BORANG CADANGAN IKHLAS RETAIL NIAGA IKHLAS NIAGA TAKAFUL (RETAIL NIAGA) PROPOSAL FORM
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1 A. IKHLAS Point, Tower 11A, Avenue 5, Bangsar South, No. 8, Jalan Kerinchi, Kuala Lumpur Tel : Fax : Call Centre No : Website : PENCADANG / THE PROPOSER TAKAFUL IKHLAS SDN BHD. ( U) (A wholly-owned subsidiary of MNRB Holdings Berhad) 1. Nama Penuh Pencadang / Full Name of Proposer Untuk Kegunaan Pejabat / For Office Use Only: No Nota Lindungan / Cover Note No. No Sijil / Certificate No. Kod Ejen / Agent Code No Siri / Serial No. BORANG CADANGAN IKHLAS RETAIL NIAGA IKHLAS NIAGA TAKAFUL (RETAIL NIAGA) PROPOSAL FO KENYATAAN MENGIKUT SEKSYEN 28 AKTA TAKAFUL Anda hendaklah memaklumkan di dalam Borang Cadangan ini, secara telus dan jujur, segala fakta di dalam pengetahuan anda atau maklumat yang anda patut tahu, jika tidak Sijil yang dikeluarkan dengan sendirinya terbatal. STATEMENT PURSUANT TO SECTION 28 of THE TAKAFUL ACT You are to disclose in this Proposal Form, fully and faithfully, all the facts which you know or ought to know otherwise the Certificate issued hereunder may be void. 2. No. KP baru / No. Pendaftaran Perniagaan / New IC No. / Company No. 3. Alamat Surat Menyurat Correspondence Address 4. No. Telefon / Telephone No. Pejabat / Office Rumah / House Bimbit / Hand Phone 5. E-mel / 6. Pemegang Gadai Janji Mortgagee / Lessor Poskod / Postcode Negeri / State Bandar / Town 7. No. Akaun Bank (Untuk tujuan pulangan wang Sumbangan pembahagian lebihan dan / atau tuntutan. Contoh: MBB0001) Bank Account No. (For the purpose of refund of Contribution, surplus distribution, and / or claim. E.g.: MBB0001) 8. Lokasi Risiko / Risk Location Poskod / Postcode Negeri / State Bandar / Town 9. Tempoh Takaful : Dari Period of Takaful : From HH/DD BB/MM B. BUTIR-BUTIR BANGUNAN / DETAILS OF THE BUILDING TTTT/YYYY Hingga To HH/DD BB/MM TTTT/YYYY 1. Jumlah tingkat / No. of storeys : Tahun dibina / Year built : 2. Jenis perlindungan kebakaran sekiranya ada (sila nyatakan) / Type of fire protection if any (please specify) : Ya / Yes Tidak / No C. 1. Berdasarkan mana-mana risiko yang anda ingin lindungi : In respect of any of the risks against which you wish to cover : 2. SOALAN BERIKUT MESTI DIJAWAB OLEH PENCADANG THE FOLLOWING QUESTIONS MUST BE ANSWERED BY THE PROPOSER Pernahkah mana-mana syarikat Insurans/pengendali Takaful menolak cadangan anda, enggan memperbaharui polisi/sijil anda atau mengenakan syarat khas? Has any previous Insurance company/takaful operator declined your proposal, refused to renew your policy/ Certificate or imposed special terms or conditions? Pernahkah anda mengalami kerugian, kemusnahan atau kerosakan atau membuat tuntutan atau pernahkah tuntutan dibuat terhadap anda selama 3 tahun yang lalu? Have you incurred any loss, destruction or damage or any claim or had any claim made against you during the last 3 years? Ya / Yes Ya / Yes Tidak / No Tidak / No Sekiranya jawapan anda "Ya" pada soalan diatas, sila nyatakan dengan terperinci nama syarikat Insurans/pengendali Takaful yang lalu, tarikh dan jumlah yang dibayar atau baki tuntutan yang belum dibayar : If you answered "Yes" to any of the above, please give full details below including name(s) of previous Insurance company(s)/takaful operator, dates and amounts paid or outstanding in respect of any claim :
