CRITICAL ILLNESS CLAIM FORM

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1 CRITICAL ILLNESS CLAIM FORM BORANGAN TUNTUTAN PENYAKIT KRITIKAL TO BE COMPLETED BY THE ASSURED / CLAIMANT PERLU DILENGKAPKAN OLEH ASURED / PIHAK YANG MENUNTUT 1. Policy No. / No. Polisi: Claim No./Tuntutan No. i - ii - 2. Life Assured s Details / Butir Hayat yang dilindungi i. Name of Life Assured / Nama Asured i iv. I.C. No. / No. Kad Pengenalan Age / Umur Occupation / Pekerjaan v. Current Correspondence Address / Alamat Surat Menyurat Terkini vi. Telephone No. / No. Telefon v Are you a GST registered? / Adakah anda seorang yang berdaftar GST? 3. Claimant s Details (if other than Life Assured) / Butir Pihak Menuntut (jika berlainan daripada hayat yang dilindungi) i. Name of Claimant / Nama Pihak Menuntut i I.C. No. / No. Kad Pengenalan Correspondence Address / Alamat Surat Menyurat iv. Telephone No. / No. Telefon 4. Nature of Claim / Jenis Tuntutan i. Name the Dread Disease you/the Life Assured is claiming? Nama Penyakit Serius yang berkaitan dengan tuntutan anda/hayat dilindungi? Describe the symptoms. Huraikan gejala penyakit. i For how long had you/the Life Assured been having the symptom prior to first consulting doctor? Berapa lamakah anda/hayat dilindungi telah menghidapi simptom sebelum pertama kali menjumpai doktor? DD MM YY Since / Semenjak HH BB TT 5. Particulars of hospital s admission, if any / Butir tentang kemasukan hospital, jika ada i. Name and address of hospital Nama dan alamat hospital Date of Admission Tarikh Masuk Date of Discharge Tarikh Keluar iii 6. Name and address of doctors who treated you/the life insured for this or any other illness/injury/condition. Nama dan alamat doktor yang merawat anda/hayat yang dilindungi bagi penyakit/kecederaan/keadaan ini atau yang lain. i. Name and address of clinic/hospital Nama dan alamat klinik/hospital Date of Consultation Tarikh rawatan Date of admission (if any) Tarikh masuk ke wad (jika ada) i

2 7. Is the Life Assured claiming from any other insurance company or other sources in respect of illness? If yes, provide the information below Adakah hayat dilindungi menuntut dari pihak syarikat insurance lain atau mana-mana organisasi lain untuk penyakit ini?jika ya, sila berikan butir di bawah : Name of Insurer/Nama syarikat Insuran Type of Plan/Jenis Plan Sum Assured/Jumlah Tuntutan Policy Number/No Polisi Declaration & Authorization / Pengisytiharan & Kebenaran I the undersigned hereby declare that the information given in this claim form are true and in the event that I make, or have in the past made, any false or untrue statement and/or suppressed and/or concealed any material facts in respect of my/the Life Assured s health and condition, the company shall absolutely forfeit my/the Life Assured s right to compensation and further reserves the right to recover any amounts paid earlier as a result thereof. Saya yang bertandatangan dengan ini mengisytiharkan bahawa maklumat yang diberi dalam borang tuntutan ini adalah benar dan bahawanya jika saya membuat atau pernah membuat sebarang kenyataan palsu atau tidak benar dan/atau menghalang dan/atau menyembunyikan sebarang fakta matan berkaitan dengan kesihatan dan keadaan saya/hayat dilindungi, syarikat akan secara mutlak berhak menarik balik hak saya/hayat yang dilindungi untuk mendapat pampasan dan seterusnya mendapat hak untuk menuntut semula sebarang amaun yang telah dibayar sebelum ini. And I hereby authorize any physician, hospital, clinic or insurance company or other organization, institutions or persons, that has any records or knowledge of me/life Assured or my/life Assured health, to disclose to Tokio Marine Life Insurance Malaysia Bhd., or its representatives any and all such information and expressly waive on behalf of myself or surgeon from disclosing any information acquired while attending me in a professional capacity. This authorization shall irrevocably bind my successors and assigns and remain valid; not withstanding my death or incapacity and a copy of this authorization shall be as effective and valid as the original. Dan saya dengan ini membenarkan sebarang doktor, pihak hospital, klinik atau syarikat insurans atau lain-lain organisasi, institusi atau orang perseorangan yang mempunyai sebarang rekod atau pengetahuan tentang saya/hayat yang dilindungi atau kesihatan saya/hayat yang dilindungi, untuk mendedahkan kepada Tokio Marine LifeInsurance Malaysia