1. You are to disclose in this form, fully and faithfully, all the facts which you know or ought to know, or the policy issued may be void.

Transcription

1 LIFE INSURANCE ARCHIPELAGO ENDOWMENT ALPHA SERIES 28 CLOSE-ENDED 24-MONTHS ENDOWMENT 10% FIXED COUPON AT MATURITY PROPOSAL FORM - INDIVIDUAL & NON-INDIVIDUAL Archipelago Life Isurace Limited (A Life Isurer Licesed by Labua FSA) Co. No. LL09829 Licece No. IS INSTRUCTIONS 1. You are to disclose i this form, fully ad faithfully, all the facts which you kow or ought to kow, or the policy issued may be void. 2. Please complete the form i CAPITAL LETTERS. All fields are madatory. Use blue/black ik oly. 3. Please idicate all optios selected with a [X]. 4. Please esure all iformatio provided is accurate. 5. Please iitial ay amedmets made. 6. Please submit completed applicatio form together with the required documets i the checklist below to: customerservice@archipelagoltd.com or fax to by 12.00PM o Friday 29 th Jue The Admiistrator will oly process this applicatio whe all required documets are received. Archipelago Life Isurace Limited ( Archipelago Life ) reserves the right to reject ay applicatio which is deemed icomplete. DOCUMENT CHECKLIST Completed Edowmet Applicatio Form For Idividual: Photocopy NRIC or Valid Passport For No-Idividual Memoradum & Articles, Form 24 & 49, Compay Registratio Certificates For Etity A set of Board of Directors Resolutio / Madate Proof of Telegraphic Trasfer (TT) ito the Archipelago Life Isurace s bak accout. Photocopy of Life Assured s NRIC or Valid Passport (If differet from proposer/ ower) KYC & Compliace Iformatio Form Foreig Accout Tax Compliace Act (FATCA) Idividual/Corporate (Proposer) A. DETAILS OF LIFE ASSURED Salutatio : Mr / Mrs / Miss / Ta Sri / Dato / Dr. / Ir. / (Others, pls state) : Full Name (As per NRIC/Passport, please uderlie surame) : Date of Birth : DD/MM/YYYY Natioality : Religio : NRIC / Passport No : Coutry of Passport Issued : Geder : Male Female Height : cm Weight : kg OR lbs Marital Status : Sigle Married Separated Divorcee Widow Permaet Address : Correspodece Address : (If same as above, tick here ) Postal Code : Postal Code : Telephoe No : Fax No : Occupatio : Compay Name : Nature of Busiess : Page 1 / 6

2 A. DETAILS OF LIFE ASSURED (cotiued) 1. Are you i good health ow? YES NO If o, please specify: 2. Ay itetio to take part i a aerial flight other tha as a YES NO If yes, please specify: fare-payig passeger with a commercial airlie? 3. Do you egage or ited to egage i ay busiess, sport or YES NO If yes, please specify: occupatio of a hazardous ature? 4. Have you udergoe or are you expectig to udergo ay surgical YES NO If yes, please specify: operatio? 5. Have you ever made a applicatio for a life/family, disability or dread YES NO If yes, please specify: disease assurace/ Takaful to this or ay other compay which has bee declied, postpoed, withdraw, is still cosidered or beig accepted with a extra premium or o special terms? 6. Are you makig or have you made ay claims o ay policies with YES NO If yes, please specify: ay other compay? 7. Have you cosulted ay doctor for ay medical complait or tests or YES NO If yes, please specify: advice sice the date of applicatio of the above certificate? 8. For Female perso covered oly, a. Are you pregat ow? YES NO If yes, how may moths: b. Do you suffer from a hypertesio or diabetes or has there bee ay YES NO If yes, please specify: complicatios related to your pregacy? 9. Do you smoke? YES NO If yes, please state umber of sticks smoked per day: 10. Have either of your atural parets or ay sibligs ever suffered YES NO If yes, please specify: or died from blood disease, liver disease, heart or kidey disease, stroke, diabetes, hypertesio, metal disorder, tuberculosis, cacer, hemophilia, AIDS, or AIDS related complex, multiple sclerosis, Hutigto s disease, polycystic kidey disease, polyposis of the colo or ay other hereditary disorder? B. DETAILS OF PROPOSER (If Differet from Life Assured) ( POLICY OWNER ) Salutatio : Mr / Mrs / Miss / Ta Sri / Dato / Dr. / Ir. / (Others, pls state) : Full Name (As per NRIC/Passport, please uderlie surame) : Date of Birth : DD/MM/YYYY Natioality : Religio : NRIC / Passport No : Coutry of Passport Issued : Geder : Male Female Marital Status : Sigle Married Separated Divorcee Widow Permaet Address : Correspodece Address : (If same as above, tick here ) Postal Code : Postal Code : Telephoe : Fax No : Mobile No : Address : Relatioship to Life Assured : CONTINGENT OWNER Full Name (Please uderlie surame) : Relatioship to Proposer/ Ower : NRIC/ Passport No. : Page 2 / 6

