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DECLARATION SIGNATURE

DECLARATION BY APPLICANT & PROPOSED PERSON COVERED

I / We have read, understood and agreed with the Aqad, Declaration And Authorisation of Power as stated in the Application Form and provided and agreed with the information stated in the Customer Fact Find Form. I / We hereby confirm that the Intermediary has explained to Me / Us in detail the important features of this Takaful plan being participated and understood the explanation given. I / We understand that it is My / Our duty to take reasonable care not to make any misrepresentation in answering the questions in this Application Form and I / We hereby declare that I / We have fully and accurately answered the questions above. I / We hereby authorise, any hospital, surgeon, medical practitioner or clinic or other person who attends to Me / Person Covered for any reason to disclose to the Takaful company any and all information with respect to any illnesses or injury and to provide copies of all hospital or medical records / certifications, including any earlier medical history. A photocopy of this authorisation shall be considered as effective and valid as the original.

CLIENT'S CHOICE

Please tick the appropriate box which is similar to the choice made in the e-Customer Fact Find Form (e-CFF Form)
I/We wish to disclose all information requested in this e-CFF Form.
I/We wish to disclose partially information requested for in this CFF Form.
I/We wish to receive product information only and do not wish to disclose any information requested for in this e-CFF Form.

CLIENT'S ACKNOWLEDGEMENT

Please tick where appropriate. Part A :
I / We acknowledge that the Intermediary has provided Me / Us with a copy of the e-CFF Form.
I / We acknowledge that the Intermediary has shown Me / Us the contents of the completed e-CFF Form in softcopy and I / We agree that a physical copy of the same form will be provided to Me / Us before the issuance of the takaful certificate.

Part B :
I/We acknowledge that the Intermediary as named below has shown Me / Us the contents of the completed Application Form when I / We signing the Application Form.
A Confirmation of Advice will be sent to you together with the issuance of family takaful certificate by your takaful operator. The statement in e-Confirmation of Advice should be attached with the takaful certificate and the copy will be kept by the operator and the intermediary.

*Witness must have attained the age of 18 years, a person of sound mind and not the nominee named.
You may cancel your family takaful certificate by returning to your takaful operator within 15 days after the date of delivery of the certificate and your contribution will be refunded immediately to you. The e-Customer Fact Find Form should be attached with the e-Application form(s). A confirmation of Advice will be sent to you together with the issuance of family takaful certificate by your takaful operator.

Signature of Applicant / Contributor
Signature of Applicant / Contributor
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Signature of Proposed Person Covered
Signature of Proposed Person Covered
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Signature of Contributor's Spouse (if applicable)
Signature of Contributor's Spouse (if applicable)

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Signature of Witness
Signature of Witness

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Name :
MyKad No.
Place :
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DECLARATION, ACKNOWLEDGEMENT AND CONFIRMATION OF ADVICE BY INTERMEDIARY

I declare and confirm that :-
All information contained in this application is the information given to me by the Applicant and/or Proposed Person Covered and I have not withheld any other information which might influence the acceptance of this application.
I have not given any statement to the Applicant and/or Proposed Person Covered contrary to the provisions as contained in the Takaful Operator's standard policy. I do not have any conflicts of interest that may affect the advice I provided to the Applicant.
I can source and recommend / advise you on the range of products and services provided by Zurich Takaful. I receive remuneration from Zurich Takaful Malaysia Berhad for providing advice on/offering their Family Takaful products.
I declare that I will treat the information provided to me in the Customer Fact Find Form and Application Form with strict confidence and will use it only for the purpose of finding in the process of recommending suitable Family Takaful products and shall not use it for any other purposes. The analysis / advice is based on the facts furnished in the Customer Fact Find Form and Application Form. I have taken reasonable steps to ensure that the advice is suitablefor the client, having regard to the facts disclosed and other relevant facts which are made available to me. I have also explained to the client about the features of the product recommended and have given sufficient information to enable the client to make an informed decision. The products stated in the Confirmation of Advice sheet have been recommended for the client to participate.
I declare that my supervisor has evaluated my advice and recommendation given to this client.
(Applicable to Family Consultant that has been contracted for 1 year or less).
In compliance with Section 16(3) of the Anti-Money Laundering, Anti Terrorism Financing and Proceeds of Unlawful Activities Act 2001, I hereby declare and confirm that I have sighted and verified the document identifying the Applicant and/or Proposed Person Covered as below:

Please tick the relevant document sighted and verified.
New I.C No.
Passport
Certificate of Registration of Business
Annual Accounts
Memorandum and Articles of Association

If the regular annual contribution is more than RM 5,000.00 and/or if the single contribution is more than RM 10,000.00, please submit a copy of the document of identification / Certificate of Registration of Business.
Signature of Intermediary
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Name of Intermediary
Place :
Date :
MyKad No.

The e-Customer Fact Find Form should be attached with the e-Application form(s). A Confirmation of Advice will be sent to you together with the issuance of family takaful certificate by your takaful operator.

CHIEF MANAGING CONSULTANT'S (CMC) / MANAGING CONSULTANT'S (MC) DECLARATION

I declare that I have reviewed this e-CFF form and to my best belief and knowledge, the advice and recommendation given by the consultant is sound and appropriate.
Signature of CMC / MC
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Name of CMC / MC
Place :
Date :
MyKad No.