TAX INVOICE / INVOIS CUKAI INVOICE NO. NO. INVOIS DATE TARIKH GST REGISTRATION NO. NO. PENDAFTARAN GST : POLITEKNIK KUCHING SARAWAK

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1 POLITEKNIK SARAWAK KM. 22 JALAN MATANG TAX INVOICE / INVOIS CUKAI INVOICE NO. NO. INVOIS DATE TARIKH GST REGISTRATION NO. NO. PENDAFTARAN GST : TI-GEN : 24/07/2018 : GCA02264 GROUP PERSONAL ACCIDENT PARTICULARS / BUTIRAN PARTICIPANT NAME NAMA PESERTA CERTIFICATE NO. NOMBOR SIJIL DESCRIPTION OF SERVICE DISKRIPSI PERKHIDMATAN PERIOD OF TAKAFUL TEMPOH PERLINDUNGAN EFFECTIVE DATE TARIKH KUATKUASA CURRENCY MATA WANG TYPE OF SUPPLY JENIS PEMBEKALAN : POLITEKNIK SARAWAK : PGP-P AGT-18 : CONTRIBUTION : 04/06/2018 TO 03/06/2019 : 04/06/2018 : RINGGIT MALAYSIA : STANDARD RATED (SR) TAKAFUL CONTRIBUTION (EXCLUDING GST) SUMBANGAN TAKAFUL (TIDAK TERMASUK GST) : RM 90, GST (0.00%) CUKAI BARANG dan PERKHIDMATAN (0.00%) STAMP DUTY DUTI SETEM TOTAL JUMLAH : RM 0.00 : RM : RM 90, This is a computer generated document. No signature is required. Dokumen ini adalah cetakan komputer dan tidak memerlukan tandatangan.

2 PGP-P AGT-18, GCA02264, 04/06/2018 POLITEKNIK SARAWAK KM. 22 JALAN MATANG 24/07/2018 Greetings Dear Valued Customer, Certificate No. : PGP-P AGT-18 Product Name : GROUP PERSONAL ACCIDENT Participant Name : POLITEKNIK SARAWAK NRIC / Co. Reg. Number : GOMT Thank you for choosing Syarikat Takaful Malaysia Am Berhad as your preferred choice for insurance and giving us the opportunity to fulfill your insurance needs. It is our pleasure to enclose the Original Certificate Document for your safekeeping. This Certificate Document outlines the terms and conditions of your certificate and your rights and obligations. Please read the document carefully and take note of all the details of your certificate. Should you require any assistance or further clarification, please contact our Customer Service at or us at csu@takaful-malaysia.com.my. We appreciate the confidence you have placed in us and we look forward to the pleasure of serving you. Thank you. Yours sincerely, SYARIKAT TAKAFUL MALAYSIA AM BERHAD ( D) Dato' Sri Mohamed Hassan Kamil Group Chief Executive Officer

3 PGP-P AGT-18, GCA02264, 04/06/2018 POLITEKNIK SARAWAK KM. 22 JALAN MATANG 24/07/2018 Salam Sejahtera Pelanggan yang Dihargai, No. Sijil : PGP-P AGT-18 Nama Produk : GROUP PERSONAL ACCIDENT Nama Peserta : POLITEKNIK SARAWAK Nombor NRIC / Pendaftaran Syarikat : GOMT Terima kasih kerana memilih Syarikat Takaful Malaysia Am Berhad sebagai syarikat insurans pilihan utama anda dan memberi peluang kepada kami untuk memenuhi keperluan insurans anda. Bersama ini dilampirkan Sijil Asal untuk simpanan anda. Dokumen ini merangkumi segala terma dan syarat yang terdapat di dalam sijil serta hak-hak dan kewajipan anda. Sila baca dokumen ini dengan teliti serta mengambil perhatian terhadap butiran-butiran Sijil anda. Sekiranya anda memerlukan sebarang bantuan atau maklumat lanjut, sila hubungi Khidmat Pelanggan kami di atau emel ke csu@takaful-malaysia.com.my. Kami hargai keyakinan anda terhadap kami dan kami akan terus berkhidmat untuk memenuhi keperluan insurans anda. Terima kasih. Yang benar, SYARIKAT TAKAFUL MALAYSIA AM BERHAD ( D) Dato' Sri Mohamed Hassan Kamil Ketua Pegawai Eksekutif Kumpulan

