TAKAFUL IKHLAS BERHAD ( U) IKHLAS POINT Corporate Head Office Tower 11A,Avenue 5, Bangsar South, No. 8, JalanKerinchi, Kuala Lumpur.
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1 TAKAFUL IKHLAS BERHAD ( U) IKHLAS POINT Corporate Head Office Tower 11A,Avenue 5, Bangsar South, No. 8, JalanKerinchi, Kuala Lumpur. Tel: Fax: Website: (A subsidiary of MNRB Holdings Berhad) Untuk kegunaan pejabat / For office use only No. Siri / Serial No : KodEjen/ Agent Code : BORANG CADANGAN SKIM TAKAFUL KEMASUKAN HOSPITAL & PEMBEDAHAN PEKERJA ASING (SKHPPA) FOREIGN WORKER HOSPITALIZATION AND SURGICAL TAKAFUL SCHEME PROPOSAL FORM (SKHPPA) A. BUTIR-BUTIR MAJIKAN / EMPLOYER S PARTICULARS 1. No. Pendaftaran Syarikat/KP / Business Registration No./NRIC 2. Nama Pencadang / Majikan / Name of Proposer / Employer 3. Alamat Majikan / Address of Employer Poskod/ Postcode Bandar /Town Negeri /State 4. No. Telefon / Telephone No Pejabat / Office - Rumah / House - Bimbit / Hand phone - 5. Alamat E-Mel / Address 6. Perniagaan/Pekerjaan / Business/Occupation Syarikat berhak untuk tidak menerima sebarang permohonan sekiranya pekerja terlibat dengan aktiviti-aktiviti yang tidak mematuhi syariah. The Company has the right not to accept any proposal where the worker is involved in any non-shariah compliance activities. B. TEMPOH PERLINDUNGAN TAKAFUL / PERIOD OF TAKAFUL COVERAGE 7. Tempoh Perlindungan / Period of Coverage Bulan/ Months
2 8. Tarikh Perlindungan / Date of Coverage : Dari / From Hingga / To 9. Bilanganpekerja yang akandilindungi / No. of worker(s) to be covered Pekerja/workers (jika lebih dari seorang (1) pekerja, sila lengkapkan Borang Butir-Butir Pekerja yang disertakan dalam lampiran ini) (if more than one (1) worker, please complete the Workers Particulars Form) C. TEMPAT PEKERJAAN / PLACE OF EMPLOYMENT 10. Hanya perlu diisi sekiranya Alamat Tempat Pekerjaan berlainan dengan Alamat Majikan di atas :- To be filled up only if Place of Employment Address is not the same as the Address of Employer above :- a) No. Pendaftaran Syarikat / Rujukan Tapak Pembinaan / Rujukan Projek Business Registration No./ Construction Site No. / Project Reference No b) Alamat Tempat Pekerjaan / Place of Employment Address Poskod/ Postcode Bandar /Town Negeri /State D. BUTIR-BUTIR PEKERJA ASING [jikapermohonanuntukseorang (1) pekerja, silalengkapkanbutir-butirberikut] : FOREIGN WORKER'S PARTICULARS [ If application is for only one (1) worker, please complete the following particular] :- 11. Nama Pekerja / Name of Worker 12. Warganegara / Nationality 13. No. Pasport / Passport No 14. Tarikh Lahir (HH/BB/TT) / Date of Birth (DD/MM/YY) 15. Jantina/ Gender Lelaki / Male Perempuan / Female 16. Taraf Perkahwinan / Marital Status Bujang/Single Kahwin/Married Bercerai/Divorced Janda/Duda/Widow/Widower 17. No. Permit Kerja/ Work Permit No.
