PRUDENTIAL BSN APPLICATION FOR SURRENDER / PERMOHONAN UNTUK PENYERAHAN TAKAFUL CCortticate Number ! Nombor Sit elt isielei sii ‘pplication Date [Takh Permohonan: - - (Bay-Month-Year/Har-Bulan-Tobun) Code / Nome of Agent/ oe Name Berge hopn suwsesms Quy wad isda Name of Participant ! Nama Peserta Name of Person Covered / Nama Orang yang Dilindungi Pm@uL MounMm|o KUULEI GIN Moe AroiUL mama EVALPI Gus MOA We The oano Assign in he we of te above mentioned cris autre and ees Prudential BSN Takaful Brad (PruBSN) to pay the Surender value inl scharge ofthe labitty of PrUBSN under the sad crite ‘Saya / Kami ATONBSL. MEARE O._ENULPL_E.ODA.. Pemiik / Pemogang Soran Hak hak milk sil ersebut datas membonarkan dan ‘momohen Prudential BSN Takaful Berhad (PruBSN) membayarnlai Penyershan dengan ciscaj dari labit seperutya kepada PruBSN di bawah sii i Pease lick the box if you have enclosed a copy of your lentty Card along wih this application fon / Ska tandakan kota ka ance telah sertakan ‘alinan Kad Pengenalan anda bersama dengan borang permohonan i. REASON FOR SURRENDER / PLEASE (/) WHERE APPLICABLE / ‘SEBAB UNTUK PENYERAHAN/ SILA TANDAKAN (v) PADA TEMPAT YANG BERKENAAN Purchase of asset /Pombelin aset Fr eter investment Untuk pelaburan lin Personal Exponses / Perbolanjaan peribadt Unsatisfactory retums / Pulangan yang dak memuaskan Unsatisfactory services / Perkhidmatan yang tidak memuaskan ‘others, please specty/ Lainian, slo nyatakan ‘TERMS AND CONDITIONS OF SURRENDER / TERMA -TERMA DAN SYARAT-SYARAT PENYERAHAN 1 The Surrendor Value wil bo detornined according to the Provisions of the said Cerificate and other such documentations required by PruBSN to prove the tile of the person claiming the payment / Nii Serahan akan dlietukan menurut Poruntukan Sil tersebut dan dokumen lain yang ‘tkehendak oleh PruBSN bagi mengesahkan hak mik indi yang menuntl bayaran. 2. Ifthe eariiate has been assigned, the orginal Asigrment Deed must bo encod / Jka sitet diserah hak, Surat kalan Serah Hak mest ortakan. 3. Upon surrender, the criicate wil be teminated afer the surrender value has been paid out by PruBSN / Si akan ciamatkan sepenuhaya setelah nila penyerahen dibayarolsh PruBS. 4. Reoinstatament ofthe crificate after surender isnot alowed /; Pangomballn semula sil solopas sorahan tidak cibenarkan, Oo (0000 [ACCOUNT DETAILS / BUTIRAN AKAUN [Noto : The account dotals ar fr Participant or Assignee only this Certficate has boon assigned) / Moe Phone Number /Nomter Telefon Biba mal Adress /Alamat Enel ol f4t Ish Tel gatyli laminate. Knute @ gmart. com Please tick (1) ONE bank category Sia tan (¥) SATU Kategori bank Convensonal Bank Bonk Konensional ‘eam Perbantan som Pose specty bank name / Se nyatakan nome bank: May BAW K Noto: sidentication refers to NRIC/ Old IC, Army | Police 1D, Bith Centficate or Passport. [Nota : “No. Pengenalan Dir moryjuk kepada No. KP Bary / Lama, No. Pengenalan Tentore/ Pols, No. Si Beranok atau Pasport Form 1D| 61001014 ‘Sumer Veron Var 4.01 Now 2018 Page sa surat of[E-CREDIT TERMS & CONDITIONS / TERMA-TERMA DAN SYARAT-SYARAT E-KREDIT. 1. Tis Orel Cut acy Fay) proved to te appa is subject to te aproa of Prue! BSN Ta Brad (PBN) and oe ems + provide a copy of his her bank statement or the fst page of his her bank passbook bearing the number and detais ofthe Account dearly showing the signature of the applicant. the copy of his/her bank statoment or the fist page of his/her bank passbook isnot provided, the applicant is ‘deemed to have confimed the Account deals provided in ths application frm (For) as valid and accurate. ‘menyediakan sats sanan ponyala bank atau halaman pertame buku ekaun bank pemohon yang mengandung! nombor den butran Akaun seta ‘menurjukkan tandatangan pemoton dengan jel. Jka salinan penyata bank atau halaman pertama buku akaun bank pemoben tdak dibeian, ‘pemaheon danggap telah mengesahkan butran Akaun dl dalam borang parmoonan in. ("Berang’) sebagai sch don fep + Provide a copy of his her Wendy card or passport where applicable) fr verification purposes. ‘menyedakan satu salina ked pengenalan atau pesport (ka berkenean) pemahon unt yin pengesshen. + Complete, sign and submat hisform fo PruBSN, ‘melengkapkan, menandatangani dan menghantsr Borang ni kepad PruBSN. 