MEMBERSHIP APPLICATION FORM
LANGKAH / STEP 1
MAKLUMAT PERIBADI / PERSONAL DETAILS
LANGKAH / STEP 2
DEKLARASI / DECLARATION
LANGKAH / STEP 3
DEKLARASI (AKTA PERLINDUNGAN DATA 2010) / DECLARATION (PERSONAL DATA PROTECTION ACT 2010)
Package Selection (Please Tick) :
Pilihan Pakej (Sila tanda yang berkenaan)
FORM B: NOMINATION OF BENEFICIARY (CONDITIONAL HIBAH) - GROUP SCHEME
Important Notes:
- This Nomination of Beneficiary (Conditional Hibah) form is to be completed by the takaful Participant who has attained the age of 16 years
where the Person(s) named below shall receive the takaful benefits including accumulated amount in the Participant Investment Fund as
a Beneficiary and not as an Executor. - The Beneficiary(s) is entitled to receive the takaful benefits on the basis of Conditional Hibah (Gift). Conditional Hibah has the effect of
transferring ownership of the takaful benefits payable to the Beneficiary(s) upon the death of the Participant and shall not form part of the
estate of the Participant or be subject to his/her debts. Conditional Hibah is however a revocable gift which the Participant may revoke
during his/her lifetime. - If the Participant is also the Person Covered, the Participant may nominate a person to receive the takaful benefits payable under the
Certificate. - If the Beneficiary under Conditional Hibah predeceases the Participant, the share of the deceased Beneficiary, upon the death of the
Participant shall be paid to the estate of the Participant unless the Participant has made a subsequent nomination in place of the
deceased Beneficiary.
Declaration & Authorization
- I, the above named Participant do hereby agree that in the event of my death all takaful benefits payable under the terms and conditions
of the Certificate be paid to the Beneficiary(s) named below on the basis of Conditional Hibah. Payment to the Beneficiary(s) named
herein shall discharge MyKhairat Management Services Sdn. Bhd. from all obligations and liabilities under the Certificate. - I hereby nominate the following as Beneficiary(s) for the above certificate.
Beneficiary Details
Beneficiary 1
Beneficiary 2
Beneficiary 3
Note:
- * Mandatory fields to be filled
- Submission of a copy of the beneficiary’s IC / Passport is encouraged.
- **Witness must be at least 18 years of age, of sound mind and cannot be a named beneficiary
- This document is prepared in accordance with Islamic Financial Services Act 2013.
PERSONAL HEALTH DECLARATION FORM
IMPORTANT NOTICE
1.You are required to take reasonable care not to make any misinterpretation when answering any questions asked by us i.e. you should answer the questions fully and accurately/correctly. Please note that all the questions that are asked by us are relevant to our decision whether to accept the risk or not and the rates and terms to be applied.
2.If there are any changes to the answers given in the application form between the time of submission of the application form and the time the contract is entered into, you are also required to disclose to us fully and accurately/correctly such changes.
3.In addition to answering the questions in the proposal form fully and accurately/correctly, you are also required to take reasonable care to disclose to us fully and accurately/correctly any other matters which you know to be relevant to our decision on whether to accept the risk or not and the rates and terms to be applied.
4.Your failure to give answers that are full and accurate may result in your policy being avoided, a claim not being paid or reduced, or the terms of the policy being changed.
5.lf you do not understand your obligation/duty as stated above or if you need any further explanation, you can contact us @ 1800-38-7777 or your servicing agent.
PERSONAL DETAILS OF MEMBER
Health Declaration
If yes, please provide Regular / Personal Doctor Details.
b) Have you ever had or been told to have or been treated for any condition, illness, disease, or disorder, whether medically diagnosed or not, affecting any of the following:
d) Female Only
4. LIFESTYLE DETAILS
5. EXISTING INSURANCE AND TAKAFUL COVERAGE
Declaration
1. I am aware that I must answer all questions, and declarations in this application, and that these answers and declarations are accurate and complete. I agree that failure to answer a question or declaration or, incorrectly answering a question or declaration, may result in termination of the sum covered, a claim not being paid or reduced, or the terms and conditions of the coverage being changed.
2. I agree to notify MyKhairat Management Services Sdn. Bhd. in writing should there be a change to any answers or declarations in this application, prior to the time that a contract is entered into, varied or renewed of the certificate. I agree that failure to notify MyKhairat Management Services Sdn. Bhd. of any such change, may result in voidance of the sum covered, a claim not being paid or reduced, or the terms and conditions of the coverage being changed.
3. I confirm that I fully understand that my answers and declarations in this application, and any other relevant documents completed by me in connection with this application and questionnaires, or amendments thereto, shall be relied upon by MyKhairat Management Services Sdn. Bhd. in deciding whether to accept my sum covered or not.
4. I hereby authorise any physician, hospital, clinic, Takaful operator/insurance company, financial institution or any other organisation or company or person that has any records or knowledge about me, my financial standing or my health, to disclose to MyKhairat Management Services Sdn. Bhd. or its representatives any or all such information about me before or after my death. I agree that a photocopy or facsimile of this authorization shall be considered as effective and as valid as the original and legally binding on anyone who takes over any of my legal rights.
5. Personal Data Protection Act 2010 (PDPA) I agree, consent and allow MyKhairat Management Services Sdn. Bhd. to process my personal data (including sensitive personal data) (‘Personal Data’) with the intention of entering into a contract of Takaful, in compliance with the provisions of the PDPA. I understand and agree that any Personal Data collected or held by MyKhairat Management Services Sdn. Bhd. (whether contained in this application or otherwise obtained) may be held, used, processed and disclosed by MyKhairat Management Services Sdn. Bhd. to individuals and/or organizations related to and associated with MyKhairat Management Services Sdn. Bhd. or any selected third party (within or outside Malaysia, including medical institutions, reinsurers, claim adjusters/investigators, solicitors, industry associations, regulators, statutory bodies and government authorities) for the purpose of processing this application and providing subsequent service related to it and to communicate with me/us for such purposes. I understand that I have a right to obtain access to and to request correction of any Personal Data held by MyKhairat Management Services Sdn. Bhd. concerning me. Such request can be made by completing the Access Request Form available at MyKhairat Management Services Sdn. Bhd. headquarters/ or contact MyKhairat Management Services Sdn. Bhd. via email at info@mycoopmed.com.my. In accordance with the provisions of the PDPA, I may contact the MyCoopMed Customer Service Centre at 1300 38 7777 for the details of my Personal Data. Such information shall only be granted upon verification.