3 18. Tarikh Luput Permit Kerja/ Work Permit Expiry Date 19. Jenis Pekerjaan / Nature of Work 20. Siapakah yang akan membayar sumbangan untuk pelan Takaful ini? / Who will pay the contribution for this Takaful plan? Majikan / Employer Pekerja asing sendiri /Foreign worker themselves E. PENGISYTIHARAN OLEH PENCADANG/ DECLARATION BY PROPOSER 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 perjanjian Takaful antara Saya / Kami dan Takaful Ikhlas Berhad (selepas ini dirujuk sebagai pihak Syarikat ) dan ianya disifatkan sebagai termaktub dalam perjanjian ini. Saya / Kami bersetuju bahawa Sumbangan Takaful Saya / Kami akan diuruskan oleh pihak Syarikat berdasarkan prinsip Wakalah sebagaimana yang ditakrifkan oleh pihak Syarikat serta menepati Shariah. Saya / Kami bersetuju membenarkan pihak Syarikat mengambil 25% 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 Shariah yang akan memanfaatkan Peserta. (Untuk maklumat lengkap, sila rujuk kepada Sijil Takaful yang berkenaan). I/We hereby declare 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 contract between Me/Us and Takaful Ikhlas Berhad (hereinafter referred as the Company ) and they are deemed to be incorporated in the contract. I/We agree that My/Our Takaful contribution 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 25% of the contribution as Wakalah Fee. I/We further agree that the balance of My/Our contribution shall be allocated into the Risk Fund and Special Fund on a Tabarru' (donation) basis and be used to help other Participants in time of misfortune and the balance 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). Perlindungan Data Peribadi/ Personal Data Protection Saya mengakui dan faham bahawa Syarikat akan memberi sesalinan informasi peribadi tersebut dengan membayar kos munasabah apabila permohonan dibuat oleh saya. I hereby acknowledge that the Company will provide a copy of all my personal information to me upon request with a nominal fees. Saya bersetuju dan mengakui bahawa Syarikat boleh menggunakan informasi peribadi saya untuk mencadangkan lain-lain produk dan perkhidmatan Syarikat yang mana pada pendapat Syarikat adalah memberi manafaat kepada saya sehinggalah notis untuk menarik balik kebenaran ini diberikan. I hereby consent and acknowledge that the Company may use my personal information to recommend me with detail of other products or services of the Company which the Company feels may be beneficial to me until written notice is issued to revoke such authorization. Tarikh / Date Tandatangan Pencadang/Cop Syarikat (Signature of Proposer / Company Rubber Stamp)
4 F. PERLINDUNGAN MAKLUMAT PERIBADI / PERSONAL DATA PROTECTION 1. Saya memberi izin dan kuasa kepada: (a) Takaful Ikhlas Berhad (bermaksud mana-mana anak-anak syarikat milik penuh dan berkaitan dengan MNRB Holdings Berhad atau Takaful Ikhlas Berhad atau mana-mana penyedia perkhidmatan yang dilantik) (selepas ini dirujuk sebagai Takaful IKHLAS) untuk memperolehi dan memproses; dan (b) mana-mana pengamal perubatan, hospital atau institusi perubatan (sama ada diperbadankan atau tidak) yang pernah merawat saya atau memiliki rekod mengenai saya atau kesihatan saya untuk menyediakan maklumat yang relevan dan dokumen-dokumen yang diperlukan oleh Takaful IKHLAS untuk menentukan sama ada untuk menerima permohonan saya atau meluluskan sebarang tuntutan yang dibuat ke atas Sijil Takaful yang dikeluarkan kepada saya. Saya juga bersetuju bahawa Salinan pemberian kuasa ini adalah berkuatkuasa dan sah seperti salinan asal. I hereby consent and authorize: (a) Takaful Ikhlas Berhad (means any of MNRB Holdings Berhad or Takaful Ikhlas Berhad owned subsidiaries and associate companies or Takaful IKHLAS or any of its appointed service providers) (hereinafter defined as Takaful IKHLAS) to obtain and process; and (b) any medical practitioner, hospital, medical institution or any person (whether incorporated or not) who has ever attended to me or has records on me or my health to provide relevant information and documents required by Takaful IKHLAS to determine whether to accept my proposal or approve any claim arising from the Takaful Certificate issued to me. I further agree that a photocopy of this authorization will be as effective and valid as the original. 