3. Subject to the approval from PruBSN on tis application, PREBSN shal pay or credit the relevant payments ofthe takaul cerifcate ‘Cerficate") Seseribed in tue Form into the Account as inthicted and autorsed by the applicant. |E-CREDIT DECLARATION / PENGAKUAN E-KREDIT_ In consideration of PuBSN agreing to grant this faci to me, thereby dedare that Daas prsetduan Pru untuk menbertan Keun i Koo Sve. ay dogen i mengethartan baw: 'PruBSN is authorised to depos the relevant payments under tbe Caricate, which are payable o me, into the Account provided ints form PruBSN diber! kuasa untuk memasukkan tayaran yang berkatan dl bawah Sil tersebut yang akan dibayar kepada saya ke dalam Akaun yang ‘iberikan cdot Borang 2. agyee not io old PruBSN able for any loses, damages, costs and expenses that! may sulfer whether direct or inivect Soya bersetyju bohewe PruB'N tak bertanggungiawab ke ats sebarang Keruien, kerosakan, kas den perbelanian yang mungkin saya alam sama 9 socarafngsung tau idk longs: * for paying oF credtng payments due to me according tothe Account deals provided inthis Form. kerana memtayaraiau menghredtkan bayeran kepade saya mengiutbutran Akaun yang diveitan di dla Borang in + inthe event of any vad or naccurate Account details thal | provided results in payment being credited ino a thie party acco, the payment made tothe accounts sil deemed as fll payment forthe relevant payments sskranya butran Akaun yang tak sah atau tidak fat yarg saya berkan menyababkan pembayaran dkredtkan ko dalam akaun pihak kta, ‘pombayaren yang dibual fu masihdianggep sebegel pembayeren penuh begibayaran yang berktan. + iffer any reason PruBSN is unable to pay er ced the payrents nto the Account rough no fault of the Company inuding but not nite to, the ayes being rejected by the fancialinstiaion, where te Account is held. Jka atas sebarang sebab PIuBSN tilak dapat membayar tau mengkreakan bayaren ke dalam Akaun ttapltukan datas. Kesalehan PruBSN, fermesuk tetap tide terhod kepada, pombayerandilak ol inst! kewangan di mana Akaun frsebut dpogang. 3 The payments made into the Account shal be @ good dscherge of PruBSN's laity to me under the Cerificate and | shall have no further claim against the Company forthe same. ‘Pembayaran yang dibuat ke dalam Akaun fersebut melepaskan iabiti PriBSN kepeda says oi bewah Sil tersebut dan saya tidak boleh membuat tuntutanselanutnys terhadoppihak Syarkat untuk perkara yong sama 4 Thereby ievocably undertake 1 keep PruBSN hares and fly indemnified against any and all actons, dams, proceedings, costs (including legal ‘costs on soiitor and cent besis) and damages, including any compensation pad by PruBSN to sete such clam, that may howsoever rie frm or be incidental to my intrusion with respect to the Faclty er Account above and any of PruBSN's payment into the Account. This auhorsaion an Inder shallbe binding upon my respective successor-r-tie, executors, administrators, personel representatives or hes Soya dengan ini secara muktamad berianj akan melopaskan den melindung! PriBSN sepenuhnya derpad sobareng dan semua tindakan, tuntuton, presiding, kos (lermasuk kos quamen alas dasar peguemcara den enakgua) dan gant! righ, termasuk sebarang pampasan yang dibayar oleh ‘PruBSN untuk ‘menyelesaikan tuntutan sedemikion, yang mungkin fay socara kebetden tmbul derpede ates erchan saya Derkenaen dengan ‘Kemudeban atau Akaun datas dan sobarang pembeyeran oloh PruBSN ke dalam Akaun tersobut. Kuaso dan tanggung Mp ni akan mengikat ‘penggant hak mi, was, penta, waki perbad atau wars Say, Form 1D| 61001014 ‘Sunender Veron Vers! 4.01Nov 2018 Page Ma cust 203[PRIVACY NOTICE / NOTIS PRIVASI ‘Wie wil process the personal data provided by you in this form and itis obligatory for you to provide the personal data required herein. Ifyou fall to provide ‘uch data, we wil not be abe to process your appication. We wll process the personal data forthe purposes of processing, assessing and determining your application or camying out any acy in elation fo orn connection wih carrying out our duties 3a taka operator. ‘Kami akan memproses data perbediyeng dverian ole anda dalam borang ii dan ia adalah waj