BORANG CADANGAN IKHLAS BURGLARY TAKAFUL IKHLAS BURGLARY TAKAFUL PROPOSAL FORM
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1 TAKAFUL IKHLAS SDN BHD. ( U) IKHLAS Point Tower 11A, Avenue 5, Bangsar South, No. 8, Jalan Kerinchi, Kuala Lumpur Tel : (General Line) Fax : (General Fax Line) Call Centre No : Website : Untuk Kegunaan Pejabat / For Office Use Only: No Nota Lindungan / Cover Note No. No Sijil / Certificate No. Kod Ejen / Agent Code (A wholly-owned subsidiary of MNRB Holdings Berhad) No Siri / Serial No. BORANG CADANGAN IKHLAS BURGLARY TAKAFUL IKHLAS BURGLARY TAKAFUL PROPOSAL FORM 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. A. BUTIRAN PENCADANG / PARTICULARS OF PROPOSER *Sila jawab semua soalan dengan lengkap. Tanda dan sempang adalah tidak memadai. *Please answer all questions fully. Ticks and dashes are not sufficient. 1. Nama Penuh Pencadang / Full Name of Proposer : No. Syarikat / Company No. : 3. Alamat Surat Menyurat : Correspondence Address : Poskod / Postcode Negeri / State Bandar / Town 4. No. Telefon / Telephone No. : Pejabat / Office Rumah / House Bimbit / Hand Phone 5. Alamat E-mel : Address : 6. Nama dan No. Akaun Bank (Untuk tujuan pulangan wang sumbangan, pembahagian lebihan dan / atau tuntutan. Contoh: MBB0001) Name and Bank Account No. (For the purpose of refund of contribution, surplus distribution, and / or claim. E.g.: MBB0001) Jenis Pekerjaan / Perniagaan : Type of Occupation / Business : 8. Tempoh Takaful : Period of Takaful : Dari From Hingga HH/DD BB/MM TTTT/YYYY To HH/DD BB/MM TTTT/YYYY 9. Lokasi Risiko : Risk Location : Poskod / Postcode Negeri / State Bandar / Town B. MAKLUMAT PENUH BERKENAAN HARTA YANG HENDAK DILINDUNGI / FULL DESCRIPTION OF PROPERTY TO BE COVERED Amaun dilindungi untuk 1, 2 dan 3 mestilah mewakili nilai sepenuhnya harta anda dimana tuntutan akan dibayar mengikut kadar atau bahagian amaun dilindungi bergantung kepada nilai sepenuhnya ketika berlaku kerugian. The Sum to be covered under 1, 2 and 3 should represent the full value of the property as claims will be settled in the proportion that the sum covered bears to the full value at the time of loss. Sekiranya anda ingin melindungi harta anda berdasarkan selain daripada nilai penuh, sila nyatakan dikotak bagi 1, 2 dan 3 yang disediakan dibawah. If you wish to cover the property on a basis of other than the full value, would you please indicate your requirements in the box below in respect of each of the items 1, 2 and 3.
2 1. Stok dan barang dagangan serta kerja-kerja yang sedang dijalankan dimiliki oleh anda atau dibawah jagaan anda atau dibawah tanggungan anda terdiri daripada : Stock and materials in trade and work in progress belonging to you or held by you in trust or on commission for which you are responsible, consisting of : (Nilai maksima bagi setiap satu barang.) (Maximum value of any single article.) Amaun Perlindungan / Sum to be Covered Nilai Penuh Nilai Kerugian Pertama Full Value / First Loss Perabut perniagaan, lekapan, lengkapan, mesin, peralatan, corak, model, acuan, pelan dan rekaan dimiliki oleh anda atau dimana anda bertanggungjawab dan sebarang pengubahsuaian yang telah anda buat dimana anda bertanggungjawab ke atasnya. Business furniture, fixtures, fittings, machines, plant and appliances, patterns, models, moulds, plans and designs belonging to you or for which you are responsible and alterations and decorations made by you as a tenant for which you are responsible. 3. Lain-lain harta selain dari 1 dan 2 di atas, Other property, not included in 1 and 2 above, (terdiri daripada) (consisting of) Jumlah Keseluruhan 1, 2 dan 3 / Total Sum to be Covered (1, 2 and 3) : C. BUTIRAN PREMIS ANDA DAN KAWALAN KESELAMATAN / DETAILS OF YOUR PREMISES AND SECURITY ARRANGEMENT 1. a) Jenis premis dimana harta yang akan dilindungi, disimpan - seperti kedai, kilang, bengkel, gudang, pejabat dan lain-lain. Nature of premises containing the Property to be covered - e.g. shop, factory, workshop, warehouse, offices, etc. b) Binaan premis? / How is the premises constructed? i) dinding / walls ii) atap / roof c) Berapa lamakah pencadang mendiami premis berkenaan / How long has the Proposer occupied the premises? d) Adakah situasi dimana premis ini akan ditinggalkan tanpa pengawasan kakitangan yang bertanggungjawab? To what extent will the premises be left without a responsible person therein? i) siang? / by day? ii) malam? / by night? Adakah rekod disimpan dengan lengkap berkenaan stok diterima dan dijual? Jika "Tidak", bagaimana amaun kerugian dapat ditentukan secara tepat? Will a complete record of stock received and sold be kept? If "No", how would the exact amount of a loss be ascertained? 3. Adakah alat penggera penceroboh dipasang? (Jika lebih daripada satu premis, sila lampirkan huraian anda.) Jika "Ya", sila berikan keterangan a), b), dan C) di bawah. Is an intruder alarm installed? (If more than one premises, please use a separate sheet) If "Yes", give details under a), b) and c)below. a) Nama bagi syarikat pemasang alat penggera / Name of alarm installation company b) Bahagian manakah di premis ini yang dilengkapi alat penggera ini. (Sila lampirkan lakaran untuk menjelaskan jawapan tersebut.) Which parts of the premises are alarm protected? (Use a sketch Plan on the space provided to indicate the above points.) c) Adakah kontrak penyelenggaraan ditetapkan? / Is there a maintenance contract in force? d) Adakah sistem kawalan pusat (CMS) dihubungkan kepada sistem penggera? Jika ada, sila lampirkan salinan perjanjian CMS yang telah ditandatangani. Is there a central monitoring system (CMS) attached to alarm? If so please attach a copy of CMS agreement signed between you and the alarm company. 4. Adakah anda mengupah pengawal keselamatan untuk mengawasi premis ini ketika diluar waktu perniagaan? Jika "Ya", sila huraikan. Do you employ security staff when your premises is closed for business? If "Yes", please give details