2 D. KETERANGAN MANFAAT DAN BUTIRAN PERLINDUNGAN SERTA SUMBANGAN DETAILS OF BENEFIT, COVERAGE AND CONTRIBUTION KLASIFIKASI PERNIAGAAN / PEKERJAAN TRADE / OCCUPATION CLASSIFICATION KADAR KEBAKARAN / FIRE RATING KELAS / CLASS 1A Dagangan Am / Retail Trading Perniagaan Am / General Merchandise Pakaian / Kasut Clothing / Footwear Kedai buku / Bookshop Makanan, dagangan am, barang-barang runcit (kecuali ubatan cina, makanan mahal termasuk sirip ikan jerung, sarang burung, abalone dan sebagainya), pembuat konfeksi dan biskut, penjual kek (tanpa membakar). Foodstuff, sundry goods (excludes chinese medicine, expensive foodstuff such as sharkfins, bird nest, abalone, etc.), confectionary & biscuit, cake house (without baking). butik, kasut boutiques, shoes Buku, majalah, alat tulis dan produk kertas / Books, magazines, stationery and paper products Aksesori / Perhiasan Isi Rumah / Peralatan Pejabat Furnishing / Household / Office Equipment langsir & aksesori, permaidani, jubin, peralatan kebersihan, lampu, lampu perhiasan, pinggan mangkuk, kutleri, barangan dapur, mesin taip, kabinet besi, kalkulator dan lain-lain peralatan pejabat (tanpa komputer & komputer riba). curtains & its accessories, carpets, tiles, sanitary ware, lightings accessories, crockery, cutlery, kitchen wares, typewriters, metal cabinet, calculator and other office equipment (excluding computers, laptops and all computer related) Salun / Salon Kecantikan dan dandanan rambut / Hair dressing and beauty Simpanan Dagangan Am / Storage of General Merchandise Restoran / Restaurant Kedai kopi dan restoran / Coffee shop and restaurants PELAN / FAEDAH / PLANS / BENEFITS SEKSYEN PERLINDUNGAN JUMLAH DILINDUNGI / HAD LIABILITI () SECTION COVERAGE SUM COVERED / LIMITS OF LIABILITY () A B C KEBAKARAN / FIRE Perlindungan : kebakaran, kilat, kerosakan disebabkan oleh Untuk ditentukan oleh Peserta (Jumlah Dilindungi untuk Seksyen ini rusuhan, mogok dan perbuatan khianat, pecahan atau sepatutnya tidak melebihi 5,000, Jika melebihi, hendaklah dirujuk limpahan dari tangki air atau paip, gempa bumi & letupan kepada pihak Syarikat) gunung berapi. Coverage : fire, lightning, riot, strike & malicious damage, bursting & overflowing of water tanks or pipes & apparatus, earthquake & volcanic eruption KECURIAN / BURGLARY Kehilangan atau kerosakan kepada harta benda yang dilindungi di bawah Seksyen A / Loss of or damage to Property Covered under Section A Perlindungan minima untuk Seksyen B : Semua pintu keluar / masuk termasuk tingkap mesti dilindungi. Minimum protection for Section B : All entrances / exits including windows must be protected. WANG / MONEY Kehilangan duit ketika dalam perjalanan, dalam jagaan atau dalam tanggungan Peserta. Loss of monies whilst in transit, in custody of, in charge of the Participant. i) Wang ketika di dalam kediaman Peserta Money in the Participants premises (s) Semasa waktu perniagaan - tersimpan di dalam peti keselamatan berkunci / peti besi keselamatan / di dalam laci berkunci dan kotak wang tunai. During business hours - in locked safe / strong room / locked drawers / cash boxes To be determined by the Participant (Total Sum Covered for this Section should not exceed 5,000, If exceed this amount, refer to the Company). PELAN / PLAN A PELAN / PLAN B 30, , , PELAN / PLAN C 80, , Selepas waktu perniagaan - simpan di dalam peti keselamatan berkunci / peti besi After business hours - in locked safe / strong room 2, , ,000.00