3 C. DETAILS OF PROPOSER / OWNER (NON-INDIVIDUAL) Type of Busiess Etity : Sd. Bhd / Pte. Ltd Others Etity Name : Etity Registratio No : Busiess Address : Correspodece Address : (If same as above, tick here ) Postal Code : Postal Code : Telephoe : Fax No : Mobile No. : Authorised Cotact Perso : D. BANK ACCOUNT DETAILS The Bak Accout Details of the Policy Ower are eeded for the creditig of maturity procedure. The ous is therefore o the Policy Ower to iform Archipelago Life Isurace Limited of ay charges to the Bak Accout details durig the teure of the Edowmet. It must be forwarded i writig to Archipelago Life Isurace Limited, together with proof thereof. Paymets will oly be made to the bak accout i the ame of the Policy Ower oly. No paymets shall be made ito third-party accouts, icludig credit cards ad market-liked accouts. Name of Accout Holder : Name of Bak : Locatio of Brach : Accout No : SWIFT / IBAN Code : I/ We uderstad that uder the requiremets of Ati-Moey Lauderig, Ati-Terrorism Fiacig ad Proceeds of Ulawful Activities Act 2001 ad FATF 40 Recommedatios Guidelies, Archipelago Life Isurace Limited s policy requires it to be satisfied as to the source of fuds before acceptig the fuds for purchasig of life isurace product(s). Source of Fuds (Compulsory) : E. METHOD OF PAYMENT Please telegraph-trasfer (TT) your sigle lump sum of edowmet directly ito the followig accout: Accout Name: Archipelago Life Isurace Limited (No-Residet Accout) Accout No: SWIFT Code: Bak: Brach: MFBBMYKLXXX Alliace Bak Malaysia Berhad Uit A-OG-02, Block A Plaza Mot Kiara 2 Jala Kiara Mot Kiara Kuala Lumpur Terms ad Coditios: Archipelago Life Isurace Limited ONLY ACCEPTS a sigle lump via Telegraphic-Trasfer (TT) of the full edowmet premium amout. NO OTHER PAYMENT METHODS WILL BE ACCEPTED. Bak s correspodece or aget charges for the TT will be bore by the Cliet. The trasactio(s) are subjected to the rules, regulatios ad market practices of the coutry of paymet. Archipelago Life Isurace Limited shall ot be liable for ay losses or delays caused by ay such rules, regulatios ad market practices. Please provide proof of trasfer. TT may ot reflect i the amout immediately ad may take up 2-4 busiess days to reflect i the said accout. Page 3 / 6

4 F. ENDOWMENT PREMIUM Archipelago Edowmet Alpha USD20,000 miimum i USD10,000 deomiatios Amout (USD) : Maximum subscriptio per policy is USD100,000 (per idividual),,. G. BENEFICIARY NOMINATIONS (ONLY applicable if the Policy Ower ad Life Assured are the same atural perso) Beeficiaries for Proceeds Beeficiary(ies) are oly etitled to the beefit upo death of the life assured. You may omiate oe or more beeficiaries uder this policy. Please esure you provide NRIC/passport o of the beeficiary(ies); otherwise the Nomiatio of a Beeficiary will ot be accepted. You may chage the beeficiaries appoited i this applicatio by otifyig Archipelago Life Isurace Limited i writig ad which must be received before your death. If o beeficiary is omiated, the executor of your estate will advise Archipelago Life Isurace Limited of the atural perso(s) etitled to receive the proceeds, failig which the proceeds may be payable to your estate subject to the requiremets of the regulatory authority ad/or legislatio. I accordace with the Labua Fiacial Services ad Securities Act 2010 (LFSSA 2010): Sectio It states that a omiatio by a policy ower, other tha a Muslim policy ower, shall create a trust i favour of the omiee of the policy moies payable upo the death of the policy ower IF the omiee is a spouse or child of the policy ower, or where there is o spouse or child livig at the time of omiatio, the omiee is the paret. A paymet uder this sectio shall NOT form part of the estate of the deceased policy ower or be subject to his/her debts; OR Sectio It states that a omiee, other tha a omiee uder Sectio 121, shall receive the policy moies payable o the death of the policy ower as a executor ad ot solely as a beeficiary ad ay paymet to the omiee shall form part of the estate of the deceased policy ower ad be subject to his debts. This sectio also applies to a omiee of a Muslim policy ower who, o receipt of the policy moies, shall distribute the policy moies i accordace with the Shariah Priciples. Full Name (Uderlie Surame) Relatioships to Shares of beefits NRIC / Passport No. Life Assured % TOTAL 100% If there are additioal beeficiaries, please attach the above iformatio o a separate Beeficiary Nomiatio Form. Please esure the total percetages omiated are equal to 100%. Appoitmet of Trustee The policy ower may appoit a Idividual or Corporate Trustee for the policy moies. Where o Trustee is appoited, the omiee who is competet to cotract, or where the omiee is icompetet to cotract, the paret of the icompetet omiee ad where there is o survivig paret, the Public Trustee shall be the trustee of the policy moies. Name of Trustee Idividual OR NRIC / Passport No. / Corporate Compay Registratio No. Page 4 / 6

