LIFE INSURANCE REGULAR PREMIUM PROPOSAL FORM. BORANG CADANGAN INSURANS PREMIUM BERKALA ‘YOUR PRE-CONTRACTUAL DUTY OF DISCLOSURE /AMtdctas equred inthis proposal form ae relevant fo Cut deision on wheter to accept the risk, and any rates and terms tobe applied. If yu are entering into a consumer faurancecomeac you havea duy to ake reasonable cave att make any misrepresenaton tous when completing this proposal form. Such duly of dsclosure shall continue {anil the time acon of magrance entre ito pursiant this proposal frm. ¥ou would alo have to ake reasonable caret disclose Ws any mater which may not be covered inthis proposal form that you Know tobe relevant fo our Sectson on whether oarecp the sk and the ats and ers tobe appli. Ifthe insurance contrat that ow ae enring into ent conser surance contra, You hve 2 Guy to dsclowe to ws amate tht you know to be relevant wo ou decision on whether to accept the risk Sat and ttre erm apd or ana eran nears coulbe cx ok he evan Sch yo sls sal comme the time a comract of nsurance is emer into pursuant otis proposal fom. Itthore samy pre-contractal misrepesenation made, te policy tay be avoided, claim denied or reduced terms ofthe policy change rte policy terminated. | KEWAJIPAN PENDEDAHAN PRA-KONTRAK ANDA | Kesemac utt-utr pong perk dt dan borg caangan in adalah elvan kepada eputusan kumi sama ada wrk menerina atau tidak risko dan kadar dan terma ‘en heal dpa ike anda mem sats hourekinsuronspengevna, anda momar tewjipan antl mongambil penjagoan munasobsh untuk kok membuat sfah natn kepada kami semasa meloghapon bora cadangan in. Keven pendedahan in adalah erterusan sehingaa ke mas kontrak nsrans in dua mena orang Zadamgon in Anda age haras mengambil penjagaon munesabah uni mendedabkan Sepa kami apap perkara sean yang teh dilipa dt dalam borg cadangan i. ‘rom ana tah seb beri hee hepuasan Kam! sama ada wok ener a ok rs daw kadar dan erma yung hendok dpa, Jia bora insurans yg an emacud! Puke konrok rams penguin, anda mempasvaikeeajfpan untuk mendedahkon kepada hamtsesuatu perkara van ande tah sega berkatonbepads yn aml sam eke wth mone atid risk dam kadar dan term yang hendakdipaka ao sarang ya muncsabah dalam hal keadean it boleh dank ta su shag! berkalion Kewstipanpendedahon it adalah berterusan sehingga ke masa komrakinsurans in dual menara horang cargo i. ike terdapatscheramg sah neat pri-tontrak pols! mangkin dla, tuna dol wu dkaramgtan. terme dalam pois ditutar. sk poi dtamatkan. ‘Not “commer nsannce conc means cota aru crac in, vari or ecw by nna wholly ox puss ua inv stra busine or Frofesion | | Nat," ins pong erin swan Konak eras ya dia, a ciperbuhard eh scr lds og make ag sum skal ia Perk dog prragagan permgu ata prion te Nomar Cage epee ae a escsast ees ‘ass Sein PAM 705020055 6 s/o9/1022 Doaozree4 ers Nae Hom in ae Stahl from otion NAD BINTI HussIN O1rg|sti ds 4o4q Plan Nae Pee tick in oly ONE oft boxe) / Nuns Plan Setanta (dala aleh SATU a sj) “7 PRUWith You" 105] PRUSenior Med 108} PRUGrowth 102] PRULady 109), PRUWealth Phas [04] PRUTerm 110) RUC {06} PRUTem Premise 113) PRUCash Dole Reward/07] PRUALI Cae ust Please mark () to state the purpose on the purchase ofthe life insurance, Sila randakan(¢) bagi menwaan juan anda atas pembelian insurans haya in Busines purpose / Twjuan Perniagaan ‘This means the life insurance is purchased for purpose relating othe Proposes trade, busines or profession innate [Examples The life insurance is purchased as protection for lan obtained for business purpose oo purchase a propery fr use of busines; oto recover los of thuiess income becuse of deaf rsckness of an employee or &ditecto or shareholder othe Proposer wade usibss 0 profesion. | Tat hermaknaincurans hover diel untuk nguan Beaton dengan perdagangan perwiagaan diay profsion Pencadang. ‘Sth cont Irans haya i gt erlang nt aman so dpa at a perma si uk momar Ba joan permtagean ital mendapa toma kllengan pendapatonpernagaan dichabkan oleh homation oan peat yang dala! fc pkera aa pengirah ate Demegong ser bag prdagangan, periagcan atau profeion Pencadang. Insurance Type Keyan Insurance /nsurans Kerman enisInsurant Employer-Employee Insurance /asurans Malik poker Partnership Insurance Jnuruns Perkanesian 77 Non-busines purpose / Bhan untuk tjuan perniggaan ‘Thismeas the fe insurance is purchased to insure the Proposes own life or ie of another person for purpose wholly unrelated to he Proposes trade, business Gr profession Ii ermakne inarans haya diel ise metic hayot Pencadang at ayer wntok orang lan, samarsokal uk untuk tijuan berkaton ‘dongon perdagangan,pernagaan atau prjesion Pencadang. 1s Life tobe Aseured under prenatal stage?! Adah aor yng akan Diiaranshan dalam pring pronatal? Yar To No! Tia INSTRUCTIONS: Please complete propa form in fullin CAPITAL LETTERS and TICK (in boxes propriate. Use DARK BLACK lnk ony. [ARATLAN: Sa lenghaplan orang Caan epoan denpan HURUF BESAR dan TANDAKAN (7) pads kt wk Jag berkenoan Gunkon dale HITAM GELAP soja Pull Name as shown oa NRIC) / Name Penh (seperti dalam Kad Pengenalan) Life A Hayat A cHILD Life B / Hayat 8 NAD iA BINT HUSSEIN Life € Haya © 4158 Agency RPN10/2021 — PageMataswral / 18 Form ID 101050= LIFE INSURANCE REGULAR PREMIUM PROPOSAL FORM. 35; BORANG CADANGAN INSURANS PREMIUM BERKALA ‘YOUR PRE-CONTRACTUAL DUTY OF DISCLOSURE /Aitdcasequred in ths proposal form ae relevant fo Cut decision on wheter to accept the risk, and any rates and terms tobe applied. If you are entering into a consumer fnurancecomeac you have «duty take reasonable cave att make any msrepresenation tous when completing this proposal form. Such duly of disclosure skal continue {antl the me acon of maaan entered ito pursiatt this proposal fmm. ¥ou would also have to ake reasonable care to disclose to Ws any mater which may not be covered inthis proposal form that you Know tobe relevant fo our decson on whether o accep the sk, nd the rates and ers tobe appli. I the insurance contract that Jou ar clring into fy nota Consumer isurance contre, you have «dy to dsclose wots a mate that you know to be relevant to our decision on wether to accept the risk St nd ttre apd ornate eran eeu cob xp ok be ean Sch yo sls sal comme th time a Sotract of insurance is emered int pursuant 9 this proposal fom. ITthere samy pre-contractal misrepesenation made, te policy thy be avoided, claim denied or reduced terms ofthe policy change rte policy terminated. | KEWAJIPAN PENDEDAHAN PRA-KONTRAK ANDA | Kesemat utt-utir pone peek dt dan borang casangan ni adalah elvan kepada eputusan kumi sama ada wrk menerina tau tidak risk dan kadar dan rma ‘on heal dpa ike anda memacski sats hourekinsuronspenggvna, anda monn kewjipan untuk mongambi penjagoan munasabuh untuk idok membuat salah rata kepada kami ema melomghaponborang cadangan in Keep pendedahan in adalah erterusn sehingga ke masa kontrak nsrans in dibuat mena orang Sadamgon nnd ap haras mengambil penjagacn mnaslhah wk mendedaba kepads kami apap perkura, sean vung telah dlipa dt dam borne cadangan Sogn tah sega beri hepa kepuasan kum! sama da untuk meer a ok risk daw kadar dan erma yung hendok dpa, Jia Kora insurans yam an memasud! Duan Kontak crane pean. anda merpnavalkewajipan untuk mendedahan kepada kami sesutu perkara van ane toh sega hrkatan kepada pas aml sam ace woth enero etd risk dam kadar dan trma yang hendok pata ao sarang Ya muncsabah dalam hal keadean it boleh diane ta shager berkalton Kewsjipanpendedahan it aalahbertorusan shina ke masa komrakinsurans it dat menarat bora cadanga i ike terdapet scare sah naa pre-tontrak pols! mangkin dla, tanta dtl sau dkuramgtan terma dalam pois dua. ak polis dtamatkan ‘Not “cmemernsannce copa reans ca of agunce craced i, varied or ec by anniv wholly puss ua inv stra busine o Fok | aca ae cn ae a Ra prrdagangan permgaa ata prion a Sot Seca nee Aes! Kl ‘in eae 705020055 6 Ss/ogj/1022 Deoaoree4 ers Nae Home in gaat Stahl from otion NAD BINTL HuSsIN O1rg|sti ds 4o4q Plan Nae Pee tick in oly ONE oft bre) / Nan Plan Satna (¢ dala saleh SATU a sj) “7 PRUWith You" 105] PRUSenior Med 108} PRUGrowth 102] PRULady 109), PRUWealth Phas [04] PRUTerm 110) RUC {06} PRUTem Premise 113) PRUCash Double Revard/07] | PRUALI Cae ust ‘Please mark (/) to state the purpose om the purchase ofthe life insurance /Sil tandakan (7) bagi menyatakan tan anda aias pembolion inarans heat in Busines purpose! Tyjuan Perniggaan ‘This means the life insurance is purchased for purpose relating othe Proposes rade, busines or profession innate [Examples The life insurance is purchased as protection for lan obtained Tor business purpose oo purchase a property fr use of busines; oto recover loss of truss income becuse of deaf rsckness of an employee or & diet or shareholder othe Proposer wade business Or profession. Ins bermatva insurons hay! belt untuk rium berkaltan dengan perdagangn,permagaan au profeson Pencadang. ‘Stag con Irans hay i ering nt aman yo dpa at aa errand momar jog permtagean ital mcndapat tema klenga pendapatonpernagaan dicbabkan oleh homation oan penvakit yang dala fc pkera ao pengorah atu ‘emegong sper bag perdagangan, periagcan atau profeion Pencadang. Insurance Type |_| Keyman Irsurance/nsurans Keyan JenisInsurant Employer-Employee Insurance /asurans Malikun poker Parnerip Insurance Jsaruns Perkanesian 77 Non-busines purpose / Bahan untuk tjuan perniagaan ‘Thismeas the ife insurance is purchased to insure the Proposes own life or ie of another person for purpose wholly unrelated to the Proposes trade, business Ce profession / Ini ermakne inurans haya dil sis linn hayot Pencadang at her uated ora lan, samarsekal Pukan untuk tijuan berkiton ‘dongonperdagangan. pernagaan atau projesion Pencadang. 