Bhd. atau wakilnya tentang sebarang dan keseluruhan maklumat tersebut dan secara nyata menyisihkan hak bagi pihak diri saya atau sesiapa yang mempunyai sebarang tuntutan atau kepentingan dalam sebarang polisi yang dikeluarkan, ke atas semua peruntukan undang-undang yang melarang doktor atau pakar bedah daripada memberi sebarang maklumat yang diperolehi semasa merawat saya ketika mereka menjalankan tugas sebagai seorang profesional. Kebenaran ini mengikat dan tidak boleh dibatal oleh waris dan penerima serah hak dan akan kekal sah, tanpa mengira kematian atau ketidakupayaan saya dan salinan kebenaran ini dianggap sama sah dan berkesan seperti kebenaran asal. INSTRUCTION / ARAHAN Supporting documents required are / Dokumen sokongan yang diperlukan adalah: i. Please attach the policy contract. / Sila lampirkan polisi. The cost of the Medical Report shall be borne by the Claimant / Kos laporan perubatan adalah ditanggung oleh Penuntut. i Please attach the x-ray, laboratory, MRI, CT scan reports, etc. / Sila lampirkan x-ray, makmal, MRI, CT scan, dll IMPORTANT NOTICE/ NOTA PENTING: Claims payment is advisable to be made via e-payment. This is in line with BNM s directive towards electronic fund transfer that is faster, safer and more convenient. To avoid any delay in payment for this and/or future claims. Please fill in the relevant information in below section ("Direct Credit facility") AND submit the required supporting documents to TMLM Bhd. However, in the event where e-payment facility cannot be made, the Claims cheque will be sent to the Claimant s address, as stated in TMLM Bhd. s records. Adalah dinasihatkan bagi pembayaran tuntutan adalah dibuat melalui e-bayaran. Ini adalah selaras dengan arahan BNM terhadap pemindahan dana elektronik yang lebih cepat, selamat dan mudah. Sila isikan maklumat yang berkaitan dalam seksyen di bawah ("Direct Kredit Terus") DAN dokumen yang diperlukan dikemukakan kepada TMLM Bhd. untuk mengelakkan sebarang kelewatan pembayaran bagi tuntutan ini dan / atau tuntutan masa hadapan. Sekiranya kemudahan e-bayaran tidak boleh dibuat, cek tuntutan akan dihantar ke alamat Penuntut, seperti yang dinyatakan dalam rekod TMLM Bhd. FOR DIRECT CREDIT PAYMENT FACILITY / UNTUK PERKHIDMATAN PEMBAYARAN DIRECT KREDIT (To be completed by the Claimant / Untuk dilengkapkan oleh Pihak Menuntut) PARTICULARS OF INDIVIDUAL ACCOUNT HOLDER / BUTIR-BUTIR PEMEGANG AKAUN INDIVIDU Name of Policy Owner Nama Pemegang Polisi NRIC No. Old / No. Kad Pengenalan Lama : Name of Bank Nama Bank Bank Account No. No. Bank Akaun Address Alamat Handphone No. No. Telefon Bimbit New / Baru : - - Important Notes / Maklumat Penting : 1. I confirm that I am the holder of the bank account specific above ( Account ) and that the details thereof are correct, true and complete. I further confirm that I have full power and authority to operate the Account. / Saya mengesahkan bahawa saya adalah pemegang bank akaun di atas dan maklumat mengenai akaun adalah benar & menyeluruh. Saya seterusnya mengesahkan bahawa saya mempunyai kuasa sepenuh berkenaan akaun di atas ( Akaun ). 2. I have read and fully understand the Terms and Conditions of the direct credit claim payment facility attached. I agree that this direct credit facility is governed by its Terms and Condition. / Saya telah membaca dan memahami sepenuhnya syarat-syarat yang dilampirkan bagi perkhidmatan direct kredit untuk bayaran tuntutan saya. Saya bersetuju bahawa perkhidmatan ini dikawal oleh syarat-syarat yang lilampirkan di muka surat belakang. 3. By completing this section, I agree that it will replace my previous bank account details (if any) with the Company and all payment under the Policy will be made to this account no. / Dengan melengkapkan seksyen ini, saya bersetuju bahawa ia akan menggantikan butiran akaun bank saya (jika ada) sebelum ini dengan Syarikat dan semua bayaran di bawah Polisi ini akan dibuat ke akaun ini. INSTRUCTIONS / ARAHAN Supporting documents required are / Dokumen sokongan yang diperlukan adalah: NRIC/Passport ( Certified True Copy )/ No. Kad Pengenalan/Pasport (Salinan Disahkan Benar) Bank Statement/Front page of Bank Account Passbook / Penyata Bank/Muka hadapan Buku Akaun Bank Others / Lain-lain : Signature of Claimant / Tandatangan Pihak Menuntut Name / Nama: Signature of Witness / Tandatangan Pihak Saksi Name / Nama: Date / Tarikh: I.C. No. / No. Kad Pengenalan: Address / Alamat:

