submission checklist for e-term plan · submission checklist for e-term plan mandatory documents :...

SUBMISSION CHECKLIST FOR e-TERM PLAN

Mandatory Documents :

Family Takaful Proposal Form

(Original signed copy)

Product Illustration and Product Disclosure Sheet - Generated from e-Term Calculator

Photocopy of NRIC – Mandatory for age admission. (Certified true copy)

Secondary identity document for permanent and residential address verification (e.g. screen

shot of HFE system, bills / statements or correspondence received from banks, insurance

companies or professional bodies)

e-TERM TAKAFUL COVER PROPOSAL FORM BORANG CADANGAN e-TERM TAKAFUL COVER

NOTE: 1. You are required to take reasonable care and not to make a misrepresentation when disclosing and/or answering all the questions in this proposal form and this duty

continues until HSBC Amanah Takaful (Malaysia) Berhad (Takaful Operator) has accepted your proposal for coverage.

2. Failure to answer the questions fully and accurately may result in the limitation of benefits, change to the terms of the Takaful Certificate and/or termination of the Takaful Certificate issued pursuant to this proposal form.

3. You should study the Product Disclosure Sheet and Product Illustration in respect of this Family Takaful Plan, which will be provided to you together with this

proposal form, paying particular attention to the benefits that are covered, benefits that are not covered, the exclusions and duties of the Participant under the Takaful Certificate.

4. You may nominate a person (“nominee”) to receive the benefits payable under the Takaful Certificate upon your death. Subject to the rights of assignee being

preserved, the nominee will receive the balance, if any, of the benefits payable. 5. You are required to inform the Takaful Operator of any changes to the information given in this proposal form where such changes occur after you have submitted the

proposal form but before the Takaful Operator accepts your proposal for coverage.

NOTA:

1. Anda dikehendaki mendedahkan dan/atau menjawab semua soalan di dalam borang cadangan ini dengan langkah berjaga-jaga yang munasabah dan tidak membuat kenyataan yang salah dan meneruskan kewajiban ini sehingga HSBC Amanah Takaful (Malaysia) Berhad (Pengendali Takaful) meluluskan borang cadangan anda.

2. Kegagalan untuk menjawab soalan-soalan secara lengkap dan tepat boleh menyebabkan manfaat-manfaat yang berbayar dihadkan, pertukaran terma-terma Sijil

Takaful dan/atau pembatalan Sijil Takaful yang dikeluarkan berdasarkan borang cadangan ini. 3. Anda seharusnya membaca Lampiran Pendedahan Produk dan Ilustrasi Produk berkaitan dengan Pelan Takaful Keluarga ini, yang akan diberikan kepada anda

bersama dengan borang cadangan ini, dengan memberikan tumpuan khusus kepada manfaat yang dilindungi, manfaat yang tidak dilindungi, pengecualian-

pengecualian dan tanggungjawab-tanggungjawab Peserta di bawah Sijil Takaful. 4. Anda boleh menamakan seseorang (“penama”) untuk menerima manfaat-manfaat yang akan dibayar di bawah Sijil Takaful ini apabila anda meninggal dunia.

Tertakluk kepada hak-hak Pemegang Serah Hak, penama akan menerima lebihan manfaat-manfaat yang akan dibayar, jika ada.

5. Anda harus memaklumkan kepada Pengendali Takaful mengenai sebarang perubahan kepada maklumat yang diberikan dalam borang cadangan ini di mana perubahan tersebut berlaku selepas borang cadangan anda dihantar tetapi sebelum Pengendali Takaful meluluskan cadangan perlindungan anda.

PARTICIPANT’S DETAILS*/BUTIRAN PESERTA* * Participant is also the Covered Person for this Plan/Peserta juga adalah Orang Yang Dilindungi untuk Pelan ini

1. Salutation/Gelaran

Others (please specify)/Lain-lain (sila nyatakan):

………………………………………………………………………….