1 Life tobe Aseured under prenatal stage?! Adah Haor yg akan Dideakan dalam pringhat pramatl? Ye lta No! Tak INSTRUCTIONS: Please complete proposal form in fallin CAPITAL LETTERS and TICK (2) n boxes a appropriate. Use DARK BLACK ink ony, LARAHANS Sa leghaphan orang cdangontpenabnys dengan NURUF BESAR dan TANDAKAN (¢} pads kava arg berkenour.Gunokan daw IUTAM GELAP sohaa Full Name as shown oa NRIC) / Name Penh (seperti dalam Kad Pengenalan) Life A Hayat A c#ILD Life B / Hayat B NAD iA BINT HUSSEIN Life €/ Haya 158 Agency RPN10/2021 — PageMutaswral / 18 Form ID 101050Proposal Number 705020055 PARTI: PERSONAL DETAILS BAHAGIAN BUTIR-BUTIR PERIBADI La Tite Gelaran 12 Gender Jantna 1.3 Ktifcaion No (OWNRIC Papert No) (te Pega Lama’Paspor RIC No/ ‘No. Kad Pengenalan Life A: Life be Assured Havas A: Hayat yong akan Dtnsaranskan Mr/ Encik Mden/ Puan Miss Ck Others Tainan Male/ elo’ Female/ Perempuan PART I: PERSONAL DETAILS. BAHAGIAN I: BUTIR-BUTIR PERIBADI Me/ Encik Mdm Puan Miss /Cik ‘Others: Laisa: Male Lelaki “7 Female / Perempuan ¥ S041 4/03 |66VO Mr/ Encik Mdm! Puan Mi Others: Label Male/ Lela’ Female/ Perempwan [1 ‘ove: accordance withthe guidelines on an-mancy laundering sued by Bank Negara Mala sla Prudential Assurance Malaysia Berhad (PAMB) I required to verify the identity of te customers Inthe even of ionlilent prot ef Wetifeation it may Fest in mn-acceptance af the Niu Morn gars panda mengenetpncephen pengutohan wang harm ag dicharkan otek Bank Negora Male, Prudential Aare Malia Berbud (PMB) , Menara Rudeatial , fersiaa TRKX barat Tan Razak Exchange , Fala Lungue mak SS. Ce SET walaysa t28dzeny.RPNLO/2021 rape Midanrar3 /18Proposal Number Nombor Cadongan 1 Adress Det Butt Almas Correspondence address (MUST bein Malaysia Not Alamat surat menyarat MESTILAH di Malaysia PART I: PERSONAL DETAILS. 705020055 BAHAGIAN I: BUTIR-BUTIR PERIBADI LIFE A: LIFE TO BE ASSURED / HAYAT 4: HAYAT YANG AKAN DIINSURANSKAN Correspondence Address / Alama suret-menyurat [Residential Address Alamar Rumah Same as correspondence adress? I no, Soma dengn lamatsart-memwrt? jp Yes No ia ak sia nyarahan Not Jalan Wajan 23, Taman Si Watan Ampang By eoe felangor County wipers Malag 64 ‘Contry Nit LIFE B: PROPOSER (If different from Life A/Spouse or Parent/Legal Guardian) HAYAT B: PENCADANG (Sekiranya berlainan dari Hayat A/Pasangan atau Ibu bapa/Penjaga Sah) ‘Correspondence Address / Alamat surat menyurat Residential Address Alamet Rumah Same a Life A? Ifo, please tate Same as Life A? If no, please state Yee No Yes — No ‘Sama dengan Hayat A? Ska tidak, A Sama dengan Hayat A? Ika tidak = ‘Hla nyatakan, Ya Nak la maaan ag ot ont: foes i LIFE C: JOINT PARENT / HAYAT. Correspondence Address / Alamat surat. Residential Address / Alomar Rumah Same as Life A? If mo, please sate ae Same as Life A? Ifo, please tate ES ‘Sama dengan Hayat A? Jka tdok, Ye No, Sama dengan Hayat A? Jka do a vila nya. sila naka, E ‘oy ne Soeet Soeur ‘What isthe Proposer’ssoure of funds to finance the premium? /Apakah sumer dana Pencadang wet membiayai premium? (Tick wherever relevant Tanda dimanea yang berkenaan) _Pilary Business income Personal savings Allowance from parents spouse amily members Ga) /Pendapotan periagaan Perjimatam peribads ‘Elan daria tu bapa /pasangan abl Keluarge Maturity of procsedsavestment Others (Please prove details) ‘Kematangan hail Pelaburan Lain lain Sle borhan maklumat orporneD ‘What isthe Propoer’s source of wealth? /Apata sumborketayaan Pencadang? (Tick wherever relevant Tanda dimana yang berkenaan) Fie Bsiesnome Investment /Asst Allowance from paces! spouse family members Gajt/Pendapotan perniagaan Pelabwran/ Harta lau darpada bu hapa /pasamgan ‘all kebarga Inheritance ‘Others (Please provide dts) Warisan Lain ain (Sila berikan mata forperinc) 18 gency RPN10/2021 — PageiMutasurar4 / 18Proposal Number PART I: PERSONAL DETAILS. Nambor Cadansan 705020055 BAHAGIAN 1: BUTIR-BUTIR PERIBADI 1.25 BENEFICIAL OWNER (OTHER THAN PROPOSER) PEMILIK BENEFISIAL (SELAIN DARIPADA PENCADANG) Isthere amy Beneficial Owner® other than Proposer? /Adahah terdapat mana-mane Pemilik Bencfsll” slain encadang? Yes/Ya No Tidak yes. plese select Jka yo, sil ph | Life tobe Assured / Haya yang chan Dinuranshan Life B (ther than Propset/ Hayat B Slain Pencadan) Joint Parent / bu Bap Bersama ("| Others please complete below / Lain lan. sla enghaan baw NOTE: “Beneficial Owner refers to any natural person who atimatsy owas oF contra a custamer on whose behalf a transactions eing conducted. Kase Index hone erm wh ar int eine ontrlener eal perion o arangment ca “Pomil Benefsel merujuk hepede manaeamaneoreng yong mcmlt ata mengavel pelanggan bagi phaknya sua ransohs dalanban. la jupe eomihorangorang yong mempanyr taste maak ke es oan yang ah etapa Fall Name (a sbown on NRIC) / Nama Pena scpert dalam Kad Pengenala) sca reeepery — riety = omtten ; wae COLT cr ee ae co = Country of Contact Number: ‘Name of Employer: Nara Nombor Felon Noma Maan eee eae ae eee sone ee Se ea ee eee | Saaremaa Ie aa a = oe 125 PAYOR (OTHER THAN LIFE A/ LIFE B/ LIFE C/ BENEFICIAL OWNER/ CREDIT DEBIT CARD HOLDER) ‘PEMBAVAR (SELAIN DARIPADA HAYAT A/HAVAT BY HAYAT C/ PEMILIK BENEFISIALPEMEGANG KAD KREDITDEBID) Inthe premium pid by somone ih than Life A Life Life’ Beneficial OwnerCroi/Debit Card Helder elle fr hs propos? yoy Ife pease complee teow. ‘Adak prem dbyar tc sescrang sca darko Hayat A/ Hayat B/ Hayat C/ Penk Benes! Pemexang Kod Kredi Debit yang ‘senah ‘dor une cada? Da a a enghaphan Full Name (as shown on NRC) / Nama Perth (sper dalam Kad Pengenalan NRICPassport No. avai To. Kad Pegenaan sport vareaepee ‘yarn ere Date of Bin: Pasion anh Lh Lil nen Contact Nember: Naureof Business Rembor Teor idan Permtagecr: County of Contact Nunber: Name of Employer: ‘egare Nonbor Tee ions ajar Relatonsip 0 abr dengan Pence Correspondence Addr / Alone! mwret-menyuret Resident Address Alamat Rumah Same Life A? Io, ples sate Ye (Ns Sume a Lif A? Ifa, peae ste. Ye) Be Sama dengon Het A? Jie dt sl matoton. |_| Yo. | Tidak Sema depen Hayet A? Jac st yoaton, 1 Yor] Tat our Sey om ee Note No: Proof of age ls required. / Buti tentang umur dipertukan. Copy of NRICTbrt cerlficate passport othe Life tobe Assured /Popose/Jint Paral Beneficial OwnevIndividual Payor is equited to be submited. ‘Slinan had pengenalan’sil helohron/pasport untuk Hayot yang chan Dinuraashan Pencadang/Tb bapa Bersama Pomilk Benefisial Pembayar Indiv perky dibantar Ceniid trt copy of Cerificate of Incerporation, Forms 3444 (othe equivalent documents) fer Payor Beneficial Owne'Coporte Proposer are requted tobe sabmtd. ‘Sclinan Sil Penabuon, Horang 24440 atau dumen lain yang setae) yang dsahkan Denar untik Pembuvar/Pemilk BenefitalPencadang Korporat perl diana. 158 Agency RPV10/2021 Page MutaswraS / 18PART 2: DETAILS OF LIFE INSURANCE PROPOSED Proposal Number ‘Nombor Cadanzan 705020055 BAHAGIAN 2: BUTIR-BUTIR CADANGAN INSURANS HAYAT Total Regular Premium Jamia Kectarahan Premium Berke Frequency of Payment / Kelerapan Bavaran | Method of Payment / Cara Bayaran Inelve gf PRUAIner, pein vs ir nd rh acting 0) Yo Hale Yearly (77 CredivDebit Card / Kad KrediDebit a ee. Fen roms rar apa =i nid tia reyaran la da) 7 —— Direct Debit / Debit Torus Monthly RM 20% Shane (7 Benet CashiChequ / Tinaitok onto at ‘rom yankee ie. + Only ONE Assrance be skated in his prpmaform. The Propo at tery 0 buy of tot © bey any ofthe sve Asuranss Hse ins, fom. ‘May SATU poo ans ee ich cp oh dB cng tak mcs i mel mans ans rs yong rong di Pombo Rider tk vain cn Penang hich medi manana = {ibn epicaton fer Somes pase nt hat i spl lb eed ba ni es and codon fr onenion pn inching thei fr oan tbe “ik adalah permohonon bag pemaran. sk ami peratonbahowa permokonn in akan pres erdasarkan rma dan sure yang dperantubkan wrk open ‘ermal hata men mf « Fictnpeter avecd remus or aly i pcr era dc se tn eat nan) nt ring mata ap) ‘tcl ty prc ston cs hh ae rend bese aol wt ne te yc Fencatong ncthuthon pave sms myn rir re rea ratio ar a ck) cn porn dat es tert pea rade, ee rama dan a ah ra dn ced ll ps dla ra col Diet Crt Apicson Fr fr anne ral yc oe repr only te ay ed pre op ce Sours ac PAM rl yale yet ibe ye’ ek cea ep wo Orin PAM ay ose dig ro Jprodt such DutNow to py thee cy sack ave or pdt sade ata I PAME tah fay the mone pyee wah om Be die aif ae "hc mones oi breaded sumed mons so PAM ie Kash urine mas wi aan Akama Nes ek ;Permohonan untuk Kredit Terus untuk semua urusan pembayaran daripada cadangan dan polisi yang mungkin dikeluarkan selaras dengan ini ke Ee eta mee cee To char Jt PAM tal per emia pentayren tempo seiahum dari tarikh pertama pembayaran kena dibayar, wag akan dianggsap sebagai wang, tidak Sere ee |A. ASSURANCE PLAN / PELAN INSURANS. 