3 ii) Wang tunai di dalam perjalanan dari kediaman Peserta hingga bank dan sebaliknya Money in transit from Participant's premises to the bank and vice versa 3, , D On insured legal liability to third parties for bodily injury / death and / or property damage. 500, dalam suatu jangka masa any one period 1,000, dalam suatu jangka masa E KEPINGAN KACA / PLATE GLASS Cermin tetap sehingga / fixed glasses 3, , F LIABILITI MAJIKAN / EMPLOYER'S LIABILITY Pekerja / kakitangan / On Employees 100, , G iii) Kemalangan Diri akibat (Diserang) setiap orang Personal Accident (Assault) per person (Bil. Maksima Individu 2) (Maximum no. of person - 2) LIABILITI AWAM / PUBLIC LIABILITY Liabiliti undang-undang kepada Peserta terhadap kecederaan 150, , , anggota / kematian dan / atau kerosakan harta benda ke atas mana-mana kemalangan mana-mana kemalangan mana-mana kemalangan pihak ketiga. any one accident any one accident any one accident KEMALANGAN BERKELOMPOK - Untuk kematian dan kehilangan upaya menyeluruh tetap. Sila lampirkan senarai nama yang dilindungi. (Terhad kepada 6 orang yang dinamakan). Sekiranya lebih daripada 6 orang yang dilindungi, tambahan Sumbangan akan dikenakan. GROUP PERSONAL ACCIDENT - On death and permanent disablement. Please attach list of names to be covered. (Limited to 6 named persons). If more than 6 named persons to be covered, additional Contribution would be applied. any one period 15, seorang seorang per person per person 1,000, dalam suatu jangka masa any one period 200, , seorang per person SUMBANGAN / CONTRIBUTIONS PENGIRAAN SUMBANGAN / COMPUTATION OF CONTRIBUTION JUMLAH KADAR* SUMBANGAN SEKSYEN PERLINDUNGAN TAKAFUL DILINDUNGI RATE* CONTRIBUTION SECTIONS TAKAFUL COVERAGE SUM COVERED % () () (i) (ii) (i) x (ii) KEBAKARAN / FIRE Perlindungan : kebakaran, kilat dan Peril yang dipilih. Coverage : fire, lightning and selected Perils a. Bangunan / On Building b. Peralatan Pejabat / On Office Equipment A c. Peralatan, Kelengkapan dan Perabot / On Fixtures, Fittings and Furniture d. e. Jumlah Sumbangan untuk Seksyen A / Total Contribution for Section A * Kadar merujuk kepada jenis perniagaan / klasifikasi pekerjaan seperti yang disenaraikan di atas. * Rate is based on the type of trade occupation classification as mentioned above. B to F Sila tandakan ( ) pelan yang diperlukan untuk Seksyen B hingga F Please tick ( ) the plan required for Section B to F PELAN / PLAN A PELAN / PLAN B PELAN / PLAN C G Sila tandakan ( ) pelan yang diperlukan untuk Seksyen G PELAN / PLAN A PELAN / PLAN B PELAN / PLAN C Please tick ( ) the plan required for Section G Bayaran seorang dikenakan untuk penambahan nama yang dilindungi. Subject to per person for additional person to be covered
4 JUMLAH SUMBANGAN UNTUK SEKSYEN A / TOTAL CONTRIBUTION FOR SECTION A JUMLAH SUMBANGAN DALAM SEKSYEN B hingga F (Seperti pelan yang diperlukan) TOTAL CONTRIBUTION OF SECTION B to F (Based on plan required) JUMLAH SUMBANGAN UNTUK SEKSYEN G / TOTAL CONTRIBUTION FOR SECTION G JUMLAH SEKSYEN A HINGGA G / SUB TOTAL SECTION A TO G 6% CUKAI PERKHIDMATAN / SERVICE TAX DUTI SETEM / STAMP DUTY JUMLAH SUMBANGAN / TOTAL CONTRIBUTIONS E. AQAD DAN KEBENARAN / DECLARATION AND AUTHORIZATION Saya / Kami dengan ini mengaku bahawa semua pernyataan di atas dan dokumen yang disertakan berhubung dengan permohonan ini adalah lengkap dan benar sepanjang pengetahuan dan kepercayaan Saya / Kami. Saya/ Kami bersetuju bahawa segala pernyataan dan akuan yang terkandung dalam borang permohonan ini akan menjadi asas kepada Sijil Takaful antara Saya / Kami dan Takaful Ikhlas Sdn Bhd (selepas ini dirujuk sebagai "pihak Syarikat") dan ianya disifatkan sebagai termaktub dan menjadi pelengkap Sijil. Saya / Kami bersetuju bahawa Sumbangan Takaful Saya / Kami akan ditempatkan di dalam Akaun Pelaburan Risiko Am (GRIA) dan akan diuruskan oleh pihak Syarikat berdasarkan prinsip Wakalah sebagaimana yang ditakrifkan oleh pihak Syarikat serta menepati Syariah. Saya / Kami bersetuju membenarkan pihak Syarikat mengambil 30% daripada Sumbangan tersebut sebagai Yuran Wakalah. Lanjutan daripada itu, Saya / Kami juga bersetuju bahawa baki daripada Sumbangan Takaful Saya / Kami akan disalurkan ke dalam Dana Risiko berdasarkan Tabarru' (derma) untuk membantu Peserta lain yang ditimpa musibah dan baki yang masih ada di dalam Dana Risiko berkenaan akan dilaburkan oleh pihak Syarikat. Sebarang keuntungan daripada pelaburan tersebut, jika ada, akan dimasukkan semula ke dalam Dana Risiko. Saya / Kami juga bersetuju membenarkan pihak Syarikat menolak Caj Pengurusan Lebihan (SAC) 50% daripada lebihan boleh-agih kasar dari lebihan Dana Risiko pada setiap tahun. Walau bagaimanapun, pihak Syarikat boleh, mengikut budi bicara dan di mana bersesuaian, mengenakan caj kurang daripada 50% daripada lebihan boleh-agih kasar sebagai SAC. Saya / Kami juga memahami bahawa lebihan boleh-agih bersih dari Dana Risiko, jika ada, akan dikendalikan oleh pihak Syarikat mengikut kaedah dan peruntukan berlandaskan prinsip Syariah yang akan memanfaatkan Peserta. (Untuk maklumat lengkap, sila rujuk kepada Sijil Takaful yang berkenaan). "I / We hereby agree that all statements made above and other documents submitted in connection with this application are complete and true to the best of My / Our knowledge and belief. I / We agree that this declaration and all statements made above shall form the basis of the Takaful Certificate between Me / Us and Takaful Ikhlas Sdn Bhd (herein referred as "the Company") and they are deemed to be incorporated as an integral part of the Certificate. I / We agree that My / Our Takaful Contribution shall be placed in the General Risk Investment Account (GRIA) and shall be managed by the Company based on the Wakalah principle as defined by the Company and in accordance to Shariah. In return, I / We agree to allow the Company to deduct 30% of the Contribution as Wakalah fee. I / We further agree that the balance of My / Our Contribution shall be allocated into the Risk Fund on a Tabarru' (donation) basis and be used to help other Participants in time of misfortune and the remaining balance in the Risk Fund shall be invested by the Company. Any profit arising out of this investment, if any, shall be allocated to the Risk Fund. I agree to allow the Company to deduct a Surplus Administration Charge (SAC) of 50% from any gross distributable surplus arising from the Risk Fund. However, the Company may at its discretion and where appropriate charge less than 50% from gross distributable surplus as SAC. I / We also understand that the net distributable surplus arising from the Risk Fund, if any, shall be managed by the Company according to the method and allocation in accordance to the Shariah principle that will benefit the Participant." (For further details, please refer to the respective Takaful Certificates). KEBENARAN Saya dengan ini membenarkan pihak Syarikat untuk memperolehi sebarang maklumat tentang saya dan/atau syarikat saya dari manamana organisasi yang mempunyai pengetahuan tentang saya/syarikat saya dan memberi kebenaran kepada pihak Syarikat untuk menggunakan dan/atau berkongsi sebarang maklumat yang diproses tentang saya/syarikat saya bagi tujuan penyediaan perlindungan Takaful dan pengendalian tuntutan kepada pihak