Mr./Encik Mrs./Puan Ms./Cik 2. Full Name (in BLOCK as per NRIC/Passport)/Nama Penuh (Dalam huruf

besar seperti di dalam K.P. Baru/Pasport)

....................................................................................................................................

....................................................................................................................................

3. New NRIC No./ No.K.P. Baru

Old NRIC No./ No.K.P. Lama Other Identification No./ No.Pengenalan Lain

- - -

- -

4. Date of Birth/Tarikh Lahir

/ /

DD/HH MM/BB YYYY/TTTT

5. Gender/Jantina

Male/Lelaki Female/Perempuan

6. Nationality Kewarganegaraan

Malaysian/Malaysia

7. Marital Status/Status Perkahwinan

Single/

Bujang Married/

Berkahwin Others/

Lain-lain

8. Individual holding Permanent Resident Status/Employment permit/Dependent's

pass/Long term visit pass/Others (Please specify) in Malaysia or other country /

Individu Pemegang Status Pemastautin Tetap/Permit Pekerjaan/Pas Tanggungan/Pas

Lawatan Jangka Panjang/Lain-lain (Sila nyatakan) di Malaysia atau Lain-lain Negara

Yes/Ya No/Tidak

If Yes, please specify./Jika Ya, sila nyatakan

………………………………………………..

9. Country of Birth/Negara Kelahiran

………………………………………………………………………………

10. E-mail Address/Alamat E-mel

………………………………………………………………………………

Please tick as appropriate/Sila tanda yang mana berkenaan

HSBC Bank Premier Customer

Pelanggan Premier HSBC Bank

HSBC Bank Non Premier Customer Bukan Pelanggan Premier HSBC Bank

11. Permanent Address/Alamat Tetap

12. Correspondence Address/Alamat Surat-menyurat

13. Residential Address/Alamat Kediaman

14. Previous Address (please complete if residing in current Residential

Address less than 3 years)/Alamat Sebelumnya (sila lengkapkan sekiranya

tinggal di Alamat Kediaman terkini kurang daripada 3 tahun)

15. Residential Telephone No./ No. Telefon Kediaman

-

16. Hand Phone No./ No. Telefon Bimbit

-

17. Occupation/Pekerjaan ………………………………………………………………………………

18. Exact Duties/Tugas Terperinci ………………………………………………………………………………………

19. Nature of Business/Jenis Perniagaan ……………………………………………………………………………...

20. Office Telephone No./

No. Telefon Pejabat

-

21. Name of Employer/Nama Majikan ……………………………………………………………………………...

22. Annual Income (RM)/ Pendapatan Tahunan (RM)

23. Please state source of fund for contribution/ Sila nyatakan sumber dana untuk sumbangan ……………………………………………………………………………..

24. Source of Wealth/Sumber Harta …………………………………………………………………………………..

25. Country of Source of Wealth/Negara bagi Sumber Harta ……………………………………………………………………………..

26. If you are a HSBC Staff, please state

your 8 digit Staff ID No./ Jika anda kakitangan HSBC, sila sertakan No. ID Kakitangan lapan digit

27. Country of Residence for Tax Purposes and related Taxpayer Identification Number or equivalent number (TIN)./Negara mastautin untuk tujuan percukaian dan Nombor Pengenalan Pembayar Cukai berkenaan atau nombor setaraf dengannya (TIN). (To be completed by Participant/ Diisikan oleh Peserta)

If a TIN is unavailable, please provide the appropriate reason A, B or C where indicated below/Jika TIN tidak dapat

disertakan, sila nyatakan sebab yang sesuai A, B atau C seperti yang ditunjukkan di bawah :

Reason A - The country where the Account Holder is liable to pay tax does not issue TINs to its residents/ Sebab A -

Negara di mana Pemegang Akaun bertanggungjawab untuk membayar cukai tidak mengeluarkan TIN kepada penduduknya