5 H. PERSONAL DATA PROTECTION ACT Archipelago Life Isurace Limited ( Isurer ) udertakes that all persoal data acquired from the Isurer from the applicatio date shall oly be used strictly for the purposes of this Edowmet Policy. 2. Ay iformatio ad data provided by the policy ower to the Isurer ad by the Isurer to the policy ower ad used by the Isurer directly or idirectly i the cotext of this Isurace Policy shall be govered by the provisios i the Persoal Data Protectio Act 2010 (herei referred to as the Act ). 3. The Isurer will use ay persoal data to process your claims, admiister your pla, service our relatioship with you, provide you with products ad services ad evaluate their effectiveess, provide you with better customer service ad for statistical aalysis. 4. The policy ower cosets to the processig of the persoal data provided to the Isurer ad to the trasfer of such persoal data to other etities for the purposes of performace of the cotract. Such persoal data shall be govered by the persoal data protectio laws of that coutry. 5. The policy ower is resposible to esure that all data provided to the Isurer are accurate at all times ad is obliged to iform the Isurer of ay chages. You may request for access to, correctio, or deletio of your persoal iformatio or limit the processig thereof at ay time hereafter. 6. Your iformatio may also be used for fraud prevetio ad audit purposes. If you give us false or iaccurate iformatio ad we suspect fraud, we will record this. We may pass such iformatio to the law eforcemet or other legal agecies, govermet or judicial bodies, or to regulators. 7. We may, from time to time, provide you with marketig iformatio about Archipelago Life Isurace Limited, our products ad services ad those associated compaies which may be of iterest to you. If you do ot wat us to use your details i this way, please Iitial here: I. DECLARATION AND AUTHORISATIONS I / We uderstad ad agree to be boud by the provisios of this applicatio form : 1. I / We hereby propose to Archipelago Life Isurace Limited for the subscriptio to the Close-Eded, Sigle Premium, 24-moth edowmet, 10% fixed coupo at maturity. 2. I / We ackowledge ad am / are aware that this is a o-deposit product. 3. I / We uderstad ad agree that this proposal, together with the policy summary ad terms ad coditios that will be issued to me/ us oce Archipelago Life Isurace Limited has accepted my/our proposal, ad ay other related documets provided by me/ us ad accepted by Archipelago Life Isurace Limited will gover the legal relatioship betwee Archipelago Life Isurace Limited ad me/ us. 4. I / We cofirm that all iformatio provided i this proposal form ad all other documets siged by me / us i coectio with this proposal, whether i hadwritig or ot, is true ad correct. 5. I / We are resposible for the accuracy ad completeess of all aswers or other iformatio provided by me/ us. 6. I / We are actig for my/ our ow accout. I / We have cosidered the suitability of this product ad made my/ our ow idepedet decisio to eter ito this edowmet pla. I / We uderstad that iformatio, opiios ad ay commuicatio from Archipelago Life Isurace Limited, whether writte, oral or implied, are expressed i good faith ad ot iteded as advice or recommedatio to eter ito this product. 7. I / We should seek idepedet legal ad/ or fiacial advice regardig this Edowmet Pla if I/ we deem it ecessary. 8. I / We uderstad that Archipelago Life Isurace Limited will accept istructios by facsimile, or other electroic meas from my/ our Fiacial Advisor/Isurace Broker oly if duly appoited ad authorised i writig by me. Archipelago Life Isurace Limited will ot be held liable for ay losses that may result from uauthorised istructios give by my/our Fiacial Advisor/ Isurace Broker. 9. I / We ackowledge that I am / We are aware that the Edowmet Pla is subjected to a 15-day coolig off period, startig from the date of receipt of policy. 10. I / We agree that Archipelago Life Isurace Limited shall pay to my/our beeficiary(s) upo my death i accordace with my beeficiary omiatios i this applicatio form, ad I / We authorise Archipelago Life Isurace Limited to do so. 11. I / We coset Archipelago Life Isurace Limited to make equiries of whatsoever ature for the purpose of verifyig the iformatio disclosed i this applicatio ad obtaiig ay other iformatio cocerig me/us from ay source whatsoever to eable Archipelago Life Isurace Limited to process this applicatio. 12. I / We hereby cofirm that I/We have read, uderstood ad agreed to the terms & coditios as stipulated i the Edowmet Pla policy cotract. Page 5 / 6