2. I hereby irrevocably consent and agree that Takaful IKHLAS may process, use, store, disclose, transfer, compile, match, obtain and/or exchange (all whether within or outside Malaysia) all my personal information provided to and/or obtained by Takaful IKHLAS as well as any information derived from or relating to my Takaful Certificate issued based on this Takaful application (collectively referred to as Personal Data ), to, from or with any person as Takaful IKHLAS may consider necessary including without limitation any agent, contractor, service provider or selected third party that provide services to Takaful IKHLAS and/or Bank Negara Malaysia or any other relevant authorities that Takaful IKHLAS is under obligation to make disclosure to, under the requirements of any law or court for any and all purposes including without limitation to: I hereby irrevocably consent and agree that Takaful IKHLAS may process, use, store, disclose, transfer, compile, match, obtain and/or exchange (all whether within or outside Malaysia) all my personal information provided to and/or obtained by Takaful IKHLAS as well as any information derived from or relating to my Takaful Certificate issued based on this Takaful application (collectively referred to as Personal Data ), to, from or with any person as Takaful IKHLAS may consider necessary including without limitation any agent, contractor, service provider or selected third party that provide services to Takaful IKHLAS and/or Bank Negara Malaysia or any other relevant authorities that Takaful IKHLAS is under obligation to make disclosure to, under the requirements of any law or court for any and all purposes including without limitation to: a) Berhubung dengan produk-produk dan/atau perkhidmatan-perkhidmatan yang ditawarkan oleh Takaful IKHLAS kepada saya dan/atau berkaitan dengan pemadanan bagi sebarang tujuan mana-mana Maklumat Peribadi saya di dalam simpanan Takaful IKHLAS; dan/atau In connection with the products and/or services offered by Takaful IKHLAS to me and/or in connection to matching for whatever purpose of any of my Personal Data under the possession of Takaful IKHLAS; and/or b) Untuk memudahkan pengendalian perniagaan Takaful IKHLAS atau operasi prosedur-prosedur dalaman Takaful IKHLAS; dan/atau To facilitate the conduct of Takaful IKHLAS s business or the operations of the Takaful IKHLAS s internal procedures; and/or c) Bagi tujuan mempromosi produk-produk lain dan/atau perkhidmatan oleh Takaful IKHLAS dan/atau mana-mana rakan strategiknya secara amnya kepada saya. Sekiranya saya tidak ingin menerima sebarang maklumat promosi daripada atau mana-mana rakan strategiknya, saya akan memaklumkan secara bertulis ke alamat Takaful IKHLAS yang disediakan di dalam borang ini. For the purpose of promoting other products and/or services by Takaful IKHLAS and/or its strategic partners, generally to me. If I do not wish to receive any promotional information from any of its strategic partners, I will notify by writing to Takaful IKHLAS s address provided in this form. d) Untuk menambahbaik produk dan/atau perkhidmatan yang disediakan oleh Takaful IKHLAS; To improve the products and/or services provided by Takaful IKHLAS; e) Untuk tujuan menyiasat, melaporkan dan pencegahan atau sebaliknya aktiviti-aktiviti yang berkaitan dengan pengubahan wang haram, pembiayaan keganasan, penyelewengan, pengelakan cukai dan aktiviti-aktiviti jenayah secara amnya, penyenggaraan pangkalan data, analisa statistik, pengesahan tuntutan, audit, pengendalian dan penyelesaian aduan pelanggan, dan hal-hal operasi seperti yang diperuntukkan oleh undang-undang; dan /atau For purposes of investigating, reporting and preventing or otherwise in relation to money laundering, terrorist financing, fraud, tax evasion and criminal activities generally, maintenance of databases, statistical analysis, claim verification, audit, customer complaints handling and resolution, and operational matters as required by the law; and/or f) Untuk sebarang tujuan proses undang-undang atau mahkamah yang dimulakan oleh atau diserahkan terhadap saya atau Takaful IKHLAS, sama ada Takaful IKHLAS adalah pihak yang terlibat atau tidak. For purposes of any legal or court process initiated by or served on me or Takaful IKHLAS, whether or not Takaful IKHLAS is a party. 3. Saya faham bahawa saya boleh meminta akses kepada dan akan memaklumkan Takaful IKHLAS jika terdapat perubahan kepada Maklumat Peribadi saya secepat yang mungkin dan bersetuju bahawa Takaful IKHLAS tidak akan dipertanggungjawabkan atas sebarang kerugian sama ada secara langsung atau tidak, atau lain-lain liability sama ada sivil atau jenayah disebabkan kesalahnyataan fakta sebenar atau penyembunyian tentang sesuatu fakta material untuk mempengaruhi orang lain untuk melakukan perbuatan yang merugikannya, serta Maklumat Peribadi yang tidak tepat atau tidak lengkap yang diberikan oleh saya.