1. Basic Assurance Please comple the relevant information to your selected assurance plan Isat Ass Shan makumat yng berktan dengan plan isarans phan anda 77 PRUWith You (051 Sum Assured /Jumloh Diinuranston YOS}02}}04061(0710911101031 15) RM 10, OOO PRUGromth 02 paler ea Coverage Term Tempoh Petindungaon (0102040607110 13} 15] to PRUCISH 06} Premium Paying Term ro2yoso7143), PRUCash Double Reward (071 Tenpoh Pembavaran Premium tos) Full Pay/Bayaran Penh PRULe@RY Senior Ma (standalone) PRUSenior Med (0s) Peeper , See rae PRULady 1091 isis Cover Pan Sum Asam! Lai isis Cover Pls (10) RM ray PRUTem 110}, ee roe PRUTem Premier HSI PRUMongage 10] mish Diesranston RM Tempoh PRUAIICre wisi 2. Option for Survival Benefit /Opxyen Plihan untuk Manfaat Kemandirian (wonton isso compte por Sava Beei ay ut wl dete Onion 1- To recive pyof the Survival Beef Jia sekayen ii tala dieu, Opven soak pombayren Mafaat Kemandirian akan mergiku’Opsyen I Untuk menerina bayavan Mafaat Kemandiran. Option 1/ Opayen 1: To receive the payout ofthe Survival Heneit/ Untuk menerima bavaran Manfaat Kemanalvin. ‘Option 2/ Oyen 2 To accumulate the Survival Benefit with us atthe prevailing ate of interest determine by us/ Uanut mengumpul Manfaat Kemanlrian dengan kami tas kadar fda yg kan etapa. [B.PRUAllocator / PRUAlosator Ameen of Premio et Ane Fenian sor Prtalte em pt of e emim in Ba Ut Asad ‘beat okep the policy inforce (where . PRUAIocsior RM PRUAllcstoradalak saan darpada prem dalam Ako Unit sas dan ia ‘wath devo and memactkon pois ela herkwathuasa ka herkenaa). 158 Agency RPV10/2021 — Page/sikasurar6 / 18Proposal Namber PART 2: DETAILS OF LIFE INSURANCE PROPOSED Nombor Cadangan 705020055 BAHAGIAN 2: BUTIR-BUTIR CADANGAN INSURANS HAYAT ‘C. RIDERS / RIDER (Pleas tick (~) in boxes as appropriate. / Sila tandakan (dalam peak yang berkenaan.) 1. For LifeA ‘Amount For Lite A ‘Amount Tom Untuk Hoya A Junto nna Hayat A Sania Tenpoh Criss Cae {osjo4 RM 7 Payor Basic {ositos) isis Guard {osi1041 RM PayorSaverLevel ‘(i104 Plan V Pelan 1 SA Rider Criss (oy RM Infant Care Phas wi Ff eoeaeeea Protect Booster (es) Rw Essential Child Phos (05) RM_ 49,000 Disbilty Cae ns) RM ‘Acc Guard Pas 10s) RM Incremental Rate / SA Booster 31 oe Aci Mod Pls os) RM Koon PRUWaiver Pas st Accilncome Plus 1081 ‘vase RM PRUValue Mod Ios) = Room & Board / Blk & RM RM Paciapat Name and address of each doctohospial > Degree and date of recovery present satus. of| septs nary adie it iow-us > Tretmet or medicaion-ype or name, tration, frequency. dosage > Situ fst dont dhe ess and cason nla si yatakan bution scare terperinc! Soper bore Fens tar dan jangka masa Keadoan, » Kate den alone sip dotorhospil 5 Tata dae tri put headean semasa dan > tah ran ea teri » Settee Cot hilar, rth “putas dan sebaberchab stan dijaanon corapleinpntemare soeaevoonyrey aero i ts tr onsen il te i ee. ae ene ees ea 138 dgeny_? 10/2021 — Pagesatorratl 0/18Proposal Number PART3: PERSONAL STATEMENT. Nombor Cadansan 705020055 BAHAGIAN 3: BUTIR-BUTIR PERIBADI Lie 4 Liebe Aue or Ciara Hee nen iar ctw Ak uA, eB, ie * Spouse or Paren/Legal guardian (i ide is proposed) / Hayat B= Pasangan Maya HayarB Hayat C ‘tau fu bapa Ponegt one Sok a der dang) nt Parent Yes No Yer NoYes No tite © fla Part ape C= Pu bapa Bers Ys Fee Rel | Me Fe |B FEMALE ONLY / UNTUR WANITA SAHAJA ‘Life ABC Question Na. 3.ka Have you ever given birth? 7 Hayat 4/81C No. Solan ‘Permabkah onde melahirkan anak? 386 () Are you curently pregnant? If yes, pleas state the gestational period and a expected dative dat ‘1iotah anda hn mengandumg? Jia yo, sla matakae usa Landungon dan ‘rth Jongh lair Gestational Period: weeks CSc Kandungare 3A ingen Pesan OF AL DOLL (Only for PRUWith You prenatal application / Untuk Havatyamg akan Ditnsuranshan ‘dalam perma prenatal saa (Gi) Please state the numberof foetuses Site nvatakanbilangon jain Number of focuses) 7 Bilangan jnin 712 More than 2 Lebihdaripada 2 (iy Haveyooundrgone ay sii iseminatin andr assed repre weno. Sane me oman (IVE) a her rceusn ey spree” 7 Femthich ‘ands meno sehorong poranay Pera dan a ebb ‘pembtan yang ds cones persopwoan nvr (VF so pros a ‘ream deg ean 2eHave you tad any disease or disorder ofthe bres cervix wr, erase ovaries Zz ica fine ba oan et arin a ‘neoialbosding Sophia ctr geen pep eee pence pdr res rb ‘tan oar sera rs popu au var hrs nai, Strid pol, pendarchan boda perbubangan Kami, lanser oka ktembuhan? {IRL Haye you eve aa Pap Soe marnmogrn, bios, lasound of he resto a Pelvis cone Biopsy or stposcony eat mae logical investigations which Fah aaa on ap Sa pomeeeeneat re meyoan Pap Soear oi is Sot at op at npn ner ‘eno pt abnormal. dni sapaye mong fompoh Fan BGM on dit 3 He yo ad any contin ding Brome cit eget 7 al Stk Sccartags, tema swan conan sap plostne, x maire Sint fd erin any of your chilrn eer steed from spina i 2 Wis 126 Down's syndrome, cleft palate, congenital heat disease, anal atesia, atrial septal 44 Asc congenial catnce congcataldeafess congenial aphasia bea Py ints hyroceptai tcelogy of fall, wanopoatton of grea veel, arcs PL SL (restate mepsnd eptie oes aegeeg eee ek tarut B5f: 4 (sper eng man ei ao. aan ara i ei ean, f v a fchamen ar oh, hematin forts bay, 43143 onde nando, sos planner emba ka t ing al and megan ni Sram ig See eae enone oe ‘aco vena pet searangLeaclancadaan abnormal angen? Life A -Lifetobe Assured or Child Hayat A - Haya ag han Dinsaransam iow Anak Life Yer No Ye Tok 139 CHILD ONLY (Applicable ifjuvenie assurance is proposed) / UNTUK ANAK SAHAJA (Bolchdiguna pak jk insurans jana dicadangton) 5191 Was the child's binh abnormal or pomatue? If yes, please provide details. Tex clcmoeally LAdakah anak in cabin abmormal atau dat cup Palen? Jka esl : ‘eran ran erperinet Keadean abnormal ‘ih weight kgs) \Numir of weeks premature ‘erat kta Tahir (hg) Bilangon mie Nang ak cab ere ; Ae ye ewe vt ete eS So ey ay spn tinea trpeic ae le acer ee ome v10/2021 Mutaswrat 1/18Number Nomor Cxtengan 705020055 PART 4; DETAILS OF EXISTING INSURANCE COVERAGE AND REPLACEMENT OF POLICIES BAHAGIAN 4: BUTIR-BUTIR PERLINDUNGAN INSURANS SEDIA ADA DAN PENGGANTIAN POLISI ‘CAUTION: It may not be advantagcous to replace an existing life insurance polley with anew one. Ifyou intend todo so, we recommend that you consult your present insurer belore making a fal decision. PERINGATAN: Mensguntian pols! insroms haya vang sea ada dengan yomg harw manghin tidak menguntunghan. ike anda ingin berbuat demikian, kami Cadamghan sapana anda mendapatan masher daripada penanggung insurans anda seharang sebelum membualkepunsen muktomad. LifeA LifeB Life Life A -Life tobe Assured or Child / Hayat A Hayat ung akan Dinsuranskanataw Amok {fe B -Spouse or Parent Legal guardian fider i proposed) Hayat B- Pasongan atau Ib bapa/Penjaga yang Soh Hayat A Hayat | Hayat C (ik rider dicadanghan) ‘Yer No Yer NoYes No Ya Tidak Yo Tidak Ya Tidak 4416 Has any proposal fr life or health sseurane on your own life or fr insurance against accident rial iiness ever been 2 ‘made 1 is or any exer company (including proposals about to be submited) yes, please provide deals Pemahlak ands jembuat Seberang ara hae ina esto. cris emelongn la ican [pom thal Rog pihak dirt ands send darada Syardat int atau sjurkat lai (lermasih cadangan bung chan ‘Gikemakahan int? Stha a, sila eran butran erperint E Life A/BIC Insurance Company Proposal/policy number! Year of ue | Type af Coverage | Sum insured (RM) Haw R0C 'Sparkat Inarane”Nomborcadangn/pols!, Tahun Ditluarkan Jens Peridungan Jah Disaransan (RM) 206. Prared ‘15, 000 B | ens 3UtF IG raady 5 244901726 4 Reu\ink One #000 4.16 Has ny of your propos for if eal, accident or eric ilies insurance made 1 this any company ever bez declined, Akteed or Seed at spel ems? Ife. plese provide deta. a ‘ermal slung calengen ands una swans hha kemelangan eau pono rte epade sarin ato rman Syria dla itangdkan can dria ps kar pang thas ke sia berian ativan erperinc Ute A/BCIesrance Company Reason ropeaolicy number itaceamic “Spares owen Sho omhor dengan pb Life C- Joint Parent/ Hayat C- bu bopa Bersama 42a Do you intend to surrender or terminate any of your existing lif insurance policies with the application ofthis new proposal, Oe et yore cy os Boer ees plies oe ans ay Be eter eh al a of ees a a yes, plate provide tll “Maah ands Porkyarwnnat menerahtan atau menamatkon mana-mana polis inurans havat onda yang sea ade dengan ign arson apn ad aia agg orn us esol non pont ‘Jung trina anghin hare herbanding deg premiu janet dbuyar Sk ysl erkanbutran eer LifeA/BIC Insurance Company Proporalpaicy number Year of sue Type of Coverage Sum Insured (RM) Hope AOC "Syria urine” Nomborcodangan/polst Tahun Dielarkan Jems Pevinargen Jah Dinsuanshan (RM) 42a th agent nay wy inflanedyou to see ot cnt any of your exiting polices? Ie, please comment on our sstsfacton of explanation gen by the agen ie Pemahah een mempengarubi anda unit menjerahkan atau menamatkan mana-mana pols anda vany sea ada dengan ‘pa cara skalpun’ dita eran Komen Berkenaan kepuasan hal anda fenang peneangun yang diberikan och jen. Life ALC Comments any! Komen ja ala wesc nets PART S: NOMINATION /TRUST (Please complete in CAPITAL LETTERS using DARK BLACK ink only) BAHAGIAN 5: PENAMAAN / AMANAH (Salt dengan menggunakan HURUF BESAR dan dakwat HITAM GELAP sahaja) IMPORTANT NOTES FOR ASSURED/PROPOSER / NOTA PENTING UNTUR PEMEGANG POLISUPENCADANG Tie (Man rye pe, clr ps (wha nosg cd rngath tr cea). att otis menoysbcwal in outers) Sica on hee la na may nak i up nda kik pong kyr ah ipod amok wept dna ol a em ma pr ¥ ‘kan untuk manfaat penama tersetue di bawah Javea! 