6 Sigature of Proposer/Authorised Sigatory(ies) (Compulsory) : Sigature of Life Assured (Compulsory) : Full Name : Full Name : Date : Date : Sigature of Witess : Official Stamp : Full ame : J. INTERMEDIARY DETAILS AND DECLARATION Itermediary Name : Itermediary Compay Name : Office No. : Mobile No. : I / We declare that: I / We are licesed Fiacial Advisor/ Broker uder Fiacial Services Act 2013 or Licesed Isurace Broker uder Labua Fiace Services & Securities Act 2010 to reder services i respect of this product. I / We have fully explaied ad disclosed the product details icludig features, beefits, risks relevat, terms ad coditios to my/ our Cliet. I / We have established ad verified (Customer Due Diligece) the idetity of my/ our cliet(s) i accordace with the Ati-Moey Lauderig, Ati-Terrorism Fiacig ad Proceeds of Ulawful Activities Act 2001 Sigature of Authorised Itermediary : K. CONTACT INFORMATION Archipelago Life Isurace Limited Co. No. LL09829 I Licece No. IS Registered Office Address: Brumby Cetre, Lot 42, Jala Muhibbah, Labua Federal Territories, Malaysia. Co-located Office: B-08-07, Gateway Corporate Suites, Gateway Kiaramas, No.1 Jala Desa Kiara, Mot Kiara, Kuala Lumpur, Malaysia. Telephoe : +6 (03) Fax : +6 (03) customerservice@archipelagoltd.com URL : L. FOR OFFICE USE ONLY Date Received : DD / MM / YYYY Complete Documetatio : AMLA Check : DD / MM / YYYY Acceptig Officer : System Iput : Yes No DD / MM / YYYY Iput Staff Name : Policy Number : Date of Issue : DD / MM / YYYY Date Dispatched / Couriered : DD / MM / YYYY Page 6 / 6

7 ENDOWMENT SERIES KNOW YOUR CLIENT (KYC) & COMPLIANCE INFORMATION FORM Archipelago Life Isurace Limited (A Life Isurer Licesed by Labua FSA) Co. No. LL09829 Licece No. IS IMPORTANT NOTES 1. This form is meat to eable a Cliet of Archipelago Edowmet Series to comply with the cliet idetificatio programmed laid dow by the Ati-Moey Lauderig, Ati-Terrorism Fiacig ad Proceeds of Ulawful Activities Act 2001, herei referred to as Kow Your Cliet (KYC) requiremets. 2. This form is oly meat for providig iformatio ad documets required for KYC compliace. PART 1 INFORMATION ABOUT POLICYHOLDER, BENEFICIAL OWNER(S) AND POLITICALLY EXPOSED PERSON(S) Sectio A Iformatio of Policyholder FOR INDIVIDUAL POLICYHOLDER Full Name (icludig ay alias) Geder (please tick 3) Male Female Idetificatio (NRIC/ Passport) No. If the iformatio are same to the completed Edowmet Proposal Form, please tick (3) the box o the right. Residetial Address Date of Birth Natioality Occupatio Name of Employer Cotact No. (iclude coutry/ area codes) Address FOR COMPANY POLICYHOLDER Compay s Name Registratio No. If the iformatio is same to the completed Edowmet Proposal Form, please tick (3) the box o the right. Registered Office Address Address of Place of Busiess (if differet) Place of Registratio/ Icorporatio/ Origi Date of Registratio/ Icorporatio Nature of Busiess Cotact No. (iclude coutry/ area codes) Address Page 1 / 6

