this Company?

_________________________________________________________________________________________________

INTERNAL USE ONLY Page 3 of 4

 d) Apakah nilai bersih harta semasa Syarikat?
What is the current nett worth of the Company?

_________________________________________________________________________________________________

e) Nyatakan untung bersih (selepas cukai) bagi tiga tahun yang lalu
State net profits (after taxes) for past three years
20 ______________________________________________________________________________________________

20 ______________________________________________________________________________________________

20 ______________________________________________________________________________________________

Nota: Salinan akaun perniagaan tahunan yang diaudit untuk tiga (3) tahun lalu perlu dilampirkan.
Note: A copy of audited accounts of business for past three (3) years need to be submitted.

19) Jika ini merupakan permohonan Takaful untuk perkongsian:

If this Takaful application for partnership

a) Bilangan rakan kongsi dan peratusan pemilikan setiap rakan kongsi _______________________________________
Number of partners and percentage of share

_____________________________________________________________________________________________
Ya / Yes Tidak / No
b) Sudahkah perjanjian jual beli disediakan? (jika ya, sila lampirkan salinan)
Has the buy and sell agreement been drawn up? (if yes, please attach a copy)

c) Adakah setiap rakan kongsi sudah atau sedang dilindungi?

Is every partner covered or being covered?

d) Berapakah jumlah perlindungan yang sudah atau sedang diambil untuk rakan kongsi lain secara individu? ________
What amount the coverage or being covered as individual?

20) Jika permohonan adalah berasaskan skim pegawai penting, nyatakan

If this application is under keyman basis, indicate

a) Bilangan pegawai dalam Syarikat yang memegang jawatan pengurusan setaraf atau lebih tinggi daripada Pemohon dan jumlah Takaful
yang sudah atau sedang diambil oleh Syarikat Pemohon.
The number of associates in the Company who are on the same or higher management level as the Applicant and amounts for which has
been or being covered by the Company.
Bilangan Jumlah Perlindungan Jumlah Sedang Dilindungi
No. Amount Covered Amount To Be Covered
Setaraf
Same Level
Lebih Tinggi
Higher Level

b) Nyatakan dengan ringkas mengapa pemohon dianggap sebagai pegawai penting.

Briefly indicate why the applicant is considered to be a keyman.

_____________________________________________________________________________________________

21) Jika Pengendali Takaful akan menjadi pemilik atas sebab-sebab selain daripada yang dinyatakan dalam soalan (18) hingga (20) di atas, sila
nyatakan di sini.
If the Takaful Operator is to be the owner for other reason than indicated in questions (18) to (20) above, please indicate here.

_________________________________________________________________________________________________

-----------------------------------------------------
Tarikh / Date : ------------------------------------
Ditandatangani oleh Pemohon / Orang Yang Dicadangkan untuk Dilindungi /
Signed by Applicant / Proposed Person Cover

Tempat / Place: ----------------------------------

------------------------------------------ Tarikh / Date : ------------------------------------

Ditandatangan oleh Perantara /
Signed by Intermediary

Kod Perantara / Tempat / Place: ----------------------------------

Intermediary’s Code: ------------------------

INTERNAL USE ONLY Page 4 of 4

Soal Selidik Pendedahan kepada Covid-19/ Coronavirus
Covid-19/ Coronavirus Exposure Questionnaire

No. Permohonan:
Application No.:

Nama Penuh:
Full Name:

1.Pernahkah anda diuji positif untuk Coronavirus/COVID-19?

Have you ever been tested positive for Coronavirus / COVID-19?

Ya/Yes No/Tidak

Jika Ya, sila berikan keterangan

If yes, please provide details

Tarikh/Date:
______________________________________________________________________________________
Keputusan Ujian tersebut/result of the test:

_______________________________________________________________________________________

2. a) Pernahkah anda dimasukkan ke hospital/pusat kuarantin/mengasingkan diri? Jika ya, sila lengkapkan
soalan 2b) & c).
Have you ever been admitted to hospital/quarantine centre/praticed self quarantine? If yes, please
complete question 2b) & c).

Ya/Yes No/Tidak

b) Sila tanda mana yang berkenaan dan nyatakan bilangan hari berada di sana.
Please tick whichever is applicable and state the number of days for being there.

Hospital/Hospital Hari/Days

Pusat Kuarantin/Quarantine Centre Hari/Days

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 Mengasingkan diri/Self Quarantine Hari/Days

c) Sila sertakan salinan nota pelepasan dari Hospital/Pusat kuarantin atau surat pelepasan isolasi untuk kes covid-19
positif.

Please submit together with copy of discharge notes from Hospital/ Quarantine Centre or isolation/quarantine release
letter for covid-19 positive case.

3.Adakah anda pernah menerima Vaksin?

Have you ever received for COVID-19 vaccination?

Ya/Yes No/Tidak

Dos 1 diterima/Dose 1 completed?

Tarikh/Date:

Dos 2 diterima/Dose 2 completed?