3 Terms & Conditions of Direct Credit Claim Payment Facility 1. I shall accept full responsibility for all transactions arising from the use of this direct credit payment facility. I agree to immediately refund to the Company in full any monies paid into the Account which I am not entitled to receive. 2. The direct credit payment facility is only applicable to existing active individual saving or current account. Joint account is not allowed. The individual saving or current account must be maintained with one of the financial institutions offering MEPS INTER BANK GIRO (IBG) service. Please refer to the following website for a current list of IBG members Syarat-syarat Perkhidmatan Direct Kredit Bayaran Tuntutan 1. Saya akan bertanggungjawab sepenuhnya untuk segala urusniaga melalui perkhidmatan pembayaran direct kredit. Saya bersetuju untuk membayar balik kepada Syarikat sepenuhnya sekiranya saya tidak berhak untuk menerima wang yang dibayar ke dalam Akaun. 2. Perkhidmatan pembayaran direct kredit hanya dibenarkan untuk individu akaun atau akaun semasa yang aktif. Akaun bersama tidak boleh diterima. Akaun individu atau akaun semasa mesti dikekalkan dengan salah satu institusi kewangan yang menawarkan perkhidmatan MEPS INTER-BANK GIRO (IBG). Sila rujuk ke laman web berikut untuk senarai semasa ahli-ahli IBG 3. Any use of correction fluid on documents required for the purposes of this request for direct credit payment facility will not be accepted. 3. Sebarang pembetulan maklumat menggunaan pen pembetulan yang dilakukan ke atas dokumen yang diperlukan untuk perkhidmatan pembayaran direct kredit tidak akan diterima. 4. I acknowledge and agree that the payment into the Account shall be a valid discharge of the Company s liability under the Policy. The Company shall not be held responsible or liable for any claims, loss, damage, costs and expenses arising from the successful processing or the unsuccessful processing of the direct credit due to malfunction of the system, electricity failure and/or any other factors beyond the control of the Company. 5. The Company is only responsible for making arrangements to direct credit the payment into the authorized Account. I acknowledge and agree that the direct credit payment facility provided by the Company is solely for my/our convenience and benefit. Therefore, for any problem or dispute arising from the processing/direct credit will be my own responsibility to resolve it with my bank (including but not limited to any problems due to a breakdown or malfunction or mechanical defect of the computer system or equipment of the bank). 6. I will ensure that the Company is notified immediately in writing of any changes, or cancellation of my bank account. Such changes or cancellation will become effective only after the Company has duly acknowledged receipt of such notification. 4. Saya mengakui dan bersetuju bahawa pembayaran ke dalam Akaun adalah bebas dari tanggungan Syarikat selanjutnya di bawah polisi ini. Syarikat tidak bertanggungjawab atau menanggung sebarang tuntutan, kehilangan, kerosakan serta kos dan perbelanjaan yang berpunca dari kejayaan atau kegagalan pemprosesan direct kredit akibat kepincangan gangguan elektrik dan/atau faktor-faktor lain di luar kawalan Syarikat. 5. Syarikat hanya bertanggungjawab mengaturcarakan pembayaran direct kredit ke dalam Akaun yang diarahkan. Saya mengesahkan dan bersetuju bahawa perkhidmatan pembayaran direct kredit ini disediakan oleh Syarikat hanya semata-mata untuk kemudahan dan faedah saya. Oleh yang demikian, untuk sebarang masalah atau pertikaian yang timbul akibat pemprosesan/penkreditan adalah menjadi tanggungjawab saya untuk menyelesaikannya dengan bank saya (termasuk tetapi tidak terhad kepada sebarang masalah akibat kerosakan atau pincang tugas atau kerosakan mekanikal sistem komputer atau kelengkapan bank). 6. Saya akan memastikan Syarikat diberi notis pemberitahuan secara bertulis ke atas sebarang perubahan bank akaun saya. Perubahan sedemikian atau pembatalan akan bermula hanya selepas Syarikat telah memberi pengesahan penerimaan notis pemberitahuan tersebut. 7. The instruction will remain effective for the protection of the Company notwithstanding death and/or incapacity on the part of the applicant unless the Company is notified to cease the direct credit payment facility. 7. Perkhidmatan ini akan terus berkuatkuasa bagi kepentingan Syarikat selagi Syarikat tidak dimaklumkan untuk menamatkan perkhidmatan ini walaupun berlaku kematian dan/atau ketidakupayaan pihak pemohon. 