5 I understand that I can request access to and will keep Takaful IKHLAS updated of any change to my Personal Data as soon as practicable and agree that Takaful IKHLAS shall not be liable for any direct or indirect loss or other liabilities under civil or criminal due to misrepresentation of the truth or concealment of a material fact to induce another to act to its detriment, inaccurate or incomplete Personal Data provided by me. G. BUTIR-BUTIR BAYARAN / DETAIL OF PAYMENT Sumbangan Tahunan / Annual Contribution Jumlah Sumbangan / Total Contribution Cukai Perkhidmatan( 6%) / Service Tax (6%) Duti Setem / Stamp Duty JUMLAH / TOTAL RM (setiap pekerja/per worker) RM RM RM10.00 RM Semua Cek hendaklah dibayar atas nama Takaful Ikhlas Berhad/ All Cheques must be made payable to Takaful Ikhlas Berhad H. UNTUK KEGUNAAN PEJABAT SAHAJA / FOR OFFICE USE ONLY Bersama ini disertakan Bayaran Tunai / Cek No Enclose herewith Cash Payment / Cheque No Jumlah / Amount RM Tarikh/MasaDiterima / Date/Time Received Tandatangan / Signature I. NOTA PENTING / IMPORTANT NOTE Caj kami tidak termasuk cukai yang dikenakan oleh kerajaan dan/atau pihak berkuasa pada masa akan datang (termasuk Cukai Barangan dan Perkhidmatan (GST)). Setelah perlaksanaan GST, kami berhak mengenakan caj GST bagi maksud Sijil Takaful ini yang dikehendaki dibayar di bawah undang-undang. / Our charges exclude tax that would be imposed by government and/or the authority in the future (including Goods and Services Tax (GST)). Upon implementation of the GST, we shall be entitled to recover from you in the respect of this Takaful Certificate that is required under the law. J. PENGESAHAN KE ATAS KESAHIHAN PENGENALAN DIRI / VERIFICATION ON AUTHENTICATION OF IDENTITY (Untuk kegunaan kakitangan Syarikat atau Wakil sahaja / For Use by Company Staff or Intermediary only) Menurut Seksyen 16(2) Akta Pencegahan Pengubahan Wang Haram & Pencegahan Pembiayaan Keganasan 2001, saya dengan ini mengesahkan perkara berikut :In compliance with section 16(2) of Anti-Money Laundering & Counter Terrorism Financing Act 2001, I hereby confirm the following : [ ] Dokumen asal pengenalan diri di semak / Original identity document sighted [ ] Salinandokumenpengenalandiridilampirkanuntukindividudengansumbangantahunanmelebihi RM 50,000. / Photocopy of identity document attached for Individuals with annual contribution exceeding RM50,000. [ ] SalinanSijilPendaftaranPerniagaanuntuksyarikatdengansumbangantahunanmelebihi RM 100,000 / Photocopy of Business Registration Certificate for Company with annual contribution exceeding RMI00, Tarikh/Date Tandatangan/Signature Nama Kakitangan Syarikat atau Wakil/ No KadPengenalan/ NRIC No Name of Company Staff or Representative
