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IMPORTANI: STATEMENT PURSUANT TO SEfiION 150 (1) 0F rHE INSIIRANcE ACT 1995 / MUSTAHAKT KENYATAAN MEhIGIKUT SEKSYEil lso (1) AKTA INSURANS 1996
this proposal form, fully and faithfulty all the facts which you know or ought to know, otherwise the poticy issued hereunder maybe invatidated. /
You are to disctose in
Anda iidalah diminta memberi maklumatsecara penuh dan jujur segala butir-butiryanganda tahu di atas borangcadangan ini, jika tidak polisi yangdikeluarkan menurut
cadangan ini boteh menjadi tidak sah.

The liability ofthe Company does notcommence until acceptanceofthe proposal has been intimated by the Cornpany or official cover noteissued / Tanggungan Syarikat
tidak akan bermuta sehingga pihak Syarikat mengesahkan penerirnaan cadangan atau fiota tindungan rasmi dikeluarkan

Name of Proposer/Employer /
Nama Pencadang/Maiikan: -

Home Address /
Alamat Rumah:

Occupation / Nationatity /
Pekeriaan: Warganegara:

NRICiPassport No. / Home Tet. No. /

l(P/No. Pasport: No. Te[ Rumah:

Name of Maid /
Nama Pembantu Rumah:

NRtC/Passport No. / Nationality / D.o.B. /

l(P/No. Pasport: Warganegara: Tarikh Lahir;

Next-of-Kio/Dependant / Retationship /
Waris Terdekat: Hubungan:

FutI Address Next.of-l(in/Dependant /

Alamat penuh waiis terdekat:
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Accidenta[.Deat.h/Permanent Disablement
1
Kematian l(emalangan/Ketidakupayaan Kekal
/
RM10,000 RM15,000 RM20,000 . RM30,000

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. l::'l MgdlcaJ, fxpinses'(Aue to accidbnt): l::' ;
Pef-b.qlqhig?nrP€f (akibat ke-aiarya
11baian ll)

Hospital and Surgical Expenses (due to accident) /

3 Up to / Sehingga
Perbelaniaan Pembedahan dan Hospital (Akibat l(emalangan) Up to / Sehingga Llp to / Sehingga llp to / Sehin6ga
RM2,000 RM2,500 RM3,000 RM3,500
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iin
I
Repatriation Benefit / lJp to / Sehingga Up to Sehingga
Manfaat Penghantaran pulang / Up to / Sehingga Up to
/ Sehingga
RM3.500 RM3,500 RM3,500 RM3,500

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Termination Expenses Benefit /
7
Pampasan Akibat Pcmbcrhentian I(eria RM25O RM25O RM25O RM25O
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Period of lnsurance / Tempoh Insurans
12 Months / Bulan fl nrraeo I nmzo flnuao fl nuss
Period of Insurance / Tempoh Insurans
24 Months / Bulan fl RMB5
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end of the month, coverage will commence on fhp.1sr hfrho I^t]au,i.-

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information likely
likety to
lo attecr lhe aftced.nrporihis
alled rhe accedanm ofthi( nro6^(rt.nd L6,.^ ]h., rrr. he^-^.^{ --r r-^
propomtma rig,ee
basis of Iho (onirad between the tomparry and myielFand
;ffi
ih;ihi;;;-fi;iil;;.ili"#:il:iii,:iil:
termr, Rl6im, w,*anti* and.onditions ro bc upresed rherern
I furiher agr"" t, i-.ifiiii"
cr.puny policy subject ro
thc requlnd p.emium / sava mengesahkan dan berikrr
endoi"a ,r,*^nli"nu.rr"irrr.l"" #
rr"'t" p"i
dr,""" ,"iirr"i-y""t-aiu*, *,rrr.r, beflar dafl bctd
leseluruhannya,<lan uya tidak nrcnycmbunyikan apu"po t"tn*n6ony""g-ru;ffiit"n.u.p"rg"rrf,i
penerinaan
ini dan
sEya berseluju bahawa cadanEdn uan peigisytih'aran-ini
irrin nen;oar asls konrrnk di
'adangan
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dan saya;.dan saya setcruinya berietuiu i,"r*tr.
foriii-iuri pihak Syar.kat rerr.klul
wrantidan sytsrdr-syarar yangdinyatatan dln dientlorsdidalaornyaatou
I",3""-li lirl-.-'TTItrn.
,u8a olemoayar prenttunt yarB diD6lukan
Ot""eiiL.,i,i* Signature of Proposer/Emp(oyer / Date / Tarikh
landalanBan Pencadang/Maiikan
Note / Nota:

For office use only / Untuk l<egunaan peiabat sahaia:

Staff ID No. f No. ID peker,a: