Berjaya Sompo Insurance Berhad (62605-U)

e-Policy Submission Sheet (Foreign Workmen)

Date 04-01-2023

Account No. No.

Intermediary KG-10009252

Agency Name NG YI SHIH

Agent Name NG YI SHIH

Batch No. EREF1568967(Gross)

Confirmed By - Confirmed Date -

Date of e-Policy No. Sub Class Insured Name e-Policy Type Gross Comm. SPPA Service TaxS/Duty Gross Payable Nett Premium Status
Issue Fees
FOREIGN
WORKERS
HOSPITALISAT NIK MHD. ABDULL
06-12-2022 Submission
Z0023914 ION AND NASSER BIN NW 105.00 10.50 15.90 0.00 10.00 130.90 120.40
Declared
SURGICAL HAMZAH
SCHEME
(FWHS)
FOREIGN
WORKERS
HOSPITALISAT
07-12-2022 HASLINA BINTI Submission
Z0024054 ION AND NW 79.40 7.94 12.02 0.00 10.00 101.42 93.48
HAMZAH Declared
SURGICAL
SCHEME
(FWHS)
FOREIGN
WORKERS
HOSPITALISAT
07-12-2022 LIDIAH BINTI Submission
Z0024055 ION AND NW 105.00 10.50 15.90 0.00 10.00 130.90 120.40
HANAFI Declared
SURGICAL
SCHEME
(FWHS)
FOREIGN
WORKERS
HOSPITALISAT JOO LEE IMPORT
12-12-2022 Submission
Z0024279 ION AND & EXPORT CO. NW 525.00 52.50 79.50 31.50 0.00 636.00 583.50
Declared
SURGICAL SDN. BHD.
SCHEME
(FWHS)
FOREIGN
WORKER JOO LEE IMPORT
12-12-2022 Submission
Z0024280 INSURANCE & EXPORT CO. NW 84.40 8.44 0.00 5.06 10.00 99.46 91.02
Declared
GUARANTEE SDN. BHD.
(FWIG)

Page 1
Berjaya Sompo Insurance Berhad (62605-U)

e-Policy Submission Sheet (Foreign Workmen)

FOREIGN
WORKERS
HOSPITALISAT JOO LEE IMPORT
12-12-2022 Submission
Z0024281 ION AND & EXPORT CO. NW 525.00 52.50 79.50 31.50 0.00 636.00 583.50
Declared
SURGICAL SDN. BHD.
SCHEME
(FWHS)
FOREIGN
WORKER JOO LEE IMPORT
12-12-2022 Submission
Z0024282 INSURANCE & EXPORT CO. NW 84.40 8.44 0.00 5.06 10.00 99.46 91.02
Declared
GUARANTEE SDN. BHD.
(FWIG)
FOREIGN
WORKERS
HOSPITALISAT JOO LEE IMPORT
12-12-2022 Submission
Z0024283 ION AND & EXPORT CO. NW 945.00 94.50 143.10 56.70 0.00 1,144.80 1,050.30
Declared
SURGICAL SDN. BHD.
SCHEME
(FWHS)
FOREIGN
WORKER JOO LEE IMPORT
12-12-2022 Submission
Z0024284 INSURANCE & EXPORT CO. NW 151.92 15.19 0.00 9.12 10.00 171.04 155.85
Declared
GUARANTEE SDN. BHD.
(FWIG)
FOREIGN
WORKERS ARENA NATION
HOSPITALISAT CLEANING &
12-12-2022 Submission
Z0024285 ION AND MAINTENANCE NW 105.00 10.50 15.90 6.30 0.00 127.20 116.70
Declared
SURGICAL SERVICES SDN.
SCHEME BHD.
(FWHS)
FOREIGN ARENA NATION
WORKER CLEANING &
12-12-2022 Submission
Z0024286 INSURANCE MAINTENANCE NW 50.00 5.00 0.00 3.00 10.00 63.00 58.00
Declared
GUARANTEE SERVICES SDN.
(FWIG) BHD.
FOREIGN
WORKERS
HOSPITALISAT
12-12-2022 INDERA BAKTI BIN Submission
Z0024287 ION AND NW 105.00 10.50 15.90 0.00 10.00 130.90 120.40
ARIFFIN Declared
SURGICAL
SCHEME
(FWHS)
FOREIGN
WORKERS
HOSPITALISAT JOO LEE IMPORT
16-12-2022 Submission
Z0024560 ION AND & EXPORT CO. NW 1,470.00 147.00 222.60 88.20 0.00 1,780.80 1,633.80
Declared
SURGICAL SDN. BHD.
SCHEME
(FWHS)