4 TABLE OF BENEFITS JADUAL MANFAAT GROUP PERSONAL ACCIDENT TAKAFUL TAKAFUL KEMALANGAN DIRI BERKELOMPOK CERTIFICATE NUMBER / NOMBOR SIJIL : PGP-P AGT-18 DATE / TARIKH : 24/07/2018 CURRENCY / MATA WANG : RINGGIT MALAYSIA NO. NAME OF PERSON COVERED NAMA ORANG YANG DILINDUNGI NO. OF PERSON BIL. ORANG COVERAGE PER PERSON PERLINDUNGAN SETIAP ORANG COVERAGE PERLINDUNGAN SUM COVERED AMAUN PERLINDUNGAN GROSS CONTRIBUTION SUMBANGAN KASAR 0001 ON STUDENTS 3,244 P01 DEATH RM 40,000 RM 90, KEMATIAN P02 PERMANENT DISABLEMENT RM 40,000 HILANG UPAYA KEKAL P05 MEDICAL EXPENSES RM 3,000 PERBELANJAAN PERUBATAN P06 FUNERAL EXPENSES RM 1,500 PERBELANJAAN PENGEBUMIAN P10 HOSPITAL ALLOWANCE(LIMIT UP TO 30 DAYS) RM 50 ELAUN HOSPITAL(HAD SEHINGGA 30 HARI)

5 SCHEDULE / JADUAL CLASS OF BUSINESS KELAS PERNIAGAAN PARTICIPANT NAME NAMA PESERTA ADDRESS ALAMAT CERTIFICATE NO. NOMBOR SIJIL NRIC/ID NUMBER NO.KAD/DOKUMEN PENGENALAN BUSINESS / OCCUPATION PERNIAGAAN / KEGUNAAN : GROUP PERSONAL ACCIDENT DATE TARIKH : POLITEKNIK SARAWAK : KM. 22 JALAN MATANG : PGP-P AGT-18 REFERENCE NO. NOMBOR RUJUKAN : GOMT : REPLACING CERT.NO. NOMBOR SIJIL ASAL : : : 24/07/2018 CURRENCY MATA WANG : RINGGIT MALAYSIA PERIOD OF TAKAFUL TEMPOH PERLINDUNGAN : FROM MULA 04/06/2018 TO TAMAT 03/06/2019 (BOTH DATE INCLUSIVE) (TERMASUK KEDUA-DUA TARIKH) ANY SUBSEQUENT PERIOD FOR WHICH THE PARTICIPANT SHALL PAY AND THE COMPANY SHALL AGREE TO ACCEPT A RENEWAL TAKAFUL CONTRIBUTION. MANA-MANA TEMPOH TAKAFUL KEMUDIANNYA DI MANA PESERTA KENA BAYAR DAN SYARIKAT BERSETUJU MENERIMA SUMBANGAN TAKAFUL BAGI PEMBAHARUAN SIJIL. SUM COVERED AMAUN PERLINDUNGAN TAKAFUL CONTRIBUTION SUMBANGAN TAKAFUL GST CUKAI BARANG dan PERKHIDMATAN STAMP DUTY DUTI SETEM TOTAL JUMLAH : RM 129,760, : RM 90, : RM 0.00 : RM : RM 90, GENERAL PAGE 1. LIMIT PER CONVEYANCE LIMIT OF LIABILITY IN RESPECT OF ALL PERSONS COVERED TRAVELLING IN THE SAME CONVEYANCE SHALL NOT EXCEED RM 3,000, AGE LIMIT: 16 TO 65 YEARS OLD 3. RATE: RM PER PERSON Page 1 of 2

6 TYPE OF COVERAGE JENIS PERLINDUNGAN : REFER TO TABLE OF BENEFITS SILA LIHAT JADUAL MANFAAT SUBJECT TO THE FOLLOWING WARRANTIES/CLAUSES/ENDORSEMENTS AS PRINTED HEREIN OR ATTACHED HERETO: TERTAKLUK KEPADA WARANTI/KLAUSA/ENDOSMEN YANG DICETAK ATAU DILAMPIRKAN SEPERTI BERIKUT : B00D C001 C003 C004 C017 C025 C026 C030 C031 C035 C040 C051 MEDICAL EXPENSES EXPOSURE AND DISAPPEARANCE CLAUSE STRIKE, RIOT AND CIVIL COMMOTION HIJACKING CLAUSE UNPROVOKED MURDER AND ASSAULT AMATEUR SPORT ACTIVITIES CLAUSE EXPOSURE CLAUSE FOOD AND DRINK CLAUSE SUFFOCATION THROUGH SMOKE FUMES AND POISONOUS GAS CLAUSE FUNERAL EXPENSES CLAUSE SNAKE AND HARMFUL INSECTS BITES DAILY HOSPITAL INCOME IN WITNESS WHEREOF THIS CERTIFICATE HAS BEEN SIGNED ON BEHALF AND WITH THE AUTHORITY OF THE COMPANY. BAHAWASANYA SIJIL INI TELAH DITANDATANGANI DENGAN KEBENARAN DAN BAGI PIHAK SYARIKAT. DATE TARIKH SIGNED AT LOKASI : 24/07/2018 : IBU PEJABAT CORPORATE SALES SYARIKAT TAKAFUL MALAYSIA AM BERHAD ( D) AUTHORISED SIGNATORY PENANDATANGAN YANG SAH Page 2 of 2