Reason B - The Account Holder is otherwise unable to obtain a TIN or equivalent number.(Please explain why you are unable to obtain a TIN in the below table if you have selected this reason)/ Sebab B - Pemegang Akaun sebaliknya tidak

dapat memperoleh nombor TIN atau setaraf.(Sila jelaskan mengapa anda tidak dapat memperoleh TIN di jadual di bawah

jika anda telah memilih sebab ini)

Reason C - No TIN is required. (Note. Only select this reason if the authorities of the country of tax residence entered

below do not require the TIN to be disclosed)/ Tiada TIN diperlukan. (Nota: Hanya pilih alasan ini jika pihak berkuasa negara mastautin yang dikenakan cukai yang dimasukkan di bawah tidak memerlukan TIN untuk didedahkan)

Country of tax residence/

Negara mastautin yang dikenakan

cukai TIN

If no TIN available enter Reason A,

B or C/

Jika tiada TIN tersedia, masukkan

Sebab A, B atau C

1

2

3

Please explain in the following boxes why you are unable to obtain a TIN if you selected Reason B above./Sila

terangkan di dalam kotak berikut mengapa anda tidak dapat memperoleh TIN jika anda memilih Sebab B di atas.

1

2

3

28. Existing life, health insurance policies, Family Takaful & health certificate with us or other companies/

Polisi insuran hayat, perubatan, Sijil Takaful Keluarga dan perubatan yang sedia ada dengan kami atau syarikat-syarikat lain

Yes/Ya No /Tidak If Yes, please specify./Jika Ya, sila nyatakan.

Name of Participant/

Covered Person/

Nama Peserta/ Orang Yang Dilindungi

Insurance Company/

Takaful Operator/

Syarikat Insuran/ Pengendali Takaful

Year of Issue/

Tahun Dikeluarkan Plan/

Pelan

Amount of Sum Insured/

Covered (RM)/

Amaun yang Diinsurankan/ /Dilindungi (RM)

PLAN DESCRIPTION/HURAIAN PELAN

Coverage Tenure / Tempoh Perlindungan Sum Covered (RM) / Jumlah Perlindungan (RM) Monthly Contribution (RM) /

Sumbangan Bulanan (RM)

Note : 1) The maximum Death Benefit for the same Covered Person under this plan, whether under one or multiple takaful certificates, shall not exceed RM500,000. 2) The monthly contribution will increase based on your attained age as illustrated in the product illustration.

Nota : 1) Manfaat Kematian maksima untuk Orang Yang Dilindungi yang sama di bawah pelan ini, sama ada bersempena dengan satu atau beberapa sijil takaful, tidak

boleh melebihi RM500,000. 2) Sumbangan bulanan akan meningkat berdasarkan kepada umur tercapai seperti tertera didalam ilustrasi produk.

PAYMENT METHOD/KAEDAH PEMBAYARAN

Payor Name (Account/Credit Card Holder)/Nama Pembayar (Pemegang Akaun/Kad Kredit) : _________________________________________________________

HSBC Bank Account /HSBC Amanah Account-i No./ No. Akaun HSBC Bank/Akaun-i HSBC Amanah

− −

Credit Card/Kad Kredit

VISA/

VISA

MASTERCARD/

MASTERCARD

Card Expiry Date/

Tarikh Luput Kad

/ MM/BB YY/TT

Credit Card No./No. Kad Kredit

1. I hereby authorise HSBC Amanah Takaful (Malaysia) Berhad to/Saya dengan ini membenarkan HSBC Amanah Takaful (Malaysia) Berhad untuk :-

(a) debit my credit card, including any new, updated and/or replacement credit card; or/debit kad kredit saya, termasuk sebarang kad kredit baharu, kemaskini

dan/atau ganti; atau

(b) request HSBC Bank Malaysia Berhad or HSBC Amanah Malaysia Berhad, as applicable, to debit my bank account above; /meminta HSBC Bank Malaysia

Berhad atau HSBC Amanah Malaysia Berhad, yang mana berkenaan, untuk mendebit akaun bank saya di atas;

(c) with the amounts payable to the Takaful Operator from time to time for the Takaful Certificate to be issued under this proposal/dengan jumlah yang perlu dibayar

kepada Pengendali Takaful dari semasa ke semasa untuk Sijil Takaful yang akan dikeluarkan berdasarkan cadangan ini.