Page 2
Berjaya Sompo Insurance Berhad (62605-U)

e-Policy Submission Sheet (Foreign Workmen)

FOREIGN
WORKER JOO LEE IMPORT
16-12-2022 Submission
Z0024561 INSURANCE & EXPORT CO. NW 236.32 23.63 0.00 14.18 10.00 260.50 236.87
Declared
GUARANTEE SDN. BHD.
(FWIG)
FOREIGN
WORKERS
HOSPITALISAT JOO LEE IMPORT
16-12-2022 Submission
Z0024562 ION AND & EXPORT CO. NW 735.00 73.50 111.30 44.10 0.00 890.40 816.90
Declared
SURGICAL SDN. BHD.
SCHEME
(FWHS)
FOREIGN
WORKER JOO LEE IMPORT
16-12-2022 Submission
Z0024563 INSURANCE & EXPORT CO. NW 118.16 11.82 0.00 7.09 10.00 135.25 123.43
Declared
GUARANTEE SDN. BHD.
(FWIG)
FOREIGN
WORKERS DECORTREND
HOSPITALISAT CLEANING &
19-12-2022 Submission
Z0024657 ION AND MAINTENANCE NW 420.00 42.00 63.60 25.20 0.00 508.80 466.80
Declared
SURGICAL SERVICES SDN.
SCHEME BHD.
(FWHS)
FOREIGN DECORTREND
WORKER CLEANING &
19-12-2022 Submission
Z0024658 INSURANCE MAINTENANCE NW 67.52 6.75 0.00 4.05 10.00 81.57 74.82
Declared
GUARANTEE SERVICES SDN.
(FWIG) BHD.
FOREIGN
WORKERS
HOSPITALISAT JOO LEE IMPORT
20-12-2022 Submission
Z0024721 ION AND & EXPORT CO. NW 315.00 31.50 47.70 18.90 0.00 381.60 350.10
Declared
SURGICAL SDN. BHD.
SCHEME
(FWHS)
FOREIGN
WORKER JOO LEE IMPORT
20-12-2022 Submission
Z0024722 INSURANCE & EXPORT CO. NW 50.64 5.06 0.00 3.04 10.00 63.68 58.62
Declared
GUARANTEE SDN. BHD.
(FWIG)
FOREIGN
WORKERS
HOSPITALISAT
20-12-2022 MHD FAIRUZ BIN Submission
Z0024723 ION AND NW 105.00 10.50 15.90 0.00 10.00 130.90 120.40
BASRI Declared
SURGICAL
SCHEME
(FWHS)

Page 3
Berjaya Sompo Insurance Berhad (62605-U)

e-Policy Submission Sheet (Foreign Workmen)