8 FOR COMPANY Iformatio of other Perso(s) with Executive Authority i.e. CEO/ COO/ CFO, excludig Director(s) registered with relevat authority i.e. listed i Form 49. If ot applicable, please tick (3) the box here. (To provide aex if the space is isufficiet) Full Name (as per official documet) Idetificatio (NRIC/Passport) No. Place ad Date of Issue Place of Birth Residetial Address Curret Natioality Occupatio Cotact No. (iclude coutry/area codes) (1) (2) Sectio B Iformatio of Cliet s Beeficial Ower(s) The purpose of obtaiig beeficial ower s iformatio is to: (a) Idetify the atural persos (whether actig aloe or together) who ultimately ow all the assets or udertakigs of the Cliet; (b) If there is doubt as to whether the atural persos who ultimately ow all the assets ad udertakigs of the Cliet are the beeficial owers or where o atural persos ultimately ow all the assets or udertakigs of the Cliet, to the idetify the atural persos (if ay) who ultimately cotrol the busiess etity or have ultimate effective cotrol over the Cliet; ad (c) Where o atural persos are idetified above, to idetify the atural persos havig executive authority i the Cliet, or i equivalet or similar positios. FOR COMPANY If the Director(s) registered with relevat authority i.e. listed i Form 49 are the same Beeficial Ower(s), please tick (3) the box here. Please ote that a Director may ot ecessary the Beeficial Ower of the compay: (To provide aex if the space is isufficiet) Full Name of Beeficial Ower (a atural perso(s)) Idetificatio (NRIC/Passport) No. Residetial Address (1) (2) Date of Birth Natioality Cotact No. (iclude coutry/area codes Address Provide iformatio of ature of Beeficial Owership (e.g. more tha 25% of owership of the Cliet) ad owership ad cotrol structure of the Cliet Page 2 / 6

9 Sectio C Iformatio of Politically Exposed Persos, their Immediate Family Members ad Close Associates Are ay of the persos i this Edowmet applicatio iclusive of Policyholder, Life Assured, Beeficiary(ies), Cotiget Ower, all the Compay Directors, all the Compay Shareholders ad Perso(s) with Executive Authority: - YES NO 1. a political exposed perso ( PEP ), that is, a perso who is or has bee etrusted with ay promiet public fuctio i Malaysia, a coutry or territory outside Malaysia, or by a iteratioal orgaisatio at preset? 2. a PEP, that is, a perso who is or has bee etrusted with ay promiet public fuctio i Malaysia, a coutry or territory outside Malaysia, or by a iteratioal orgaisatio who has stepped dow from his promiet public fuctio? 3. a immediate family member or a close associate of a PEP or a PEP who has stepped dow? Note: If ay of the Sectio C above is Yes, please proceed to fill i the PEP form (Part 2 below) for each politically exposed perso, immediate family member or close associate idetified. PART 2 FORM FOR POLITICALLY EXPOSED PERSONS ( PEP ) Iformatio about PEP, their immediate Family Members ad Close Associates. (To provide aex if the space is isufficiet) Name of PEP Described ature of promiet public fuctio that the perso is or has bee etrusted with (for example, as a domestic PEP, a foreig PEP, or a PEP of a iteratioal orgaizatio) Period of time i which the perso is/was a PEP Provide iformatio o the perso s source of wealth Provide iformatio o the perso s source of fuds i the proposed busiess relatioship Name of perso who is a immediate family member of a PEP Described ature of the perso s relatioship with the PEP Provide iformatio o the perso s source of wealth Provide iformatio o the perso s source of fuds i the proposed busiess relatioship Name of perso who is a close associate of a PEP Described ature of the persos relatioship with the PEP Provide iformatio o the perso s source of wealth Provide iformatio o the perso s source of fuds i the proposed busiess relatioship Please attach all relevat supportig documets o screeig ad searches performed for PEP, their immediate family members ad close associates: - Google ad/or Word-Check searches - Compliace database search results Page 3 / 6

10 CLIENT S DECLARATION I / We declare that the iformatio provided i this form is true ad correct. I am / We are aware that I / we may be subject to prosecutio ad crimial sactios uder writte law if I am / we are foud to have made ay false statemet which I / we kow to be false or which I / we do ot believe to be true, or if I / we have itetioally suppressed ay material fact. All iformatio give here is correct ad complete, ad I / we authorise The Archipelago Group to verify the same ad obtai iformatio from ay fiacial istitutio, the Director Geeral of Ilad Reveue, credit iformatio or credit refereces providers ad ay other sources. Name of Proposer/ Policyholder/ Compay Name Desigatio (if applicable) Idetificatio (NRIC/ Passport) / Compay Registratio No. Date Sigature / Authorised Sigatory(ies) Compay stamp (if applicable) Page 4 / 6