Tarikh/Date:

4. Sepanjang 30 hari yang lepas, pernahkah anda mengalami gejala seperti batuk berterusan yang baru atau
tidak diketahui puncanya, deman bersuhu tinggi, sesak nafas atau gejala Coronavirus / COVID-19 yang lain?
Within the last 30 days have you experienced symptoms of a new or unexplained continuous cough, a high
temperature or fever, breathing difficulties or any other symptoms of coronavirus / COVID-19?

Ya/Yes No/Tidak

Jika Ya, sila berikan maklumat lanjutan seperti tarikh, jangka masa,rawatan,keputusan pemeriksaan(jika
ada),nama dan alamat doktor/klinik/hospital yang merawat. Sila sertakan salinan keputusan ujian- Jika ada.
If Yes, please provide further details i.e date, duration, treatment, result of investigations (if any), name and
address of treating doctor/clinic/hospital. Please attached together with copy of test result- if any.

5.Sepanjang 30 hari yang lepas, pernahkah anda terdedah secara langsung kepada individu yang pernah
disahkan atau disyaki dijangkiti Coronavirus / COVID-19?
Within the last 30 days have you been in direct contact with someone who’s been confirmed or suspected to
have Coronavirus / COVID-19?

Ya/Yes No/Tidak

Jika Ya, sila berikan maklumat lanjutan ie tarikh terdedah, tarikh mengasingkan diri,rawatan,keputusan
pemeriksaan(jika ada),nama dan alamat doktor/klinik/hospital yang merawat. Sila sertakan salinan keputusan
ujian- Jika ada.

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 If Yes, please provide further details i.e date of direct contact, duration of self isolating, treatment, result of
investigations (if any), name and address of treating doctor/clinic/hospital. Please attached together with copy
of test result- if any.

6.Sepanjang 30 hari yang lepas, pernahkah anda mengasingkan diri disebabkan oleh gejala Coronavirus /
COVID-19? Within the last 30 days have you been self-isolating due to symptoms of Coronavirus / COVID-19?

Ya/Yes No/Tidak

Tarikh kuarantin selesai/Date of quarantine completed?

7.Sepanjang 30 hari yang lepas, pernahkah anda dinasihatkan untuk mengasingkan diri bagi sebab-sebab
yang lain? Jika YA, sila terangkan.
Within the last 30 days have you been advised to self-isolate for any other reason? If YES, please elaborate
further.

Ya/Yes No/Tidak

Jika Ya, sila berikan maklumat lanjutan ie sebab mengasing diri, tarikh terdedah, tarikh mengasingkan
diri,rawatan,keputusan pemeriksaan(jika ada),nama dan alamat doktor/klinik/hospital yang merawat. Sila
sertakan salinan keputusan ujian- Jika ada.
If Yes, please provide further details i.e reason of self isolating, date of direct contact, duration of self
isolating, treatment, result of investigations (if any), name and address of treating doctor/clinic/hospital. Please
attached together with copy of test result- if any.

8.Adakah anda kini menetap di negara selain dari negara kediaman anda yang biasa atau sudahkah anda
kembali ke negara kediaman anda yang biasa sepanjang 4 minggu yang lepas?
Are you currently residing outside your usual country of residence or have you returned to your usual country
of residence within the last 4 weeks?

Ya/Yes No/Tidak

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 Jika YA, sila berikan maklumat: Negara / Bandar / Tarikh Berlepas / Tarikh Ketibaan / Tarikh kepulangan yang
dirancang.

If yes, please provide information: Country / City / Departure Date / Arrived Date / Planned return date.

9.Dalam 3 bulan yang akan datang, adakah anda bercadang untuk mengembara ke negara selain dari negara
kediaman anda yang biasa?
In the next 3 months, do you intend to travel outside your usual country of residence?

Ya/Yes No/Tidak

Jika YA, sila berikan maklumat: Negara / Bandar / Tarikh Perjalanan / Tempoh yang Dirancang.
If yes, please provide information: Country / City / Date of Travel / Intended Duration.

Saya mengaku bahawa jawapan yang telah saya berikan adalah, sepanjang pengetahuan saya, benar dan saya
tidak menyembunyikan sebarang maklumat penting yang mungkin akan mempengaruhi penilaian atau
penerimaan permohonan ini.
Saya bersetuju bahawa borang ini akan menjadi sebahagian daripada permohonan insurans saya dan kegagalan
untuk mendedahkan mana-mana fakta penting yang saya ketahui berkemungkinan membatalkan kontrak.

I declare that the 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 this application.
I agree that this form will constitute part of my application for insurance and that failure to disclose any material
fact known to me may invalidate the contract.

Tandatangan: Tarikh:
Signature: Date:

Nota / Notes :
1. Borang ini mestilah dilengkapkan oleh orang yang dinyatakan dalam surat penyata permintaan tertunggak
yang dikeluarkan. / This form must be completed by the person specified in the deferment letter issued.
2. Sekiranya orang yang dinyatakan dalam surat penyata permintaan tertunggak berumur kurang dari 16 tahun,
borang ini mestilah ditandatangani oleh pemohon. / If the specified person stated in the deferment letter is
less than 16 years old, the form must be signed by the applicant.

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