6 K. KETERANGAN FAEDAH / PERLINDUNGAN / DESCRIPTION OF BENEFITS /COVERAGE MANFAAT KEMASUKAN KE HOSPITAL & PEMBEDAHAN / HOSPITAL & SURGICAL BENEFITS 1) (a) Bilik & Makan Harian (Maksimum tiga puluh (30) hari) Daily Hospital Room & Board (Maximum up to thirty (30) days) (b) Unit RawatanIntensif (Maksimum lima belas (15) hari) Intensive Care Unit [ICU] (Maximum up to fifteen (15) days) 2) BekalandanKhidmat Hospital / Hospital Supplies and Services 3) BilikPembedahan / Operating Theatre 4) Yuran Pembedahan (Tidak termasuk pemindahan organ) Surgical Fees (Exclude organ transplantation) 5) YuranPakarBius / Anesthetist's Fees 6) LawatanPakarPerubatanDalam Hospital (Maksimumtigapuluh (30) hari) In-Hospital Physician Visits (Maximum up to thirty (30) days) 7) LawatanPakarPerundinganDalam Hospital (Maksimumtigapuluh (30) hari) In-Hospital Specialist Consultation Visits (Maximum up to thirty (30) days) 8) YuranAmbulan/LaporanPerubatan / Ambulance Fees/Medical Report Fees HAD MAKSIMUM TAHUNAN KESELURUHAN (Butiran 1 hingga 8) MAXIMUM OVERALL ANNUAL LIMIT (Item 1 to 8) Bayaran yang dikenakan mengikut bayaran yang selaras dengan Bilik & Makan Kelas Ketiga (ke-3) sehingga maksimum RM60 sehari di Hospital Kerajaan Malaysia Bukan Korporat mengikut Akta Fi 1951, Perintah Fi (Perubatan) 1982 As charged in accordance to charges consistent with Third (3rd) Class Room and Board to a maximum of RM60.00 per day in a Non- Corporatised Malaysian Government Hospital in conformance to the charges specified under Perintah Fi (Perubatan) RM10, SUMBANGAN TAHUNAN (Sebelum 6% CukaiPerkhidmatandan RM10.00 DutiSetem) RM (SetiapPekerja) ANNUAL CONTRIBUTION (Before 6% Service Tax and RM10.00 Stamp Duty) (Per Worker) Nota Penting: Important Note: Semua faedah-faedah yang dibayar bagi setiap ketidakupayaan bagi setiap tempoh Takaful yang diberi tertakluk kepada Had Tahunan Keseluruhan sebanyak RM10, bagi setiap pekerja yang dilindungi. All benefits payable for any number of disabilities in any one given period of Takaful is subject to Overall Annual limit of RM10, per covered worker.
7 BORANG BUTIR-BUTIR PEKERJA ASING FOREIGN WORKER'S PARTICULARS FORM SENARAI NAMA PEKERJA YANG DILINDUNGI DI BAWAH SKHPPA / LIST OF WORKERS TO BE COVERED UNDER SKHPPA Nama Pencadang / Majikan / Name of Proposer / Employer Pendaftaran Syarikat / KP / Pasport / Business Registration No./ NRIC / Passport Bil No. Item No. Nama Pekerja Name of Worker Warganegara Nationality No. Pasport Passport No. Tarikh Lahir Date of Birth (* Jantina)/ (* Gender) **Taraf Perkahwinan / Marital Status No. Permit Kerja/ Work Permit No (DD/MM/YY) Tarikh Luput Permit Kerja/ Work Permit Expiry Date Jenis Pekerja / Nature of Work *** Siapakah yang akan membayar sumbangan untuk pelani Takaful ini? Who will be paying the contribution for this Takaful plan? Rujukan / Reference: * Jantina / Gender:(L) Lelaki / Male;(P) Perempuan / Female **Taraf Perkahwinan / Marital Status S - Bujang/Single M- Kahwin/Married D - Bercerai /Divorced W - Janda/Duda / Widow/Widower ***Sumbangan dibuat oleh/contribution paid by: E - Employer/Majikan FW Pekerja asing/foreign worker
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