8. In the event the direct credit payment facility is unavailable or in the event that any information and/or document(s) provided or submitted with this Direct Credit Claim Payment Form is incomplete, invalid and/or inconsistent, the Company will issue a cross cheque payment to me. 8. Syarikat akan mengeluarkan cek sekiranya perkhidmatan direct kredit bayaran tidak ada atau sekiranya maklumat yang diberikan tidak mencukupi dan / atau tidak konsisten untuk melakukan perkhidmation ini. 9. I agree that all payment under the policy will be credited into the Account, unless I notify the Company otherwise. 9. Saya bersetuju bahawa semua bayaran akan dilakukan melalui Akaun, melainkan jika saya memberitahu Syarikat sebaliknya. 10. The Company may at its sole and absolute discretion terminate this direct credit service at any time without assigning any reason by giving one (1) day notice in writing to the Policy Owner. 11. Notice of successful and unsuccessful payment - the Company will write to inform the Policy Owner of the successful or unsuccessful transaction. 10. Syarikat boleh menggunakan budi bicara mutlak untuk menamatkan perkhidmatan pembayaran direct kredit ini pada bila-bila masa tanpa memberikan sebarang alasan dengan memberikan sehari (1) notis pemberitahuan secara bertulis kepada Pemunya Polisi. 11. Notis kejayaan dan kegagalan pembayaran direct kredit Syarikat akan memaklumkan secara bertulis kejayaan atau kegagalan transaksi direct kredit kepada Pemunya Polisi. 12. Cancellation - To discontinue the direct credit service the Policy Owner must inform the Company in writing immediately. The Company will write to inform the Policy Owner on the cancellation effective date. 12. Pembatalan Untuk menghentikan perkhidmatan pembayaran direct kredit, Pemunya Polisi mesti memaklumkan Syarikat secara bertulis dengan serta- merta. Syarikat akan memberitahu secara bertulis kepada Pemunya Polisi tarikh pembatalan perkhidmatan pembayaran direct kredit.

4 Personal Data Notice & Consent Form Notis Data Peribadi & Borang Persetujuan 1. Data Privacy / Data Privasi Your personal information will be strictly processed in accordance with the Personal Data Protection Act 2010, other related legislation and our own strict internal policy. / Maklumat peribadi anda akan diproses dengan ketat selaras dengan Akta Perlindungan Data Peribadi 2010, undang-undang lain yang berkaitan dan polisi dalaman syarikat kami yang ketat. 2. Processing of Personal Data / Pemprosesan Data Peribadi We will use the information you supply on this form to, among others, process your claim and/or administer any policy that you may have with Tokio Marine Life Insurance Malaysia Berhad (TMLM). The personal information, which is either supplied by you or by other members of your family, will include policy information, financial information and sensitive personal data about you and any other members of your family if they are also covered by this insurance (collectively Personal Data ). Sensitive personal data may include such things as information on physical or mental health or medical condition, political opinions, religious or other similar beliefs, commission or alleged commission of any offence ( Sensitive Personal Data ). / Kami akan menggunakan maklumat yang anda bekalkan dalam borang ini, antaranya termasuk untuk, memproses tuntutan anda dan/atau menguruskan mana-mana polisi yang anda miliki dengan TMLM. Maklumat peribadi tersebut, samada dibekalkan oleh anda atau ahli keluarga anda yang lain, termasuk maklumat polisi, kewangan dan data peribadi sensitif berkenaan anda dan mana-mana ahli keluarga anda sekiranya mereka juga dilindungi di bawah insurans ini (secara kolektifnya dirujuk sebagai Data Peribadi ). Data Peribadi sensitif mungkin merangkumi perkara seperti maklumat kesihatan fizikal atau mental atau keadaan kesihatan, pendapat politik, keagamaan atau kepercayaan yang serupa, salah laku undang-undang atau pengataan salah laku undang-undang ( Data Peribadi Sensitif ). Your Personal Data will be collected, held on computer and/or in manual files, used, disclosed and otherwise processed by the members of TMLM (including its employees, representatives, reinsurers, agents and affiliates) to facilitate the performance and administration of our functions as an insurance company. / Data Peribadi anda akan dikumpul, disimpan