11 TO BE COMPLETED BY LICENSED FINANCIAL ADVISOR / BROKER RISK ASSESSMENT OF CLIENT Note: The followig are examples of factors that to be cosidered whe performig risk assessmet. 1. Is the Cliet physically preset for the idetificatio purposes whe establishig the busiess relatioship? If yes, please aswer questio 6 (example of documets: Valid passport, NRIC) 2. Is the Cliet egagig the registered/ licesed Itermediary/ FA to perform complex or uusually large trasactios, or uusual patters of trasactio that have o apparet of visible ecoomic or lawful purpose? 3. Are ay of the persos listed a politically exposed perso (at preset or has stepped dow) or immediate family member or a close associate of a politically exposed perso (at preset or has stepped dow)? 4. Are ay of the persos idetified from coutries or jurisdictio which the Fiacial Actio Task Force (a global stadard settig body for ati-moey lauderig ad combatig the fiacig of terrorism) has called for coutermeasures icludig the applicatio of ehaced customer due diligece measures? 5. Do ay of the persos idetified fall ito ay other categories of customers which the licesed/ registered Itermediary/ FA cosiders may preset a high risk of moey lauderig or the fiacig of terrorism, or which licesed/ registered Itermediary/ FA suspects is committig or facilitatig moey lauderig or the fiacig of terrorism? 6. Please provide supportig documet(s) if the aswer to ay of the above questios is Yes. YES NO I / We declare that 1. I am / We are licesed Fiacial Advisor / Broker uder Fiacial Services Act 2013 or licesed Isurace Broker uder Labua Fiace Services & Securities Act 2010 to reder services i respect of this product. 2. I / We have fully explaied ad disclosed the product details icludig features, beefits, risks relevat ad terms ad coditios to my / our cliet (s). 3. I / We have established ad verified (Customer Due Diligece) the idetity of my / our Cliet (s) i accordace with the Ati-Moey Lauderig, Ati-Terrorism Fiacig ad Proceeds of Ulawful Activities Act Name : Sigature : Date : FOR ARCHIPELAGO S OFFICE USE ONLY RISK ASSESSMENT RESULT Cliet Risk Ratig Low Medium High Recommedatio for Acceptace of Cliet Recommeded Not Recommeded Name of Recommedig Officer Date Sigature COMPLIANCE APPROVAL Approval for Acceptig of Cliet Approved Not Approved Name of Approvig Officer Date Sigature Page 5 / 6

12 SPECIAL DECLARATION FORM (To be filled by the Proposer) I, (Idetity Card No. or Passport No. ) hereby declare that the followig iformatio provided below are true ad correct to the best of my kowledge: (a) Source of Wealth (describe & idetify with details e.g. corporate registratio umber) : (b) Source of Fud (describe & idetify with details e.g. divided declaratio memo etc.) : Name (as per Idetity Card or Passport) : Sigature : Cotact No. Date : For Office Use Oly Received by : Date : Reviewed by : Date : Approved by : Date : Remarks : Page 6 / 6

13 Please submit this together with your TT applicatio form to the bak Date : Bak Name : Address : Istructios to Bak : 1. Bak Charges : OUR 2. Do ot covert to MYR 3. Beeficiary to receive full amout Brach : Dear Sir / Madam, RE : Bak Charges Istructio : OUR Edowmet-Isurace Premium Subscriptio I, NRIC / Passport No. wish to do a telegraphic-trasfer (TT) of amout to Archipelago Life Isurace Limited. The recipiet accout details are as follows: Bak Details for Archipelago Life Isurace Limited USD Accout Beeficiary USD Accout Number Baker Address Swift Code Archipelago Life Isurace Limited (No-Residet Accout) Alliace Bak Malaysia Berhad Uit A-OG-02, Block A, Plaza Mot Kiara, 2 Jala Kiara, Mot Kiara, Kuala Lumpur MFBBMYKLXXX I will bear ALL of the related telegraphic-trasfer charges for this trasactio iclusive of correspodet aget s bak charges. Archipelago Life Isurace Limited will receive the et amout of Thak you. Yours sicerely, Name : NRIC / Passport :