FOREIGN
WORKERS
HOSPITALISAT JOO LEE IMPORT
22-12-2022 Submission
Z0024850 ION AND & EXPORT CO. NW 420.00 42.00 63.60 25.20 0.00 508.80 466.80
Declared
SURGICAL SDN. BHD.
SCHEME
(FWHS)
FOREIGN
WORKER JOO LEE IMPORT
22-12-2022 Submission
Z0024851 INSURANCE & EXPORT CO. NW 67.52 6.75 0.00 4.05 10.00 81.57 74.82
Declared
GUARANTEE SDN. BHD.
(FWIG)
FOREIGN
WORKERS
HOSPITALISAT
03-01-2023 LEGASI SENADA Submission
Z0025174 ION AND NW 210.00 21.00 31.80 12.60 10.00 264.40 243.40
SDN. BHD. Declared
SURGICAL
SCHEME
(FWHS)
FOREIGN
WORKER
03-01-2023 LEGASI SENADA Submission
Z0025175 INSURANCE NW 50.00 5.00 0.00 3.00 10.00 63.00 58.00
SDN. BHD. Declared
GUARANTEE
(FWIG)
FOREIGN
WORKERS ARENA NATION
HOSPITALISAT CLEANING &
03-01-2023 Submission
Z0025218 ION AND MAINTENANCE NW 210.00 21.00 31.80 12.60 0.00 254.40 233.40
Declared
SURGICAL SERVICES SDN.
SCHEME BHD.
(FWHS)
FOREIGN ARENA NATION
WORKER CLEANING &
03-01-2023 Submission
Z0025219 INSURANCE MAINTENANCE NW 50.00 5.00 0.00 3.00 10.00 63.00 58.00
Declared
GUARANTEE SERVICES SDN.
(FWIG) BHD.
FOREIGN
WORKERS ARENA NATION
HOSPITALISAT CLEANING &
03-01-2023 Submission
Z0025220 ION AND MAINTENANCE NW 105.00 10.50 15.90 6.30 0.00 127.20 116.70
Declared
SURGICAL SERVICES SDN.
SCHEME BHD.
(FWHS)
FOREIGN ARENA NATION
WORKER CLEANING &
03-01-2023 Submission
Z0025221 INSURANCE MAINTENANCE NW 50.00 5.00 0.00 3.00 10.00 63.00 58.00
Declared
GUARANTEE SERVICES SDN.
(FWIG) BHD.

Page 4
Berjaya Sompo Insurance Berhad (62605-U)

e-Policy Submission Sheet (Foreign Workmen)

Grand Total 7,545.28 754.52 981.92 422.75 180.00 9,129.95 8,375.43

No. Payment Mode Cheque No. / Card No. / Payment Cheque Bank Cheque Date e-Policy Allocated Amount(RM)
1 Cash - - - Z0023914 130.90
2 Cash - - - Z0024054 101.42
3 Cash - - - Z0024055 130.90
4 Cash - - - Z0024279 636.00
5 Cash - - - Z0024280 99.46
6 Cash - - - Z0024281 636.00
7 Cash - - - Z0024282 99.46
8 Cash - - - Z0024283 1,144.80
9 Cash - - - Z0024284 171.04
10 Cash - - - Z0024285 127.20
11 Cash - - - Z0024286 63.00
12 Cash - - - Z0024287 130.90
13 Cash - - - Z0024560 1,780.80
14 Cash - - - Z0024561 260.50
15 Cash - - - Z0024562 890.40
16 Cash - - - Z0024563 135.25
17 Cash - - - Z0024657 508.80
18 Cash - - - Z0024658 81.57
19 Cash - - - Z0024721 381.60
20 Cash - - - Z0024722 63.68
21 Cash - - - Z0024723 130.90
22 Cash - - - Z0024850 508.80
23 Cash - - - Z0024851 81.57
24 Cash - - - Z0025174 264.40
25 Cash - - - Z0025175 63.00
26 Cash - - - Z0025218 254.40
27 Cash - - - Z0025219 63.00
28 Cash - - - Z0025220 127.20
29 Cash - - - Z0025221 63.00
Total Amount Received (RM) 9,129.95

Page 5
Berjaya Sompo Insurance Berhad (62605-U)

e-Policy Submission Sheet (Foreign Workmen)

Agent's Stamp & Signature

*Credit Card, Signatory must be Cardmember and signature as per Card Account.

Credit Cardholder Signature

Name :
Date :

Page 6