10 Adta Perkinidmasan Kewangan 2013 (FSA). a oe 5.2 Wheea at scratol ysl poorer fer an outa uaa be poy ony Whee mates ppt he ain) compat crt sl he Mach Wheetsmnas) wat nconqear cea prea eng ma rm yap ownr a eer oye Be GE hase stu aery mma by oS a ramon dn le i nea dr ce rr ea oe Sd alfa Seer npeen nad Saaek dn ml omen eens kripcoir erona Bu shaps apa pono soa icp alt pad Tomeszel aller pomaye lt car rena pee Cech leat epson ma ng Pegg Ama aoe Se omen Jot dann eh Ka mah pene anack 53 It snr hn nc mie oct conc, ee ec salle ‘ogee rsetpo ogo ia orar onpan pgs aera 5.4 Yourmateuin or tase writen cone ie wr sro oa ans wh nt ore io rete peo il gate Ipecfomonathr epg meer teap wom propa om rufous mop oer ade fogs anna omg yom nc min pr hn merge toe (ie ules ek ehh Pa sp fast meter a mayan tn, as Meo a cet Sv 5.5 Nowaticra a Masi aed rp er seins fs Mase asap el drt te cy nner ani a “Saad cen peje canescens oh is pas a nang arate Ba edalah noah sgl ora Cannan 5.6 The wits tion ase yeof nae arene ore ‘Skt esl sdorarsorang berms a as os epoca aa peng anh ema 5.7 When tuts cea he mines lee poly monysaran xa anetarbntay, yer tb noinets) eve poe ‘Size ene gen Pron an rp chap et dm boc ofr. atone ac tana nin a 7 ate ih ep mera ‘RnB ars esa ay mov ha ll aera esa 8 Ponerinae Oe FSA, fe eat Payent f ay Menu LP and eal At Pi. ‘Srl pened TOFS en monary mega Beran Wang Pa awh Pe a dr Pe Remon De 4188 Agency RPN1O/2021 — PageiMutasurer1 2/18Proposal Number PART 5: NOMINATION / TRUST ‘Nambor Cadaneon | 705020055 Do you ave any child? /Adatah anda mempunval anak? Details of Nominee(s) J Buti Putr Pena First Nominee / Penama Pertama Fall Name (as shown on NRIC)/ Nama Penh (scpert dalam Kaa Pengenalan) cei es Moths Yb Tart Lahr Nationality Warganegara Relationship Muburgan Shaee Perkongsion ‘Second Nominee! Penama Kea Full Nume (as shown on NRIC)/ Nama Penh (scpert dalam Kad Pengenalan): [NRIC/Passport No. [Na Kad Pongal Posport Date of Bich Tarith Lahr Nationality Warganegaro Relationship Hubungan ‘Share Perkongsian ie. ‘Third Nominee / Penama Keriga Full Name (as shown on NRIC)/ Nama Penh (sepert dalam Kad Pengenalan) Dayle SonBaley Yan NRICPasipor No. Mes Dayottars Month Ban Your Toh Date of Bits TTI arith Laie Natonly Warganepora Relationship Hubangan shar ‘Perkongsian * ouren Nomine/ enama Keompat Full Name (a8 shown on NRIC)/ Nama Penuh (seperti dalam Kad Pengenalan): NaiCPasgrt No, ae Day Hari Month Baan Yene Tahu Date of Bich arith ahi Li Nationality Wrarganegara BAHAGIAN 5: PENAMAAN / AMANAH Yes/No Ye Tidak ‘Correspondence Address Alamat surat - menyurat ‘Same as Life A? Ifo, please sate. Yes |) No ‘Sama dengan Hayat Aka ida, sla nyaakan Ye Tak Conn nore Correspondence Address Alamatsurat-menyurat Same as Lite A? Io, please state Yer) No ‘Sama dengan Haya A7Jika tidak. sla myaakan Ya Tidak Nese Correspondence Address Alamat surat menyurat Same as Life A? Ifo, please state Yes No ‘Soma dengan Heya A7Dka tidak, sila myatakan Ya Tidak Coane: Correspondence Address Alamat surat menyurat ‘Same as Life A? IF, please state Yes No ‘Soma dengan Hayat A7Ja tidak, sila nyatakan. Te Tidok Gown gor 158 Agency RPN10/2021 — Page/studaswarl 3/18Proposal Number PART S: NOMINATION / TRUST Nombor Cadangen 75020055 BAHAGIAN 5: PENAMAAN /AMANAH Details of Truste(s)/ Buti-butir Pemegang Amanch INSTRUCTIONS: Tobe complete ony if the Proposer i non-Muslim and the nominees) i'r the Proposes spouse and/or cil, o paren (wien theres no spouse ‘or child iving athe ime of making this nomination) UARAHAN: Pere dist slirnya Pencadang bukan beragoma Isom dan penama laah pasangon daw/atav anak, ata ib bapa (ka tadapasangan atau amok yang hip ‘waka penamaan i dibua). [Atany time and fom time to time, the poicyholder shall have the soe and absolut right to revoke, subsite or terminate any trste() or appint any ational trstc(s) without ny reason and widhout consent of any tsce or nomince. Such right may be exercised in respect of any uses), whether appointed by the policyholder or deemed ‘appointed automatically pursuant tothe Financial Services Act 2013. Pada bila masa dan dari masa he semasa, pemegang polisi mempuavei hak tungeal dan mutlak untuk menarit halt, menggention atau menamatkan seiapa pemegor-pemezang) amanah ata mela sesiapa pemesarg(‘pemexon) amanaltambahan tan sebareng alasan dan tanpatzinan sesiapapemegang mana aan ‘encima Hak in boleh dlalsanakan berkenaan dengan ssloa pemegargt pemegang) onanah, somada dant ole pemegan pols atau dianggap ata dla secara ‘ruomatik merurut Akta Perthidatan Kewargan 2013 First Trustee / Pemegang Amanah Pertoma Fall Name (as shown on NRIC)/ Nama Penh (seperti dalam Kad Pengenalan RICIPasspor No Correspondence Address /Alamar surat - mensurat Na Kad Pongal Paper Same as Life A? Ifo, please state. Yes) No Date of Bh ———— Sama dengan Hayat AJ tidak sla myer, Te Tak Tath Labi I Nationality Warganesara Conny Nera Signature of Trostoe Tandatangan Pemegang Amanah ‘Second Trustee / Pemegang Amanah Kedua Full Name as shown on NRIC)/ Nama Penh (sepert dalam Kad Pengenalan) [NRIC/Passport No. Correspondence Address Alamat surat - menyurat Kit Peep ret epee ‘Same as Life A? If, please sate. Yes [-) Ne, Date of Bint “TTT ‘Sama dengan Hayat 47a tidak sla myaakan, Ye Tidak Tarth Lahir Nationa Warganegara Soi: Signature of Tastee Tandarangan Pemesang Amanah 138gency RPV10/2021 — PogeiMubaswal 4/18Proposal Number PART 6: POLICY DOCUMENT PREFERENCE Nombor Cadangan 705020055 BAHAGIAN 6: PILIHAN KONTRAK POLISL Please provide the policy document in English Only / ila sediatan dokumen polis dalam Bahasa Ingers sahaja \Note The poicy doeument wil be provided in bath English and Bahasa Malaysia if the box i not checked(7) ‘Nowa: Dokumen pots akan dsediaan dalam Bahasa Inggeris dan Bahasa Malaysia ka koak tidak ditandaan (7) {would lke to receve/ Say ing menerima: 4) policy document through PRUACcess Pls or any available channels 2s advised by PAMB for electronic delivery. ? ‘With this, wil not receive the physical policy document. E-dokumen polis melalui PRUAGCese Plat at melas soluran tersedia yang PAMB nasihatkan untuk penvampaian eekironik. ‘Dengan ini saya tdak kan monerima dokumen polis fiikl. by) E-crrespondence, such as via email and/or SMS, in substitution of the printed physieal copy, once this is made available in the future. zm E-surat seperti medal emel dant SMS, sebagai gant kepada slinan thal beret, ji Edman tersedia pada masa hadepan NOTE, NOTA: |, Please ensire valid mobile amber & email adress are proved under Part ‘Sia pasta leon Dimbt & alamatemel yang sah dibeikan dalam Behasian 2, Physical policy document wil be delved if the box snot checked (Y) or details are incomplete Dalumen pos fal akan dsanpaikan scram peak tidak ditandakan(\) ata butiran tidak lengkap. 