3 5. Huraikan secara ringkas alat-alat keselamatan (seperti jenis kunci, alat-alat penutup) dimana ianya digunakan. (Jika boleh, sila berikan buatan kunci) Briefly describe the security devices (e.g. type of locks, shutters etc.) which are used on (Provide makes of locks if possible). a) pintu luar / external doors b) tingkap hadapan / front windows c) lain-lain tingkap luaran / other external windows d) tingkap di bumbung bangunan / skylights e) lain-lain bukaan luaran (seperti pintu di bumbung) / other external openings (e.g. trap doors), comprising : 6. Adakah semua pintu, tingkap atau sebarang bukaan dikunci rapi ketika di luar waktu perniagaan. Jika "Ya", sila huraikan sistem kawalan yang digunapakai. Are all external doors, windows and other openings fastened and locked when your premises is closed for business. If "Yes", please provide details of your security arrangements. Adakah barangan berharga disimpan dengan rapi di peti keselamatan ketika diluar waktu perniagaan? Jika "Ya", sila berikan butiran untuk a), b) dan c) dibawah. Will articles of value be secured in a safe when the premises is closed for business? If "Yes", give brief details under a),b) and c) below. a) Maklumat Peti Keselamatan / About the safe : Pengeluar Manufacturer Model Model Tarikh dibuat, jika diketahui Date of Manufacture, if known Berat, jika diketahui Weight, if known Adakah ianya dibina di dalam atau dilekapkan ke struktur premis? Is it built into or fixed to the structure of the premises? b) Kunci keselamatan - adakah semua kunci untuk peti keselamatan dialihkan dari premis ketika premis ditutup? Key security - are all keys to the safe removed from the premises when closed? c) Apakah jenis dan nilai terendah barangan yang disimpan di peti keselamatan? What is the nature and minimum value of the items placed in the safe? D. 1. PERLINDUNGAN TAKAFUL / INSURANS DAN PENGALAMAN KERUGIAN YANG LEPAS TAKAFUL / INSURANCE AND PREVIOUS LOSS HISTORY Adakah anda pernah dilindungi daripada "Perlindungan Kecurian" atau "Perlindungan Semua Risiko"? Jika "Ya", sila berikan nama Pengendali Takaful / Insurans. Have you previously covered against either "Theft" of "All Risks"? If "Yes", please give name(s) of Takaful operator(s) / Insurer(s). Sepanjang 5 tahun lepas, adakah sebarang kecurian atau cubaan memasuki premis ini atau mana-mana premis yang didiami oleh anda? Jika "Ya", sila jelaskan. During the last 5 years, have thieves ever entered or attempted to enter, of these or any other premises occupied by you? If "Yes", please provide details. Tarikh Date Nilai Kehilangan Amount of Loss Harta yang Terlibat Property Lost Butiran Circumstances 3. Pernahkah Syarikat Insurans / Pengendali Takaful untuk Perlindungan Kecurian bagi risiko yang dicadangkan ini Has any Insurer / Takaful Operator in respect of the risks to which this proposal relates ever a) menolak, enggan memperbaharui atau membatalkan perlindungan. Jika "Ya", sila berikan butiran. declined a proposal, refused renewal or terminated an insurance / takaful. If "Yes", please give details. b) mengenakan tambahan pada sumbangan untuk pembaharuan atau meletakkan terma khas? Jika "Ya", sila berikan butiran. required an increase of contribution or imposed special conditions? If "Yes", please give details.
4 4. Adakah anda atau mana-mana ahli lembaga pengarah atau rakan kongsi perniagaan anda yang pernah disabitkan atau didakwa (tetapi belum dibicarakan) dengan rompakan, atau sebarang kesalahan yang berkaitan dengan harta benda? Jika "Ya", sila berikan butiran. Have you, or any director or partner in business, ever been convicted of or charged (but not yet tried) with theft, or a related offence, or any other offence against property? If "Yes", please provide details. 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 dimasukkan ke 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 40% 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 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 40% 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 any 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. NOTA PENTING / IMPORTANT NOTES 1. Segala terma dan syarat-syarat perlindungan 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 Syarikat. No Cover is in force until this Proposal has been accepted by the Company Untuk perhatian anda, perlindungan ini adalah tertakluk kepada warranti sumbangan 60 hari. Dengan waranti ini, perlindungan ini akan dihentikan dengan serta-merta melainkan sumbangan telah dibuat dalam tempoh 60 hari dari tarikh perlindungan ini berkuatkuasa. Your attention is drawn to the 60 days Contribution Warranty attached to the Certificate. By this warranty, the certificate is automatically cancelled unless the full contribution is paid to the Company within 60 days from the commencement date of cover. Sebarang perubahan kepada maklumat yang diberikan hendaklah dimaklumkan kepada Syarikat dengan segera. Kegagalan memaklumkannya memberi pihak Syarikat hak untuk menolak semua tanggungan. 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. 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
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