untuk anda memberi dala perbad! yang dkehendaki ‘kepada kami tka anda gagalberbuat demon, karn tidak akan dapat memproses permohonen anda. Kami akan memproses data peradl bagi tyjan Pemprosesan, penfaan dan menentukan permononan anda atau menjalantan sebarang aktvtl Yang berkatan dengan operas kam sebagai pengendall ‘We may share the data with our relate, associated or afitated companies (this includes entity within the Prudential Group of Companies or Bank Simpanan ‘Nasional Group of Companies), service providers under contract who hep with our business operations (ncludng those oversees); any person, who is under ‘8 duiy of confidentiality and who hes undertaken to keep such ta confident; and any person consented by you oro whom we are under an obligation to ‘make disclosure under the requirements of any law rules, regulations, cout order, codes of practice or guidelines binding onus incung, without istaton, ‘any applicable regulators, govemmental bodies, or indus recognised bodes such as the Life Insurance Assocation of Malaysia end Malaysian Tokaf ‘Associaton, and where otherwise required by law. Kami munghin akan brkongsi data torsebut dengan syarikatboraitan, sekutu atau gabungan kam (lermasuk ent dalam Syarkat Kumpulan Prudent! atau ast mungkn dpindahkan kepada ent lersebul sebagai sebehagien daripade gabungen etau pengemblelien. ke anda membekolkan data perbad Dihakpihek lan sepert ai kelvarge, peniaga sah, penama, pengareh, pemegang saham atau pengawai aia pastkan anda eh mendapatkeiinan mereka ‘dan membawat noi hi untuk perhatian mereka, ‘Where you clct to it our right o process the porsonal data, you may contact us. For avoidance of doubt, the withdrawal or lation does not include ‘processing of mandatory personal data. Ths noice shal be read together with our Privacy Pebcyon our weit, ww pruben oem. my and our Privacy Notice {gut Proposal Ferm. yeu have any quostion about this notice, please contact- Customer Service Oficor E-mail customor@pruben.com my | Telophone: 03 2053 7188 | Fax: 03 2725 8585. tka anda memilth untuk menghackan hak kami untuk memprosos data perc, anda boleh berbvat demkian secara bertuls kepada kam. Untuk ‘rquan, penarikan balk atau pembatasan tak termasuk memproses data penbedt yang waj. Nos ini hendskih dibacs bersama Polisi Prvast dt loman web kam, www.praben com my den Novis Prive! kamy di dalam Borang Cadengan. ka ands mempunyei sebarang soaian mengenai ots in, la Pubunge Pogawai Khuzmat Pelanggan, Emo: customer@prabsn com my | Telefon: 032053 7188 Faks: 03 2725 8585 DECLARATION / PENGAKUAN ‘understand that / Saya memahsm bohaws 1 My appication wil not take elect units accepted and notified to me by Pru'SN. | Permohonan saya tia akan berkuatkuasa sehingga ia citer ‘don dimakiumian kepada saya oleh PruBSN. 2. My application must reach PruBSN alts Principal fics in Kuala Lumpur by 3.00 pm. onthe day before a Valiation Date as described inthe certincate ‘document. / Permotionan saya mest! sampal ke PruBSN dl bu Pejabotnya of Kusis Lumpur sebelum jam 3:00 petang sebelum Tarkh Penisian sepert) Yang dinyatakan dalam dokumen si 3. PriBSN wil not accept e-mail oF faxed copy ofthis application. | PruBSN tidak akan monerima o-mol atau salina faks untuk permohonan i 4. I deciare that | am not a bankrupt. | have not commited any act of bankruptcy win the last twelve (12) monihs and that no recehng order or ‘adjudication in barkrupicy has been made against me during tat perod.! Saya mengaku bahawa saya bukan mufis, saya idok melakukan Seberang tindakan mufis dalam tempoh dua belas (12) bulan yang ats dan ada arahan penenmaan atau penghakiman mus tlan bust ke alas saya delam tampon tersotut. Sionatr fParcpant Assignee (fay) Name/Nana: AMGUL MOWAMAD MALO ‘andtongon Peso Pomogorg Ser Hak (i 2) Sermon! Identification Number" No. Pengenotan Dia* Aloo =\1- CONG. pee ireee aia Signature of Winess / Tandatangan Saks Nome! Nome: NOROULSURIANA YAHATS ee oe. SSE Ty Date Tat 34 J 2/2649) Form 1D | 61001014 Prantl BSN Totatl Bara (740051-4) Loe Menara Pratl No. 10, Jl Sut ora, 50250 Kula Lamp ‘Cumtomer Sern (32053 7188 Fax C3 2725 S86 E mat cuctmerGpndn comm Wetter cam ‘Surender Veron | eri 40/ Now 2016 Pape Mk sua 303