3. You wll be ated via SMS andi email if mal address is provided) once the F-plicy documents delivered electronically o you. 15 days fee lok period stars from the date of hat SMS andor email ‘And akan diberitahu mela’ SMS dart eme! ik lama emel dberikan) apabileE-dolumen pols tela dsampeitan kepada anda secaraeekromit.Tempoh ‘ada porcuma utd 1S hart ermal dari arith SUS dan atau emel terse PART 7: DECLARATION (Please read carefully before signing this proposal form) BAHAGIAN 7: PENGAKUAN (Sila baca dengan telitisebelum borang cadangan ini dtandatangani) Compliance withthe Applicable Requirements by PAMB. ll poticable Re by "Reperiuan Yong Digi Pabal oleh PAM. Thc aici a PAMB ray Oecbbged comp with at is ce and abut dssion choos ove ear obser lh repent or expectations ofthe la eine nn nyc maf ff ais nd rst ofeach pai ude Sn fan other rey athe: (ese epulton bodies ibe" Authors and each an "Author n varios jusictons 2 promulgated and amended fn time ome (the Requirements) Iahis SSenecan, Unc apec tt PAMI nay bic any andl spr snare scomplancso adhere (cst vlna or bese) wih he Appheable Reuenets. SS dn hare Pah wcnghi aan wed mean ca, nega al hry on et dn mk meh rd menghomots meat ao Monch keetaan ex lekendehendan-unian,peretran, pornteh gor pardhan od pine pasar, omalon bak dan permnta ata prseuan dene Orang ‘ram chal porcine dn iat era hal loa aon cr ("Pha rca dan stay“ pa eka) data lat an ‘Seperation ip rma on (ep Yre Di oa) Sogn nt sug bos ao ME ‘monsomba sarang den sel anak unt memasttan pean ata epuhanny sama ada sake ha seblye) dengan Keprhuan Yong Digun Pak Consent by customer for disclosure of information t third parties. ‘Kebenara ole intuk pendedahon mallu hepade pik ketiga. ANC ners het PAM Say disclose my/our particulars or any infomation to any Authority in connection with the Applicable Requirements whether effected diretly or ‘en tngagh any of PAMB'S Head Offices) rather flsted corporations orn such manner as PAMB deems fit /We shall provide PAMB with further information as may Beever dca ay Autry wih sr in ws ray be ened enue, ‘Sova lCant erscnjir baa PMB toteh mendedhkon Putr-butr syarkom’atowsebarang matumat kepada mana-mana Piha Bertuasaherhubung dengan Kepetean Yang Dine Pak sama ada dlaksnakan secora langue ata dihanar mel mana-mana bu peibat PAM anew syiht-svarr berkaian yang lin ata dengan Sra jang PAN angenp waar, Sayaka chan membeika makluml laut kepada PAM setagumana yng dikchendali bagi pendedahan hepa man mana Chak Berknas dalam mast yg munghin dikchendal semejarna rovided to PAMB. ‘Agreement by customer to update changes fo personal 1 any ether informatio ‘Perrujua oeh pelengean una mengemasin utr bu perbad tun sobarang maXlumat lain yng dibeikanhepada PAM. Tre ier apreto copa wth PAM to cable PAM to comply wit ts obligation under all Applicable Regimens conering els o my/our policy with PAMB. ‘Sine jae bervca wnt bekerjascma dengan PAMB bagi mondolckan PAMB memati Kewajipanaya di bawah semua Keperuon Yang Diguna Pata brkenaan ‘dengan say tps dengon PAM {We apres to update PAMB in mel manner of any change of any of he details sre provided o PAMB: Siva lon ern antl momaltunkan seca Borer hpade PAM tpat pada mason mengenalSebarang perubahan kepada mana-mana bution yang telah thorn kepada PAM {@) If am an individual oify PAMB immediately if my penona deniiation number, adres, lephone number, natosliy, tx status or tx reside ‘anges orf ecome te eden! moe Ban one cue. ce i Sia Say seorang nd soa chan seers membertah PANE ka nomborpongenaln peribwd ala nombor telefon. kewarganegoaan, rack ta ck ‘masini sora ever tk aya mena mast chal lebih daripada sebua negara 0) ermnsecemme rans penne ve etn tempat ec Sonate tt a ror fs ae ene AS ps ee ent ieee grates ne Tem ponepeng cham itm pol an pengavel ch da enfsal ong mem a mena hd dard 59% sear ka a iepengen laelan (AES l'on mi pir ws a a pte i es enna rte ss ek nr pict et sea Spee att meee ence : : Se ee eames ed rset a ttn SSeS eee a 1 Ve do not provide PAMB with the information or documents requested in a timely manner o if ny infermation or documents provided are not up-to-date, acura Complcte, Une agree tat nordr to ensure PAMB's ongoing compliance or adherence with the Applicable Requirements “Sitaeeham! idk memberikan meklumet can doamen yong danina hpade PAMB ta pada mass ait ebarang matumat ie dotumen yang diberitan tu adalh Tid tint, toate Tenghap, seams horse Bahan ag! memati Pema ata kepanuhan PAM yung Dererastan kepada Reperduan Yang Diguaa Pala 2) tothe extent permited under applicable lav, PAMB may wild payment of ay amount dc to melus (or oa persona representatives) under my/our policy in (©) Ssikae in he Applicable Requrenons ender hae ay ra hot) ane ae Seta yung ionakan bow nc suns yng agua po, PAN bach menahanbearan anu yang perk day kepade ayant il kam dt ‘Ru ol ava don mont Keperia Yag Dg Pal a tu meray mcr scat ep mama Pl Berks argo) de tag (®) _ PAMB may tae any and all steps as it deems it to ensure is compliance or adherence withthe Applicable Requirements, or otherwise to protect its legal andor ‘Sommer ners PAM Potch mengambil sebarang dan sepa langhah yang ia angeap wajar untuk memasitan pematuhan atau kepatuhannys hepada Keperluan Yang Diguna Paka teupun seblnya metindungihepentingana dss undange-undang dan tau perdeoganganny ass agency 8PV10/2021 — Page/ttutasurarl 5/18Proposal Number PART 7: DECLARATION Nombor Cadungen 705020055 BAHAGIAN 7: PENGAKUAN AA) PRIVACY POLICY / POLISI PRIVASI {We hae read the summary of Pradenial Assurance Malaysia Berhad (*PAMB")'s Privacy Policy below and understand tha this is enya summary of PAMB's Privacy Policy ‘dis ot intended to be taken the fll weston of the same. The fll version of PAMB's Privacy Plicy ison PAMB's corporate weit and will be updated from time to ine. {The ts vest of PAMB's Privacy Policy On ts corporate wets hal take precedence over ty pracy pois peveuly daplayed on corporat website AN uate AME voc Py sate aiid ns cope webte rbysecnlc means ory any ober method if eel the mance app alr consent Ue market developments on ‘Ray pesonal ata inclaing bn sestve personal sta (“Personal Data”) provided in his proposal stl be processed in accordance with PAMB's Privacy Policy displayed on its Steam elah metaca rnghason Poli Pras Prudential Assurance Moles Brkad (-PAMB" di kwh dan memhami haa badly se rinhasen Post ‘Privat PANE dan Dera sta dam sohage vert penuh Versi pena Polls Privat PAM boleh didapa! dl laman web korporat PAME da akan demas drt ‘masa ke semasa. Ver terknt Post Pris PAMB di lana web krporat PANE akan menggantkan sebarong pols pol privas an dipaparkun sebelum ind laman web Korporatm ‘pongemasinan kepoda Pols! Prva PANE eka dimaltumdan d aman web forpratna et mellu pera lkironi, atau mela perm yang fain Ji Lat rasa eadacahadath sesua selapas mempertinbanan perkeninangan pasaran mona rant each. ‘ipa data perbad fermasi paps data pera sang sens (Data Perhad) Sng aiberthan dalam Cadungan akan dproses mengiku Pols Privat PAMB yang ‘downtrka laman web Korps. ‘Summary of Privacy Policy / Ringkasan Polisi Privasi 1. Parpose of Collection /Tujuan Ve PRM (fered toa “ur “we" ores) may se any Personal Dat prove in this proposal and elec by us subsequently fr the flowing purposes: 0 process your {pian () nsw proces nce po, roc and mea cnt and unwinds) prac aa ars) 1 ei Sat ‘Tiny for nsrance. financial or weakh management products and srvices (6) design and provide you wa fue insurance, Financia, elated products and services : (D0 ‘Soman wih you) to Somply wth ny regulon ote legal roqurements; ht vestigate and sce cums and tc and pever fad (wht or ot lating oh policy ‘Stuod in espoct ofthis appicaton () carry ot checks ing agen Including Pua ted wo cet eference agencies and racing companies () wo provide Caster sees. (ho pero aad easing or rofing (0) rr poly review ott ana (mt ew soles on roca nl tial aaa) ‘Sntragan nebo pig nyo as est cr pol Cantar whe uch rr, nl rig yb vid yuo hd pati cary at sync Wor coer wath tr nr gt tng nrg my iho son prov You wi orate ays ‘ur procs which maybe oes yon nd (3) ny oter purposes mentioned our Pray Poly Fan Per ham el enn Peal oy dra a cn do don oh a evar ra beri fa) nt memprsespermofionan anda 0) antak metab dan menproses ols nears, tanta rant dan peuotan,heselamaan da sma pergunderaian: ©) lund memprases ardhonpembavara: (dunt ‘cleo ands wi prodik dan prthidnatan incurs pong ‘ta Kayan: fe) untuk mero ‘enol dan menyehan anda dongon isis, pros danprthidatan Kean dan yan brkaton ase mas depen: (wt dengan anda) nnd mena fern atu ier adam yo a) tsk mera don mryeesaan Buta dan meen dat ence Pein xa cc a ck ea rps cn rh des 1 ed eran oe mean nara hl pee ‘pan red dan rit merge: ed mere lng, wth melts pun atom tn profiling: (antl eluant ‘Aaa parang clog Bar td mela porn dan cals seats) memberan ada, mana au ksienass ea anda eb ‘Petongen a oka pang kot mane facdah mont etna mang er fk Kam na poate () mera as ki are beh ‘ea nan Perkin dengan mpgs tam haga sara nara: pemadna daa) mena sera ho ubvops() meme anda mana merger ent dn ata pre rods oak hg ang magn monark ma and dan) apa atu an scan outa dala Pols Pres kam ‘The Pena Dat wl bs stored tr for a long a5 you (x your joint policed) ar our custo ng if eau by aw oc is aes pees ‘Data Peribadterscut akan disinpan soma ada ak eborapa laa yang and tay pomegang pol brsama anda) adalah pelanggan kama lebih lama ia dipertukan leh undang-tndang ata sebaga selanys per 2. Classes of Third Parties Klas-Kelas Piha Keiga SiS my doce the Panna Dito tt pares (th ouside Maloy fr the purposes tins in Scion 1 inching () our fences usines pars) doce, Insta spciists, spas rinks (eo resentative or eermatari (reser corps an re-skaficonpie,() clas vestigation oman: (0) oeaisations {hat consti cins nd underring iormatio forte surance Indust, aud preesion ganar, ether isrance cmparisor tal oprors (whether det or rough Fru preven organisations or other persons named in thi eton) and datases regis (and heir Gperar) tse by the surance Indust to snayse ad check infomation fecommamiation pelahtnn psn stn emetic peat profesional sta kewangen peso (prt aon fr Eee pelette bape ct rr nd as ogo Apa tae: akan Kore tt ke perks on sae era (ens potas und dan mab) Kump Proce