ketiga jika pihak Syarikat anggap ianya perlu. Saya juga faham bahawa pihak Syarikat akan memberikan sesalinan maklumat tentang saya yang diperolehi oleh pihak Syarikat kepada saya jika diminta. CONSENT I hereby consent and authorise the Company to seek any information related to me and/or my company from any organisation that has records or knowledge of me/my company and hereby consent that the Company may use/or share any information that the Company may have about me/my company being currently processed by the Company for the purpose of providing Takaful coverage and claims handling, to such third parties as the Company deems necessary. I hereby acknowledge that the Company will provide a copy of my personal information upon request. Tandatangan Pencadang/Signature of Proposer : Cop Syarikat/Company's Stamp: Tarikh/Date :
5 F. KAEDAH PEMBAYARAN / METHOD OF PAYMENT Saya membenarkan Pusat Kad Kredit untuk mendebit Akaun Kad Kredit saya sepertimana yang dinyatakan di bawah dan untuk membayar Takaful Ikhlas Sdn Bhd (TISB) jumlah Sumbangan yang sewajarnya bagi IKHLAS Retail Niaga yang saya sertai berjumlah (termasuk duti setem) Saya juga memahami bahawa pembayaran akan bermula selepas pihak Bank menerima dan memproses borang persetujuan ini. Saya bertanggungjawab memaklumkan pihak Bank dan TISB secara bertulis mengenai sebarang perubahan yang mungkin membatalkan arahan ini. I hereby authorize Credit Card Center to debit my Card Account as indicated below and to pay Takaful Ikhlas Sdn Bhd (TISB) the amount for the appropriate Contribution of IKHLAS Retail Niaga which I have agreed amounting to (Inclusive of stamp duty) I also understand that my first payment shall only commence after the Bank receives and processes the application form. It is my responsibility to advise the Bank and TISB by written notice of any change which invalidates this authorization. Nama Pemegang Kad : Name of Card Member : No Kad kredit : Tarikh Tamat : Credit Card No : Expiry Date : Tandatangan Pemegang Kad / Card Member's Signature Tarikh / Date G. 1. NOTA PENTING / IMPORTANT NOTES Sila ambil perhatian pada tempoh 60 hari waranti Sumbangan yang tercatat pada Sijil ini. Dengan waranti ini, Sijil Takaful dibatalkan secara automatik kecuali Sumbangan penuh di bayar kepada Takaful IKHLAS dalam tempoh 60 hari dari tarikh permulaan perlindungan. Sekiranya urusan Takaful ini melalui broker, broker ini bertindak bagi pihak anda atau untuk tujuan pembentukkan kontrak Takaful ini. Adalah penting anda membuat bayaran penuh Sumbangan kepada broker anda secepat mungkin dan pada bila-bila masa dalam tempoh 60 hari waranti Sumbangan untuk membolehkan broker anda mengirim Sumbangan awal kepada Takaful IKHLAS. Anda dinasihatkan untuk meminta broker anda memberi anda resit broker dan Takaful IKHLAS untuk Sumbangan yang telah anda bayar. Your attention is drawn to the 60 days Contribution warraty attached to the Certificate. By this warranty, the Takaful Certificate is automatically cancelled unless the full Contribution is paid to Takaful IKHLAS within 60 days from the commencement date of cover. Please note that if this Takaful is transacted through broker, the broker is acting on your behalf for the purpose of formation of this contract of Takaful. It is important that you make the full payment of the Contribution to your broker as soon as possible and in any case within 60 days period of the Contribution warranty so as to enable your broker to remit the Contribution early to Takaful IKHLAS. You are advised to request your broker to furnish you with the broker's and Takaful IKHLAS's receipt on the Contribution that you paid. 2. Segala terma dan syarat-syarat perlindungan Sijil ini adalah termaktub kepada persetujuan dari TAKAFUL IKHLAS SDN BHD. Unless otherwise agreed upon, TAKAFUL IKHLAS SDN BHD 's standard terms and conditions of the Certificate applies. 