di dalam komputer dan/atau fail-fail manual, diguna, didedahkan kepada atau sebaliknya diproses oleh ahli Syarikat TMLM (termasuk pekerjanya, wakil-wakil, penanggung-penanggung insurans semula, agen-agen dan sekutu-sekutunya) untuk memudahkan perlaksanaan dan pentadbiran terhadap fungsi kami sebagai sebuah syarikat insurans. We may also obtain your Personal Data from other sources, such as bureau or agencies established or to be established by regulatory authorities, operators of registers or databases available to the insurance industry, other external database suppliers, governmental departments, agencies or authorities, licensed credit reporting agencies, any party who has, does or will provide products or services to you and to whom you have granted consent, our commercial partners, insurance intermediaries, reinsurers, third party administrators, other insurance companies, your attending doctors, hospitals, other medical professionals, facilities or pharmacies, lawyers, agents, proposed assignees, policyholders, benefit plan administrators and your employer, or related persons or organizations from whom such information would be essential for the proper processing of the data within the purpose as stated herein. / Kami juga mungkin memperoleh Data Peribadi anda daripada sumber-sumber lain, seperti biro atau agensi-agensi yang ditubuhkan atau akan ditubuhkan oleh pihak berkuasa kawal selia, operator rekod atau pangkalan data yang tersedia kepada industri insurans, atau pembekal-pembekal data lain, jabatan kerajaan, agensi atau pihak berkuasa,agensi laporan kredit yang berlesen, mana-mana pihak yang telah, sedang atau akan membekalkan produk atau khidmat kepada anda dan kepada siapa yang anda telah memberikan persetujuan, rakan-rakan komersil kami, pihak pengantara insurans, pihak penanggung insurans semula, pengurus pihak ketiga, syarikat insurans yang lain, doktor perawat anda, hospital, ahli profesional, kemudahan atau farmasi perubatan yang lain, peguam, agen, penerima serah hak yang dicadangkan, pemunya polisi ber, pihak pengurusan pelan manfaat dan majikan anda, atau orang-orang yang berkaitan atau organisasi daripada mana maklumat sebegitu adalah penting untuk pemprosesan data yang sepatutnya untuk tujuan yang dinyatakan di sini. 3. Impact resulting from failure to supply information / Akibat daripada kegagalan untuk membekalkan maklumat You may choose whether or not to provide your Personal Data to us. The failure to supply your Personal Data as requested may result in us being unable to evaluate your claim, which may lead to your claim being denied. Hence, it is obligatory for you to provide us your Personal Data when you choose to make a claim via this form. / Anda boleh memilih sama ada hendak memberikan Data Peribadi anda kepada kami atau tidak. Kegagalan untuk memberikan Data Peribadi anda seperti yang diminta mungkin akan mengakibatkan kami tidak dapat menilai tuntutan anda, yang mana boleh membawa kepada tuntutan anda ditolak. Dengan itu, adalah menjadi obligasi anda untuk membekalkan kepada kami Data Peribadi anda apabila anda memilih untuk membuat tuntutan melalui borang permohonan ini. 4. Purposes of Collecting Personal Data / Tujuan Mengumpul Data Peribadi Your personal data will be collected, used and otherwise processed by us for the following purposes: / Data Peribadi anda akan dikumpul, diguna dan sebaliknya diproses oleh kami untuk tujuan-tujuan berikut: (a) (c) (d) (e) (f) (g) (h) (i) (j) for claims processing, evaluation, administration and settlement; / untuk memproses tuntutan, menilai, mentadbir dan penyelesaian tuntutan; for underwriting, risk assessment and audit purposes; / untuk pengunderaitan, penilaian risiko dan tujuan audit; to administer and manage your policy, including to obtain reinsurance; / untuk mengurus dan menyelenggarakan polisi anda, termasuk mendapatkan penanggungan insurans semula; for detection and prevention of criminal activity or fraud in connection with an insurance transaction; / untuk mengesan dan mengelakkan aktiviti jenayah atau penipuan berkaitan dengan transaksi insurans; to conduct credit and financial checks; / untuk menjalankan pemeriksaan kredit dan kewangan; to ensure that our records are correct; / untuk memastikan bahawa rekod kami adalah betul; for disclosure to authorized third parties including: your employer and its representatives, agents and affiliates (where, for example, you are insured