da sep PAM may release Personal Data provided herein to any person or organisation for third party marketing and promotion purpose ‘This pemission may be withdrawn at any time by leting PAM know in writing. PAM dibenarkan membert Data Peribadi yang diber i sini kepada mana mana individu atau organisa bagi tyjuan pemasaran dan romost kepada pak ketiga. Kebonarn int both ditak alk pad bla-ia masa dengan membertahy PAN secara erndls 4. Consequence of filing to provide Personal Data Akiba member Date Perba iinet pct heat yuo ie he Pol Dae 1308 om previ yor Peron we may mt eal prove ‘Wlanlnanyetaken cbt fh fo pemberion Daa Perbad yang dma oleh kami dla wk anda ek membeitn Daa Period ham kam muhin ‘dh dapat mensediakan produ tau perthximetan vane anda lah mins 4. Access and Correction Rights /Alses dan Hak Pembetlan Th addition to ght sted vrhin PAMB Privacy Policy avalible on our corporate website, you have the right 1o request acess o and corection of any Personal Data that you [rove to ws If you want to exercise your right, of you require any der information, you Can cott PAM Customer Service Officer by tekepne af 608-2771 0228 of by Ea at customer com m,n preven PAM fo perdi tons ur esa he ey pres tit youve vente Penal Daa SPAN, yu ay ihn any af pio, wih lus peo Sexi) a (hy ein PAM Rn ‘isonping halk yong dation dalam Post Priv! pong dg oman nes Koporar am ands mapa hak wt moni ie ‘erhadap sb Dat Pera agen erika ep om Jk ond ign melakanchon hak and ayia and momen apa mio lain anda bole est Kt Penn Pca oon 271 (238 “ta alk Csomer maradona comms, Kel meng PANB wk eats pada ar ct don and enberhan Daa Pera kepecks PAM. ana Boch mona alk mana enn Bohai kebenaan i, mae bean ‘etenaan dogin Skye) dan (7, dengan meer PAM neva ort. ‘. Acting on someone else's behal/Bertindak Bag! ‘When you peur Peron Data about another ponents ou Se atc wah pr) hs) nora ich erat) al og ‘Fos nd bead Rc so ue) pla es ocr hy oy © eh ea understands, “Irae mento hr Dats Pert nd an ana tela dirt asa fc indivi rach unt etna pha (8) memalumba individ rebut ‘ahr emda memberkan Dota Perbacaya kepada aml dan anda lah mendapat persctyannya nt beruat seem: dan) menlask Post Priv amt ‘pada dvi erst dan nd rebut memchart, bere dan member sea eps PAMB tad monproses Dans Perbadina erdasarkan Pols Priva ka 158 Agency RPN10/2021 — Pageistutaswarl 6/18Proposal Number PART 7: DECLARATION Nomibor Cadangan 705020055 BAHAGIAN 7: PENGAKUAN 18) GENERAL DECLARATION / PENGAKUAN UMUM [iWe declare vat the tnformtion given inthe propesal form and any information Uwe have given to PAMB or PAMB's medical examiner iste, fll and compete and we have gt withheld ay ‘Siya'Kam! mongat bakawa matumat vamg diberi dalam Borang cadangan dan sebarang malumat lain yang saya/hami toh member kepada PAMB atou kepada ‘pemeriksa perubsian PAMB adalah benar, penuh dan lenghap dan sava/kami tidak menvembunyikansebarang maklumat penting. We nesta tha th ase wil bein ules anu PAM hve given mes writen approal anise he lean policy whist Vw amare alive arin ‘Siya/Kami memohani bohewa insurans tidak akan bermula melainkan dan schingga PAMB telah memberikon soya! klulusan secara bers dan mengeluarkan polis ‘yang borkatansemasa sayavkam masik dup dan dalam Keadaan kesthaien Vang bat ‘MyOur application i no inked to any statement made bythe PAMB!'s agent (name below). We have given no cher information (except as writen in his aplication and as {irae Uwe know PAMB's agent has given no other information, relating w ay crmsances which my affext PAMB's decision to provide cover. PAMB's agent has ily xpi all he ems o mers andthe answers we have iven we cand secure emo sat at eon deg shah edt hen PAN oy dopa Bowe, Svan a mene sear ua ai seer van res daa prmohonai pergola jon member sbararg maint an berkaion dengan sbarang leaden eet rp net ct eputec PE nad ender force Een PUD la mets pene oma rma eps pean da wpa ik {ine Peron ala na dan pa {fine yl PAM st ry cg in myth f muro wire rt hi be asad which pens ars his {propos form or wich may happen before PARI ase the eleva poly In hse Crcumszances, PAM ray ees yOu Proponl agai ‘Sow Kami monpueltnggungoob unk merbertah PAMB mongena sebarang prabahan pada kesiaion sara ay ksiatan swam ato er ata bapa ca ana “nutans yg an caro yong bela seeps sya komt mnandatagan orang cadangan in ata sebum PAMB mengelarkan po yang erkaian. Daa keadan In. PAM boleh mena semua cadangan savakami” Wehvethe dt to give PAMB my/our’ (he chido be assured personal informatio within tee mend fm the te otc if Vi wat prenatal cover inthis application Sa Kani meng uu momen makumatpertad anak sae ana yok csr) hepa PMB daa masa tg dan dari crt ahi ‘ia saya mahaan paral dalam permohonan ‘We agree to pay the meal fcif Ve ll wakeup PAMBs writen acceptance of my/our propos Sapam Boron unk member vara pores ka aya ham goal poerimaan erdizan PAMB hag cada seen FU pay myour rei in cash, by cheque ob bank rane toorthraugh anyone her han detly to PAM, wile st mylaur own isk PAM wil nt ave any esponsibility ifmyleur premiums lat r does not each PAM. Stun mfr premian ava a ay daa bh at rea eta lat dara PMB lara isho sya ser: PAM ‘dak mempuna sebarang onggunghsd i proton soe am agate dah seme cpa Ps 1rWe have roquested for, studied, and understond the product discloure shoet, brochures any), sle/podc illustrations ny) and other marketing material any). UWe thavs paid particular attention to those benefits which ae guaranteed and those Bonefs which are not guaranteed and myiour tesa. policy owner under the policy ont, fd these ater have Been adequately explained to meus by PAMB's agent ‘SayuKamt telah memine, mengkaj dan memahant lampiran keterangan produ risalak-risalah(jita ad). thiras jualan/prodhkia ada) dan keterangan pemasaran ‘ik ada). SayaKur telak members perhrian Uhuus terhadap manfaat tejamin dan manfat fda terjamin dan rages soyakami sebagai pemilik pols dalam kontrok (polis dn perlara'perkaa in telah djelastan dengan momuaskan oleh ej PAMB hepade saat (6) EXTENSION OF COVERAGE TERM /PELAN/UTAN TEMPOH PERLINDUNGAN PRUWith You [), PRUWean Pas (0: ‘songs the Bnei are lin fron te expiry tf the pti ised puma 1 be 7), Le have bes made evarethat PAMB lexi ech ‘sot Of te nets ds based on Polly sateen so i Liebe sels as Ro vo tay ofc re maximum coverage GF SPplcabo, whichever wear nse change the appicabity of exes of covergs em tr he pol) set Wi he ove, Uwe asad ta: TTPAME wilentimct tke unis om he poly accurts ery month ring te exe coverge em o pay forthe relevant chars, es an tn ui te evant tenets arcmin ar 2 Weinsy be eque by PAMB pay atonal premium so that the policy ascent cas value ove fr the reevat chage, fs and anes ‘Selo manfatmanfast mash berths pada tr mat lis vn diklarkan brat dengancadangon (pol) xayaha telah dihaman Sh fi ‘ma mph iC nit lit ir em 10 ur pada har ad kan tan ton tompoh prndurgon mama Perkonaan) yang mana eb owal melanan say! meng eer tak ‘pela tompon perimdongonselepas pol ieluarkan. Dengan saa oka bart TT PAM oleh tres morgen dar akaun pos sep bulan sepanjang tengo perindagan yang dlanudanunek membeya cj fi dan cd yang herkenaan Shing manus man erenaon domatan dan ERR psn os PA a momar romion aha! memaion pls men language af don eng berkenan NoTE/ Nore: ‘Your aise ily undead the mporance andthe npc of xteson of coverage ems desribed input dorset brochures (any se! “fue dathrar a nomen Lepore conte plgeon enph perndngn spencer ang Argh dam kami ktrga rah, spor ang itera pr ‘Mulia a), ran uae eterangon ponaron ke a da kota elit 138 Agency RPN 10/2021 — Page Mutasurael 7/18ae PART 7: DECLARATION JoeseeCadangen 705020055 BAHAGIAN 7: PENGAKUAN I ois rca upeeytaemnaegtbciope ra emeat eee or eae ie eo ee {fairies et i oni Ree a cee a = a I aerate deee a val pbb ie Pb mg aren hoa Sega once AMD yak malformation fon any dct, mail pci pil rch any ect okowele of yc rth sf an gas ny [ements wi wea Ay ce anos ae mal ng yg Ibarjne who nese any of year yale. ‘PAM morn mmo dreds man-made hpi tli sg mony crane ca esthetnspkam ‘eau ere ear eee en hc fens ah ae ng rat Ot os te oe a naa aed sla lan regi steading ec ep shia an mal mcrae hal sya aging ‘We uns nage hanes eget of docu ion ria by nw x PAM’ inert pc, PANE wil only ein ria piel oe td 2 Se eee ere Pant al bl Ur aprt Sch samen Tee le wa tl acl ae Fea ts econo cng po or Fm ph pon pan do on eh PAN hy om ae eenrel x ‘Soe No de flan dee PAN adeno ca rth PS meine cam oe PM la pba aie Oth tranny dane cl rf eek pos mewhonkpas PAM el nak porn on ae PMB co mad? {Wein wage tint oa tt esl ay fi ests een Engh aha Wyse ft ropa em an ie eof fteeceinand consao th Eng nguge vor of rye or sl preva ante even cf ‘Soh mr or hegre ey tr aetna wr alas ges Bar Maks rang cada dan ‘Ri aun an ca poten von Boks gers raged la daa dan dns. Ha, - Signature of Life A Soman of Li BG itt fem Lik 1 be Signe of Lie C (Note: This box isnt applicable for jovenile Spouse Payor S Tindasongan Cooeeel Soe anion (vale emacs "™atmemn Heer Tandetangan Hayat A ropes) Tandatngan Paya! B scram eran {ota: Rang