3. Perlindungan ini tidak akan berkuatkuasa selagi Borang Cadangan ini belum diterima oleh pihak Syarikat. No cover is in force until this Proposal Form has been accepted by the Company Sebarang perubahan kepada maklumat yang diberikan hendaklah dimaklumkan kepada pihak Syarikat dengan segera. Kegagalan melaporkannya, menyebabkan pihak Syarikat berhak untuk menolak semua tuntutan. Any changes in the information given must be reported to the Company immediately, otherwise the Company will reserve the right to decline all liabilities. Perlindungan yang disebutkan di dalam Borang Cadangan ini tidak bermaksud sebagai bahan bukti penerimaan oleh pihak Syarikat melainkan ianya telah dinyatakan di dalam Sijil / nota perlindungan yang mengesahkan perlindungan. Coverage(s) requested in this Proposal Form is not to be construed as an acceptance or commitment on the part of the Company unless the same is incorporated in the Certificate / cover note evidencing such cover Sijil akan dikeluarkan dalam tempoh tiga puluh (30) hari bekerja selepas permohonan anda diterima oleh pihak Syarikat, jika kesemua dokumendokumen (termasuk semua maklumat dan dokumen tambahan dari penaksiran pengunderaitan) yang lengkap diterima. Upon receipt of completed documents (including all additional information and documents arising from underwriting assessment), a Certificate will be issued within thirty (30) working days after your application is accepted by the Company. Adalah penting bagi anda untuk menyimpan resit yang diterima daripada pihak Syarikat sebagai bukti pembayaran Sumbangan. It is important for you to keep the receipt from the Company as proof of payment of the Contributions.
6 UNTUK KEGUNAAN EJEN ATAU PEJABAT / FOR AGENT'S OR OFFICE USE ONLY PENGESAHAN IDENTITI PELANGGAN / VERIFICATION OF CUSTOMER S IDENTITY (Seperti di dalam Peruntukan Akta Pencegahan Pengubahan Wang Haram & Pencegahan Pembiayaan Keganasan 2001) (As per requirement on Anti-Money Laundering & Anti-Terrorism Financing Act 2001) (Untuk Kegunaan Kakitangan Syarikat atau Perantara Sahaja) / (For Use by a Company Staff or Intermediary only) Saya dengan ini mengaku bahawa saya telah melihat Kad Pengenalan / Sijil Kelahiran / Pasport / dokumen pendaftaran syarikat yang berkaitan / surat / dokumen pengesahan individu yang mewakili syarikat dan mengesahkan pengenalan/ identiti Pencadang / Peserta dengan menggunakan dokumen-dokumen tersebut. I hereby declare that I have sighted the original NRIC / Birth Certificate / Passport / company-related registration document / authorization letter/documents for any person authorized to represent the company and verified the identity of the Proposer / Participant through these documents. Signature NRIC No. Name Designation
BORANG CADANGAN IKHLAS NIAGA TAKAFUL ( OFFICE NIAGA) IKHLAS NIAGA TAKAFUL (OFFICE NIAGA) PROPOSAL FORM
A. IKHLAS Point, Tower 11A, Avenue 5, Bangsar South, No. 8, Jalan Kerinchi, 59200 Kuala Lumpur Tel : 03-2723 9999 Fax : 03-2723 9998 Call Centre No : 03-2723 9696 Website : www.takaful-ikhlas.com.my PENCADANG
More informationGUW-PFR029/00 Permata (01/12/11)
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