CONFIRMATION AND AGREEMENT BY PERSON TO BE COVERED/

PROPOSER OF ELECTRONICALLY SUBMITTED PROPOSAL

[to be attached and form part of the Proposal for Family Takaful together with all other forms/qualifications that have been submitted to the
Takaful Operator electronically in applying for a takaful certificate]
NBZ-FCOEF-V07-072013-TAKAFUL
Head Office: Menara Great Eastern 303 Jalan Ampang 50450 Kuala Lumpur Telephone: (603) 4259 8338
Fax: (603) 4259 8808 Customer Service Careline: 1 300 13 8338 E-mail: i-greatcare@i-great.com.my Website: www.i-great.com
Great Eastern Takaful Sdn. Bhd. (916257-H)
Page 1 of 2
Certificate No. Proposal No.
AGENT'S DECLARATION
I hereby declare that I have sighted the original NRIC/Passport/Birth Certificate of the Person to be Covered and the Proposer and verified the
identity(ies) of the Person to be Covered and the Proposer through the use of such NRIC/Passport/Birth Certificate. In case of the Proposer
being a corporate customer (including company and business), I have sighted the original/verified true copy of its certificate of
incorporation/registration, identification document of its directors/shareholders/partners and of person authorised to represent the corporate
customer, and verified their identities through the use of such documents.
I further declare that I have adhered to the requirements of the Proper Financial Advice Checklist and have disclosed all required information
and advice to the Proposer. I have also explained and given the Proposer the full set of Takaful Operator's approved Benefit Illustration and
Product Disclosure Sheet relevant to the proposed products. I hereby confirm that I had clicked on the agent's confirmation box in the
electronic "Confirmation Note From the Soliciting Agent". By so doing I understand that I had confirmed that the party/parties to the proposed
certificate had/have fully understood the contents of the E-Form(s) together with the statements made and answers given by him/them to the
questions therein and that he/they had duly indicated his/their agreement to submit the duly completed E-Forms to the Takaful Operator for
processing.
I agree to preserve the confidentiality of information disclosed to me in the Prospective Certificate Owner Fact Find Form by the Prospective
Certificate Owner and not to release such information to third parties, and to restrict the use of such information only for the purpose of
recommending Family Takaful products.
The analysis/advice in Prospective Certificate Owner Fact Find Form is based on the facts furnished in the Form and other relevant facts
which are made available to me. I have taken reasonable steps to ensure that the advice is suitable for the Prospective Certificate Owner,
having regard to the facts disclosed in this Form. I have also explained to the Prospective Certificate Owner about the features of the product
recommended and have given sufficient information to enable the Prospective Certificate Owner to make an informed decision.
I hereby certify and witness the following signature(s) was/were made in my presence and that to my own personal knowledge it is the
signature(s) of the Person to be Covered/Proposer/Credit Card Holder.
LEADER'S VALIDATION (only applicable for year 1 agent/Financial Advisor)

Based on the information provided by the Prospective Certificate Owner, I agree with the recommendation/product advice given.
CREDIT CARD HOLDER'S DECLARATION
I have read and fully understand the information and authorization contained in the electronic Easi Pay Service Form. I agree that the
authorization is governed by the Terms & Conditions specified in the electronic Easi Pay Service Form. In addition, I must inform Great
Eastern Takaful Sdn. Bhd. in writing of the cancellation of the authorization at least thirty (30) days before the next contribution due date. The
authorization shall remain binding upon me until Great Eastern Takaful Sdn. Bhd.'s receipt of my written notification to cancel the
authorization.
0793554036 0793554036 0793554036 0793554036
NBZ-FCOEF-V07-072013-TAKAFUL
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* For applications of the Agent's own takaful or his immediate family members, the Agent's immediate Officer or GM or the Takaful Operator's Executive or Head
of Business Development/Administration Manager/Head should countersign,verify and confirm the information to be correct at Signature of Leader.
Month Year
/ /
Day
Date
Certificate No. Proposal No.
I/We confirm and agree that I/we had made all the statements and given all the answers in the electronic proposal for family takaful and any
other accompanying electronic and/or hard copy form(s) or questionnaires submitted and that they are true and authentic as transmitted to the
Takaful Operator; and their contents therein shall form the basis of the Takaful Contract between myself/ourselves and the Takaful Operator.
I/We understand that the Takaful Operator, believing them to be such, will rely and act on them as the basis of the takaful. The Takaful
Operator may void the certificate (if issued) if there is any non-disclosure, misrepresentation, misstatement, inaccuracy or omission.
I/We confirm that I/we have given the agent undersigned no other information in connection with this electronic proposal for family takaful,
except that contained in the electronic proposal for family takaful and/or hard copy form(s) or questionnaires submitted. I/We also confirm that
save for brochures, benefit illustrations and documents duly authorized by the Takaful Operator, the undersigned agent had not given me/us
any document or information to induce me/us to participate into a Takaful Contract with your Takaful Operator.
I/We further agree that the takaful applied herein shall not take effect and no cover whatsoever will be provided by the Takaful Operator until a
certificate is issued to me/us on the said electronic proposal for family takaful and/or electronic forms and/or questionnaires and the first
contribution has actually been paid and received in full by the Takaful Operator during the lifetime and good health of the Person to be
Covered/Proposer and I/we understand that I/we will always reserve the right to return the certificate document to the Takaful Operator for
cancellation within 15 days of delivery to me/us.
I/We understand and agree that any participant who participates in i-Medik Rider will receive 10% annual limit increase if there is no claim
submitted and approved in the previous three (3) year period. I/We understand that I/we am/are also entitled to receive the same benefit if I/we
were to participate in i-Medik Rider.
I/We hereby authorise any doctor, medical practitioner, physician, hospital, laboratory, surgeon, nurse, medical staff, clinic, insurance company
and takaful operator, organisation or institution, that has any records or knowledge of me/us or my/our health, to disclose to the Takaful
Operator or its representative any information about me/us, my/our health, medical history and any hospitalisation, advice, treatment, disease
or ailment, and I/we authorise the Takaful Operator and its representative to give and release any such information to any party to process this
application and for the administration, analysis or processing of claim. A photocopy of this authorisation shall be effective and valid as the
original.
I/We confirm that the agent undersigned has provided me/us with a copy of the completed Prospective Certificate Owner Fact Find Form. In
relation to the extent of the disclosure of my/our information in the Prospective Certificate Owner Fact Find Form, I/we confirm that I/we had
selected
Option 1 I/We wish to disclose all information requested for in this Form.
Option 2 I/We wish to disclose partial information requested for in this Form.
Option 3 I/We wish to receive product information only and do not wish to disclose any information requested for in this Form.
as set out in the Prospective Certificate Owner Fact Find Form.
For Proposal for Family Takaful (Third Party) only:
I (the Proposer) agree to Hibah (gift) the total contributions paid to the Person to be Covered. This Hibah aqad shall not be applicable if the
Proposer is a company/organisation and the Person to be Covered is an employee or a director of the company/organisation.
Instruction: Please use thick dark BLUE color pen to avoid being taken as non-original document.
PROPOSER'S/PERSON TO BE COVERED'S DECLARATION
Signature of Proposer (Owner)
(If other than Person to be Covered)

Name
Signature of Person to be Covered

Signature of Credit Card Holder
Name
Signature of Agent
Name
A/C No.
Signature of Leader *

Name
Rank
Name
New NRIC/BC/Passport No.
5273554034 5273554034 5273554034 5273554034
SYAWARI BIN BASIR
SABARIAH BINTI CHE SAB
860802-35-5138