in bun untuk insurans jana} apads Hoyat sang akan DiinsuransanPasargan (ttimya ritr Spe Payor Basie carla)? ou ‘apo PeigaSoh karan saranda) Nore /NorA: Tt you de nt rcv the policy document within 30 days after sending us the proposal and al sporting documents please contact the Customer Services tine. ‘Tvanda tak mene dokumen pols dalam janghamasa 3 hari selepas menghantarcadangan dan dokamen-dokumen sokongon kepada komt, sla hubung lion Peritimaton Palanan PART8: AGENT'S DECLARATION / BAHAGIAN 8: PENGAKUAN BJEN ‘dele thatthe information inthe proposal frm isthe only information given to me relating othe person(s) spoying for assurance and Ihave not witb any other {sfomaton whch migt influence PAM acceptance of is proposal eee a “/- declare tat thaye sighted he rginal NRICbith cortfiatepassprt corporat documents such acerca of ncrpration, Fons 24& 49 (othe equivalent documents), tnd weried the ent of the above personwcorporats enti. 1 Tt etait oot cme ham leptin te ming aia) person spying for ssurance. Saya menga awa meklumat dalam brung cada in adalah satesaturys maklumat yang dibeikon hepa ay mengena pibakt phat) ya memohon nsurans SoSipe ac trent scharane meena a yong mengtn har Fist dalom pmertnecn codegontat. Saya mengal hahawa soe telah melt salinan asa had pengenaansjil elahironpasrtdkumenkorporat seperti penubuhan, Borang 24 & 49 atau dlumen Tain yong snare) srt mengeahan det orngventtkopora das. . Sya mong bare saa lah member dan menlelaskn dengan memuaskan lamprankteangun prod risalaisalaika oa), trast ualanfproduia ad) dan eorngn peasants ad hepa di aig momo ara ‘Signature of Aget/Tandtongon Een fab TTT PR ae a eee ee oe cena are ere ner ipa a ee ee ea a ee a a asin Sepz gan inh rmengezaht esc cnet mengerattnn botena persed enscnal ong dba dan dlsytharkn eck Pencadangpade Doran codongan oe eee Witness Name / Nama Saks [NRICIPassport No. / No. Kad Pengenalan/Pasport Aadiess Alama ‘Note: The Witness must be atleast 18 years of age and cannot be a named nominee or trustee ‘Now: Seksi mestla berumar 18 tahun ke atas dan bukan penama eau pemegang amanch pang telah dant iss Agency RPV1O/2021 — PageiMutawatl 8/18 Prudential Assurance Malaysia Berhad 198301012262 (107655-U) Level 20, Menara Paden, Prsiaran TRX Barat, $5188 Tun Razak Exchange, Kuala Lumpur, Malaysia. PO. Box 10025, 0700 Kuala Lumpur. CCastomer Service Hotline: 603-2771 0228 E-mail customer myst@pradental.com.myCREDIT/DEBIT CARD ENROLMENT FORM. BORANG PENDAFTARAN KAD KREDIT/DEBIT (pant cna oer como enya UT BUT Karo Cartholdr's Name (as shown om NRC) NADIA Bits dussin ena Saeanomae Ne 3i,Saten Watan 23, Taman $xi Water, Aengang Selangor p= {£000 SAE Malaysia Steeda Ne dl, Tatan Watan 23, Taman Sr Watan Mepang, Selangor = bgov0 SET Malays recone Pfs [ola [ef] os] cls [910] (oo cnmcrmmnrcnmournreuastrvennoe cuits TH (6a Isle Saacnepeaaiontiudipgeesagisiaaiaieies ee Malaysia seri dyat44@ gmail. com ron Gust Cole Execatiog MUTT Insurance ame of Employer/Business Radeltal Assurance Malaya Berhod: ote to. ony No. egraton OUST, Malay st Savoeaoes 5 [4 [6/0] - [1 |S |6]o} - (3 [6]2 |¢]- [4 |e | 4lé cord te om] BT ing an May pan aa 7) teteat [ IMPORTANT NOTES /NOTA-NOTA PENT: ‘ree ric nea ed ac & Marcador 2 acne tian at not yrs pret inh or Cr er ants oe Ae ‘ae mere Kd Orb rg sero ko rn gio ho en nwt hme meyonto eekramc eog ie wpa 4 eave retero your ret car/San Statement for evidence ofpayments ‘oun enyate Ko Keon endo untatbat perbayoran Prt rnc rad 80101222 (ES . FORM 1D 10802001 / 10801003] evi 20, wears rea ersaran TH Bort SSIS Tun ax xchange, Kal ur. 0.x 10025, S700 Kas amp ————— ‘arc ee 3770s nal casonempepeecormy Page score‘PART 2: AUTHORIZATION FOR CARD OEDUCTION/ 7A 2. ARAVA PENOTONGANY MELALUI FAD Thereby authorize the bank appointed by PAM to de my card account forthe ital premium or he proposal ors Ted below ad for he subsequent premium tobe pid? {the poly/polces tobe sues pursuant to the proposal ori, naar subsequent premium tobe pad under the polyps Usted below ‘SRePemisrenie Su eeens syne Poko oeed srs oak of erercaee of Poly convertion open saezacon of trms and conins, oo any the reason prow Under he eortermentoned poy pices ca z z 3 a 5 mioneemr | tosor00ss Name (Proposar/Recwed Nada Hassan ‘raseot Aner lta Carthaer pose Wk) appropri [sagan Pecan Pernpony pa argos Pepa ad il ado] maa org Seno] ‘pone ‘rend Family Js ‘Stepat tegmeter Ueda ees Gunn an Botha cee i Dojojo}O) jojgjojojo|y gojo|jo|0) jogojojo|o) ooo oO] joo ojojojo0 dogg) joojqqoaja goog) jojojoo0jja IMPORTANT NOTE/ ROTA PENT: ‘fan amy ced te reno fr having the shove Crt ole the payer forth uae apt o ple wi ea belo, whichever appa / ‘eee ton oh rab tat monn omen ft ibpe pnb a pms an psn bh ee why mane res 1. The Crd elder woupporing forthe ured at oy ng expenses, cing nuance premio. / ‘The nce ons otha my Credh/De Cad ‘Thence snorincone ee. ‘he fanced botresingin Mls / love ana atecton ‘PART 3: PREMIUM PAYMENT INSTRUCTIONS///c1ii1 2 ANAMAIN PEW/BA ARAN PREWIUI [omaha or ebro cin po SD oO ‘hari prmioms due, Automatic Premium Lan, tcest fan] an he subeequent premiums due fo he above poy/polces tomy Cect/Dei Caras stated above. oe ‘earn pemiamand he teagan emis forthe above paey/pkest my GeV Debt ads ated above. ‘anon prenuria rAiorai:resan aan t tacheda he bone pokes wilco ocr eres ul alle usar sure fly eps PART 4: CARDHOLDERS SIGNATURE/ A /A0IA1N& JANDATANGAN PENUNYA AD Tava understood and peed to he contents fh fo, nding the Osta PrinacyDedarton at page of Wis form Taree and understand tat PAM wll at on my instructions a ‘ths form and PAM sot obliged to very my relatorship with he proposer andr assured and/or fe ssured ofthe proposal forms and posted inthis frm. he Cote Hi - ser/bntna gress tane 4 S= _ ‘Barstor o~ _Agent/Bank/PAMB Representative's Contact No. one? alae a edna Asan Mopar 00126107685) FORMID 10801001 / 10801003 | tew!21 Mera made. rrren tie ar Ras ato, ovr Bot 10, STC Rusa Ln “Customer Serace Hote: 632774 O22, mat castomer mys@prudetal omy hoes‘PART 5: DATA PRIVACY DECLARATION /s//s0A0) 5 P=NGANUAN DATA PERIBADI 1. undestand that not obligatory for met give the personal data being requested here but do not, Prudent azurance Mays Bored (PAMG} wl not be able ‘Perorm tr obigason to mea int be blo ary aut he the purposes below ‘Understand, agree and autberze PAME (and any Od party append by PAM on | 2 PANG’ behalf to collec hoe, use, delete, sctne, aster nd process many other ‘ro al my persona datalgven now or tat is ubeaqy obtain by PAMB ry ime {ovine forthe purpoteso paymenjcoecton a premiums aa the seve leant > ‘he proce of prem poymet/coletion, or caring out any ati loon f0 OF Inconnection withering out PAM dates as annsure. Toachleve tes purposes, PAMB may anser ae shar hy personal att nds Cr oransatons win PAN rou of compares eter thd partes sucha: banks Shatter third pany sere rowders PANG hs appointed [tat prove semstatie, ‘ciecommunieator, payment, ata processing ata storage or ther Serve o PAM Inconnertin at he purposes above) As some ofthese ir pares re not located Maloyse, PAM may Warster my personal data places outsce of Malay. "nae the righ tose the personal information AME hols about me, and to have t Corrie fs wrong wil contac PMB Cstome Sere Hote st 603-20260228 renal customer mysBpruaertia.com my | wan 0 60 this or have any ether queries or complaints in respect of my personal data, Unesspreverts PANE Irom Berorming ts oblgatone to ma oreo agsinc he very purpore that Rave ven the Berra ct Pa can wr apart otis pemissen Dy EINE PAB INO ‘PART 6: TERMS AND CONDITIONS/i//AGiAIv 6 TENA TERIVA DAN SYARATSYARAT [The premium amount wit be avtematialy debited to the Cardholde’s ato known = the poucntredt/Onbt Card Account pon the tantacion eng sucessuly Droceed by the relevant Panda imsttiton wih which the Applicant hols 2 Creai/Debit Cardaceount. 2 The Appican’ssuthorzation herein to deduct premium payments fom Cred Debit Grasso be dese a autho fo PAM to charge te Cath chau ate Santer rere dees pat PANE Te oot rome tec For new propor! payer, premium deduction wit canmence upon rect of the propos form and Grede/bebe Card tnoimant Ferm Shou ths smount be noua, ‘hetppizar hereby theres PAM to deduct the balance of remum reaured unde ‘he proposal All paynets wil ve held unde the proposal url the poy commences thd oteterent sat be payee PAM is under ne obligation to honour any Crede/Debt Card debt irstrction uns there ie suficlet avatabie inst inthe Credit/Debit Card Account 3 the Une the Uansation performed. The Apantshallacep fl responsbity for althe transactions arin rm the ue of {hs Cret/Deti cara pursuant ets form, The instruction wil remain eective fr the protection of PAMB notwithstanding death {nd incapoey onthe part ofthe Aplant ess PAM inated ocease rhe Geb Inthe event that he Applian shes tater the CediVDebl Card deat or anal hs Suthercston pense be advised that PAM wil ony approve and pve effect to the ‘eration or cancelation wv fourteen (14) doy rom the date PRUE receives the ‘amples prescribed frm, Pease be aovied ns that PAM unaie to accede fo ary ‘thor request hats ot provided ths erm “Te Appeat murtinform PAM in wring of changes tothe Cred /Debit Card Account| ‘umbers, ndasing ew aecourt numbers issued under “lost car” or “converse {temination or cancelation of red/Debit Card Accounts nd chargeserterewalofespry ‘The Applicant agrees that PAMB shall be ened to impose chrges as deemed {oncepite for providing the saree pursuant tS Torm with por notice tothe ‘opteane AME reserves the right to change the Terms and Contons ané determine the ‘srangemertsorthe service ronidesereunder 3 dere, PANE shal ot be response or lable for any cam, los, domage, cst and expenses ‘soa fom the unaiccosstal proceang ofthe charging af emia amounts oF ‘emtance for any reason whatsoever, ncuing but hte mafuncton of stm, ‘ecto ature, naceute or insucent noration beg supe bythe Appa Paws may withdraw from proving the service mentioned hereunder a any tie ‘thot plot tice and without ssgring ary reason snd PAMB ha ot be eld able ‘oranylereor damage uhichmaybesuMeredby he Appicat a esto Such aon Dy Ad's authored t refund any monies debited earieypursuat to ths form tothe Dooleant by creing the sum Ino the Ceat/Debt Card Account and PAM. sho ‘orester be fl acharged rom al blgatons pertain to the same. Shows ay ‘Sepa or sue are regacing ay payment or refund of mani bla pursuant hs {erm the propose andlor he essured andthe Applicant sal fer ony tocachather fr ‘eed ndesohton Pease not ht al cpr of he premiums, charges and payments forthe ropes forms) ‘rd poey/pocer ertinedin eh frmmaybe subject oars a he apple realing teh shal be payed ye poy ower Inthe event ha there shall be any confit or aonssences Between the Engh and {anata Malaysaversons the wordngin ths forma forthe purpose! terretation Snd-constrton the ingich language werson shal prev and be gen fleet hs. FORM 1D 19801001 / 10801003 Prk ric tp Std 909101282 0S.) e208. Mera Prete te SS To fata xorg ha up. 800 70 ump Version 05/2 ea Page osoAPPLICATION FOR DIRECT CREDIT PERMOHONAN UNTUK KREDIT TERUS PRUDENTIAL Instruction: To be completed in DARK BLACK ink only and tick the boxes as appropriate. ‘Arahan: Sila isi dengan menggunckon dakwat HITAM GELAP sahoja dan tandakan dalam petak yang berkenoon, Proposal/Pley Number/ Nobo Codonga/Pol il Fose 100s 2 3 ‘ 5 « ‘ppleton Data Tri Permohoran Proposer/assreds ame Nome Percasona/ W141 2022 [Madin Gist tussin ee cE -Agent/nkPrtenal Assrance Maya genta rade Asrince Maa ‘aen/BankPdetl surance alas Dec Reet if) tere eps ae Ahad Rents ether 04 02984 Nadim Bion tssin DLASHI3 407 important Neter/ Note Peting a. this appicaton for Direc Credit Facity (‘epplication”) only alowed for a valid bank account wth a licensed financial institution in Malaysia that partcates in the Interbank GRO [i payment system ("czoune}) Perohonan wnat mn Kredit Terus (‘permononan”) in) la. adem Assurance Maayua Serad ("PAM") may approve this applcaton to grant the Dict Credt Facty (Fait) le Ws. siotte Sisto, The Payee wil be informed in wing, PAMB approves ths. sppation Berhad” (PAM) be an ths form, “Payee” is reterring to te proposer/assured/plicy owner of the Proposals and Policies, or the person Pursuant inthe Proposal and Poey/ Down boron in. Penrino” edouh mek teode pencodor/Pemesong Pon le. Please compte the Direct Cred section for arrangement for al the payouts from the polices sted inthis frm to be credited to the payee’ selected ben account. PAM. wil pay al these payouts Into the payee’s bank account that is registered with us. Otherwise, PAM may consider relying on Algal service or produc, such as DuitNow to pay these payouts to the payee, only it such service oF product is made avaiable. if PAMB isnot able to bay the monies tothe payee within Yeo from the date the monies frst become payable, the monies wil be regarded 25 uncaimed monies. Hf 50 AMG is vequted to lodge the unclimed monies with labatan Akauntan Negara Malaysia/ 0 lenghonion povanion ext ‘PART 1: BANK ACCOUNT DETAILS (as appeared in the bank passbook or statement) BAHAGIAN 1: BUTIRAN AKAUN BANK (seperti yang tetera di dalom buku akaun bank atau penyata bank) Bank Name? ome Bonk Maybank opteantsname/vonoesvon | Nadia bint Hussia ‘Account Type rs Aton 1SY2120 SOSH | “Teri where aporopitey ‘Account Nod No ou [1 Conventional/Korvensiono! ) nade kotok yang io PassporyPokce/Army/Compary No. eMC No(O/ {SOU -OF -649) eswation Noo oseon Hs PART 2: STATEMENT OF DECLARATION / 2H/AGIAN 2: ENYATAAW PENGAKUAN in crieratin of PAMB approving tl apletn, Wwe, who amare ao the Poye, herby ae apd dade Wet) loyal ecsay Teas sat ny ar ret he vet mans pale ptr he Paps and Poy Wane $i the Account PANE chen membay 2. PANE shal continue to pay/eredit the Monies into the Account unt and uness PAM receves a written irstruction from the Payee to revoke the authority {vento PAMB pursuant to this applation or PAN approves «new appiation to change the Account detas proved inthis appliation, at least one (1) Iman toe tenet payne sate 0! or ees ebay rere darn won oh Me rend ure doe baad 7S) FORM ID 10801027 | ‘ee!20.uenrs rrr xa 58 en Rak ictangs Kal Lau Mei 0. ot 2S, TION Lares 4209 tne Serves etn 43236028 Ek same iO tn my pormeners2. PAMB shall not beheld Kable for any lozss that we may suffer or have suffered, whether directly or indirect if for any reason PAMB is unable or delayed to ay and credit the Monies into the Account through no felt of PAM, including But ot Iited to, the payment being rejected by the Financia insittion (Shere Asan deta 0 onus jin soya tonggung ot te set tet in AMD fl he Mares Whe lyme er ee ame re led to recees/ 50)2/Kom 5. PAMB is hep harmless and fully indemnified against any and all actions, dims, procedings, costs (incling legal costs on solictor and chent basis) nd damage, including any compensation paid by PAM to settle such claim, that may howsoever aris fom or be incidental to my/our instruction pursuant {otis applation. The autoreaon and indemnity contained. in tht appesten shall be bidng upon my/our respective successor te fseeuten,sdmiseatr, personal representatives and/or Res: and #8¥ inno kon 0 ee understand and sree oe flow Ost Privacy Deano Sye/Komifoham den best hepadePengkuan Det Perbdi ber la) Any persona! data collected or held by PAM (whether given now ot subsequent to PAM) canbe processed and used to proces this application, for data ‘duties at an insurer, updating PAMB's records, marketing and promotion of other financial matching, fraud detection an preduets and services by PA (Purposes"bfSetcran 2 revention, discharging PAME lb) Yo achieve these Purposes, PAM (and any thd party appointed by PAMB) can transfer and dscose the personal data to third partes such as financial institutions, reinsurers, claims investigator companies, other Insurers, industry associations, PAMB's intermediaries, individuals o entities within, PAM, rou of companies of PAM and Prager ps, x well as other thr ity save providers PAM has appointed. Some ofthese hr partes re no lect n Maly, PAM ca artr te pariona tat lacs oui of Maly Jc) we understand that Uwe have 2 right to get acess and request for corection of any perianal data held by PAMB. Such requests can be made st PAMG': Customer Serve Centre ane Soy/Komfonam bahowe sayarkam! mempunyct hak untuk okses dan me abut Keates mon “Ts Data Privacy Declaration canbe revised rom time to tie, of wich the notice of any sich reson can te enon PAN’ scoroorate webs o by sch ‘ther means of communication Gaemed sutale by PAMB) Pengorian oto Perbod! in boleh duboh dort semasa ke no 7. We understand and age that untess a longer period of document retentions equ by aw or PAM Internal poe, PAM wil only tain the original Physical documents submitted to PAMB for 6 months from the date PAMB received that document. PAM shal not be held able for disposal of such fdocuments, Therefore, i we want the orginal physical document to be returned, I/we wil have to submit the request to PAM inthe form PAMB decides teithin 3 months fom the date PAM frst received that document so/2/Kom nemichar dan bevsetulu Bahawa melainkan undonpurdong atou pols is Nat: In the event of any anbiguty between the Ergsh and Base Meloy version, the Engh version shat Sieur of epcet ondtangon Pema nen WADIA Wye HSS Mare Nae ot tas oreo taper: FSOA IY OF EAA PART 3: STATEMENT OF WITNESS / 81/AGIAN 3: KENVATAAN SAKSI T hereby certify the above sigature(s) was/were made in my presence 52y0 dengan in) mengesahton bohawa tandora a ats buat ai Note: The witness must beat least 18 years of age and cannot be a named contingent assured/named nominee/trustee. Not: Sots! meson berumur 18 tahun ke ates dan bukan PenvixKontingen/Penama/Pemegang Amana yang fl Signature of Witness) Torcotongan Saks! ‘Witnese's Name/ Novn2 So INRc/Passport Noy No. Ko rode surance Mate Beas 78) FORM ID 10801027 | tn=!22.mewrs rds Pere Txt S84 Tin cng Langu Mage P.O Soc 70 umpteen 0 tune Sr tine 63 116028, Gna coon mpneiion.my Pel ses a