under a insurance policy obtained through your employer), other insurers, brokers, credit organisations, underwriters, reinsurers, policyholders, benefit plan administrators, those to whom we outsource certain business operations, commercial partners of the TMLM, regulatory authorities, bureau or agencies established or to be established by regulatory authorities, operators of registers or databases available to the insurance industry, professionals working on behalf of the members of TMLM such as loss adjusters, lawyers, auditors, persons conducting actuarial or research studies, accountants, consultants, surveyors, external claims data collectors, investigators and medical professionals, and any other contractors or sub-contractors as required or permitted by law or as we may determine to be necessary or appropriate; / untuk pendedahan kepada pihak ketiga yang diberi kuasa termasuk: majikan anda dan wakil-wakilnya, agen dan sekutu-sekutunya (di mana, contohnya, anda diinsuranskan di bawah polisi insurans ber yang diperolehi melalui majikan anda), syarikat insurans yang lain, broker, organisasi-organisasi kredit, pengunderait, pihak penanggung insurans semula, pemunya polisi ber, pihak pengurusan pelan manfaat, kepada mereka yang mana kami telah menyumber luar operasi bisnes kami yang tertentu, rakan-rakan komersil Syarikat TMLM, pihak berkuasa kawal selia, biro atau agensi yang telah atau akan ditubuhkan oleh pihak berkuasa kawal selia, operator rekod atau pangkalan data yang tersedia kepada industri insurans pihak profesional yang bertugas bagi pihak ahli Syarikat TMLM seperti penyelaras kerugian, peguam, pihak audit, mereka yang melaksanakan penyelidikan aktuari atau kaji selidik, akauntan, pakar runding, peninjau, pengumpul data tuntutan luar, penyiasat dan profesional perubatan dan mana-mana kontraktor atau sub-kontraktor lain yang diperlukan atau dibenarkan oleh undang-undang atau yang diputuskan oleh kami sebagai perlu atau bersesuaian; to manage and service our relationship with you and provide you with better customer service; / untuk menguruskan dan menyelenggarakan hubungan kami dengan anda dan menyediakan khidmat pelanggan yang lebih baik kepada anda; for market research, statistical analysis and surveys; / untuk analisis pasaran, analisis statistik dan kaji selidik; for data transfer to, and sharing with, other members of the TMLM and/or third parties acting on our behalf, including those located outside Malaysia. / untuk pemindahan data kepada, dan berkongsi dengan, ahli-ahli lain dalam Syarikat TMLM dan/atau pihak ketiga yang bertindak bagi pihak kami, termasuk di luar Malaysia.

5 5. Contacting Us About Your Rights of Access to or Correction of Your Personal Data or Ceasing the processing of Your Personal Data / Menghubungi Kami Berkenaan Hak-Hak Anda Untuk Mengakses Kepada Atau membetulkan Data Peribadi Atau Membatalkan Pemprosesan Data Peribadi Anda You have the right to request access to, and correction of your Personal Data held by us and you may make any enquiries or complaints in respect of your Personal Data by contacting our Customer Service Representatives at from 8.40 a.m. to 5.30 p.m., Mondays to Thursdays and 8.40 a.m to 5.20 p.m on Fridays (exclude public holidays) or us at customercare@tokiomarinelife.com.my. You also have the right to request us in writing to cease processing your Personal Data. / Anda berhak untuk meminta akses kepada, dan membetulkan Data Peribadi yang disimpan oleh kami dan anda boleh membuat apa-apa pertanyaan atau aduan berkaitan dengan Data Peribadi anda dengan menghubungi Wakil-wakli Pelanggan kami di dari 8.40 pagi hingga 5.30 petang, Isnin hingga Khamis dan dari 8.40 pagi sehingga 5.20 petang pada hari Jumaat atau emelkan kepada kami di customercare@tokiomarinelife.com.my. Anda juga boleh meminta secara bertulis untuk kami berhenti memproses Data Peribadi anda. I, the undersigned acknowledge receipt of this Personal Data Notice and Consent Form given pursuant to Section 7 of the Personal Data Protection Act I hereby confirm that I give explicit consent, in accordance with the provisions of the Personal Data Protection Act 2010, on behalf of myself and any family members, dependants, or other persons specified in this form (collectively other persons ), to the members of TMLM to collect, use, disclose, transfer, share or otherwise process my Personal Data and the personal data of the other persons including sensitive personal data for the abovementioned purposes. I confirm that where I have provided personal data about the other persons, as part of my claim, I have obtained the consent of the individual(s) concerned to enable TMLM to use their personal data, including any sensitive personal data. I also confirm that I have brought the Personal Data Notice to the attention of the other persons who confirm that they understand, agree and authorize TMLM to deal with their personal data in accordance with the declaration above. / Saya, yang bertandatangan di bawah mengakui penerimaan Notis Data Peribadi ini dan Borang Persetujuan yang diberikan selaras dengan Seksyen 7 Akta Perlindungan Peribadi Saya di sini mengesahkan bahawa saya memberi persetujuan yang nyata, mengikut peruntukan Akta Perlindungan Peribadi 2010 bagi pihak saya dan mana-mana ahli keluarga, tanggungan, benefisiari, pemegang amanah, wakil peribadi, penama, penerima serah hak atau sesiapa yang dinamakan dalam borang ini (secara kelompoknya orang-orang lain ), kepada ahli Syarikat TMLM untuk mengumpul, mengguna, mendedahkan, memindahkan, berkongsi atau sebaliknya memproses Data Peribadi saya dan data peribadi orang-orang lain termasuk data peribadi sensitif untuk tujuantujuan yang dinyatakan di atas. Saya mengesahkan bahawa di mana saya telah memberikan data peribadi berkenaan dengan orang-orang lain, saya telah memperoleh persetujuan individu(individu-individu) yang berkaitan untuk membolehkan TMLM menggunakan data peribadi mereka, termasuk apa-apa data peribadi sensitif. Saya juga mengesahkan bahawa saya telah membawa kepada Notis Data Peribadi ini kepada perhatian orang-orang lain yang telah mengesahkan bahawa mereka memahami, bersetuju dan memberi kuasa kepada Syarikat TMLM untuk berurus dengan Data Peribadi mereka mengikut deklarasi di atas.. Signature of [Policy owner/assignee/beneficiary, trustee, or personal representative] Tandatangan oleh [Pemegang Polisi/Penerima Serah Hak/benefisiari, pemegang amanah, atau wakil peribadi] Full Name: Nama Penuh Date: Tarikh

6 CONFIDENTIAL MEDICAL CERTIFICATE CANCER (To be completed by life assured s expense) SIJIL PERUBATAN SULIT KANSER (Untuk diisi atas perbelanjaan assured) Name / Nama : Claim No. / No. Tuntutan : Date of Birth / Tarikh Lahir : Policy No. / No. Polisi : The below named is insured with us against the happening of certain contingent event associated with his/her health. A claim has been submitted in connection with his illness/injury. To enable us to assess the claim, we would be grateful for your co-operation in the completion of this form. Orang yang namanya dinyata dibawah diinsuranskan dengan kami terhadap kejadian tertentu yang berlaku. Satu untutan yang berkaitan dengan penyakit/ kecederaan telah diserah kepada pihak kami dan untuk membolehkan kami memproses tuntutannya, kami menghargai kerjasama anda melengkapkan borang ini. Cancer of specified severity and does not cover very early cancers: Any malignant tumour positively diagnosed with histological confirmation and characterized by the uncontrolled growth of malignant cells and invasion of tissue. The term malignant tumour includes leukemia, lymphoma and sarcoma. For the above definition, the following are not covered: (i) All cancers which are histologically classified as any of the following: a) pre-malignant b) non-invasive c) carcinoma in situ d) having borderline malignancy e) having malignant potential (ii) All tumours of the prostate histologically classified as T1N0M0 (TNM classification) (iii) All tumours of the thyroid histologically classified as T1N0M0 (TNM classification) (iv) All tumours of the urinary bladder histologically classified as T1N0M0 (TNM classification) (v) Chronic Lymphocytic Leukemia less than RAI Stage 3 (vi) All cancers in the presence of HIV (vii) Any skin cancer other than malignant melanoma Kanser keterukan tertentu dan tidak melindungi kanser tahap awal: Sebarang tumor malignan yang didiagnos positif dengan pengesahan histologi dan bercirikan pertumbuhan sel malignan yang tidak terkawal dan serangan tisu. Terma tumor malignan termasuk leukimia, limfoma dan sarcoma. Untuk definisi di atas, berikut adalah tidak dilindungi: (i) Semua kanser yang secara histologinya diklasifikasikan sebagai berikut: a) pra-malignan b) bukan invasive c) karsinoma in situ d) mempunyai malignan pinggiran (borderline) e) mempunyai potensi malignan (ii) Semua tumor prostat yang secara histologinya diklasifikasikan sebagai T1N0M0 (Klasifikasi TNM) (iii) Semua tumor tiroid yang secara histologinya diklasifikasikan sebagai T1N0M0 (Klasifikasi TNM) (iv) Semua tumor pundi kencing yang secara histologinya diklasifikasikan sebagai T1N0M0 (Klasifikasi TNM) (v) Leukemia Limfositik Kronik kurang daripada RAI Tahap 3 (vi) Semua kanser dengan kewujudan HIV (vii) Sebarang kanser kulit selain melanoma malignan Note: This form is to be completed at the Patient s expense. Borang ini untuk diisi atas perbelanjaan Pesakit. 1. (a) Name of Patient. / Nama Pesakit The Patient s identity card number from your records. / Nombor kad pengenalan Pesakit daripada rekod anda 2. (a) Are you the Patient s usual medical attendant? / Adakah anda doktor yang biasa bagi pesakit? (c) If yes, for how long? / Jika ya, sudah berapa lama? If not, please provide the name and address of the usual medical attendant if known to you. / Jika tidak, sila berikan nama dan alamat doktor yang biasa dengan si mati jika anda tahu. 3. Medical Details / Butir Perubatan (a) (c) (d) Date you were first consulted for this condition. / Tarikh kali pertama keadaan ini dirujuk kepada anda. What was the symptom complaint of and the duration of the symptoms when you were first consulted? / Apakah gejala yang wujud dan berapa lama gejala ini telah wujud pada kali pertama dirujuk kepada anda? Please provide full and exact details of the diagnosis. / Sila nyatakan butir diagnosis dengan lengkap dan tepat. What stage did the disease reach? Please describe using the appropriate staging classification. / Apakah tahap penyakit ini sekarang? Sila huraikan tahap dengan menggunakan pengkelasan.

7 (i) Was the disease completely localized? / Adakah penyakit ini betulbetul setempat? (ii) Was there invasion of adjacent tissue? / Adakah berlaku invasi terhadap tisu yang berdekatan? (iii) Were regional lymph nodes involved? / Adakah kawasan nodus limfa terlibat? (iv) Were there distant metastases? / Adakah berlaku metastasis jauh? (e) On which date did the Patient become aware of this illness? / Bilakah kali pertama Pesakit diberitahu tentang penyakit ini? (f) If the diagnosis is leukaemia, please provide details of actual type. / Jika diagnosis ialah leukemia, sila nyatakan butir tentang jenis sebenarnya. (g) Please give results of any investigations performed, i.e. laboratory tests, histopathological tests, and any other tests. / Sila berikan hasil bagi apa-apa kajian yang dilakukan, contoh, ujian makmal, ujian histologi dan juga apa-apa ujian yang lain. (h) (i ) (j) Please attach copies of any relevant reports that are available. /Sila lampirkan salinan bagi apa-apa laporan yang berkaitan. Has the Patient previously suffered from this condition or any related illness? / Pernahkah sebelum ini Pesakit mengalami penyakit ini atau apa-apa penyakit yang berkaitan? If yes, please state dates of consultations, name and address of doctor consulted and the resulting diagnosis. Jika ya, sila nyatakan tarikh perundingan, nama dan alamat doktor dan hasil diagnosis. (k) Please give the name and address of all doctors, specialists or hospital to which the Patient has been referred or attended for this condition. / Sila berikan nama dan alamat bagi semua doktor, pakar perubatan atau hospital yang kepadanya Pesakit telah dirujuk atau dirawat untuk penyakit ini. Date Tarikh Name of Doctor/Specialist/Hospital Nama Doktor/Pakar Perubatan/Hospital Address of Doctor/Specialist/Hospital Alamat Doktor/Pakar Perubatan/Hospital (l) Have you treated the Patient for any other illness? If yes, for what complaint and when? / Pernahkah anda merawat Pesakit kerana apa- apa penyakit yang lain? Jika pernah, apakah penyakitnya dan bila? 4. Please give any other information which in your opinion will assist our Chief Medical Officer in assessing this claim. / Sila berikan apa-apa maklumat lanjut yang ada pada pendapat anda dapat membantu Ketua Pengawai Perubatan kami menilai tuntutan ini. I hereby declare that the foregoing answers are each and all true to the best of my knowledge and belief. Saya dengan ini mengaku bahawa setiap dan semua jawapan di atas adalah benar sepanjang pengetahuan dan kepercayaan saya. Signature of Doctor / Tandatangan Doktor Name of Doctor / Nama Doktor: (In Block Letters / Dengan Huruf Besar ) Qualification/ Kelayakan: Address and Official Stamp / Cop Amalan Date / Tarikh:

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