2. I also hereby agree to the following terms and conditions/Saya dengan ini bersetuju dengan terma-terma dan syarat-syarat berikut:-

(a) I hereby consent and authorise the Issuing Bank to disclose to the Takaful Operator my new, updated and/or replacement credit card for my continuous

participation in this Takaful plan;/Saya dengan ini memberi izin dan membenarkan Bank Pengeluar untuk mendedahkan kad kredit baharu, kemaskini dan/atau

ganti saya kepada Pengendali Takaful untuk penyertaan berterusan saya dalam Pelan Takaful ini;

(b) This authorisation shall remain in force until the Takaful Operator receives a written notification from me for any change of information to my payment

instruction or to cancel this authorisation; and/Pemberian kuasa ini akan kekal berkuatkuasa sehingga Pengendali Takaful menerima notis bertulis bagi sebarang

perubahan maklumat berkenaan dengan arahan pembayaran saya atau membatalkan pemberian kuasa tersebut; dan

(c) The Takaful Operator shall not be held responsible or liable for any claims, loss, damage, costs and expenses arising from the successful processing of the debit

or the unsuccessful processing of the debit due to exceeding credit limit, malfunction of system, electricity failure and any other factors beyond the control of

Takaful Operator./Pengendali Takaful tidak akan bertanggungjawab ke atas apa-apa tuntutan, kerugian, kerosakan, kos dan perbelanjaan yang timbul akibat

proses pendebitan yang berjaya atau proses pendebitan yang tidak berjaya akibat melebihi had kredit, sistem tidak berfungsi, kegagalan elektrik atau lain-lain

faktor yang di luar kawalan Pengendali Takaful.

Signature of Account/Credit Card Holder :

Tandatangan Pemegang Akaun/Kad Kredit ___________________________________________ Date/Tarikh : ________________________________

DECLARATION/REPLACEMENT/EXTENSION OF EXISTING CERTIFICATE/

PENGISYTIHARAN/PENGGANTIAN/PENAMBAHAN KE ATAS SIJIL SEDIA ADA

Do you intend to replace any of your existing Family Takaful Plans with us or with any other Yes/Ya No/Tidak Takaful operator with the proposal of this new Family Takaful Plan? Adakah anda berniat untuk menggantikan mana-mana Pelan Takaful Keluarga anda yang sedia ada dengan kami atau dengan pengendali Takaful yang lain menerusi permohonan Pelan Takaful Keluarga yang baru ini? If Yes, please state the replacement reason and provide further information on the plan to be replaced (Takaful Operator, plan name and Sum Covered) Jika Ya, sila nyatakan sebab penggantian dan berikan butir-butir lanjut berkenaan pelan yang hendak digantikan (Pengendali Takaful, nama pelan dan Jumlah Perlindungan)

…………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………… Reminder: Replacing an existing certificate with a new certificate is not in your best interest. Below are some of the reasons: Peringatan: Menggantikan sijil sedia ada dengan sijil baru bukan dalam kepentingan terbaik anda. Antara sebab-sebabnya adalah seperti di bawah:

(i) Coverage may not be based on standard terms; Perlindungan mungkin bukan berdasarkan terma-terma biasa (ii) Contribution amount is higher as age increases. Jumlah sumbangan adalah lebih tinggi apabila usia meningkat. (iii) Due to high initial cost, the time taken to build up the cash value for a new certificate is longer. Disebabkan oleh kos permulaan yang tinggi, tempoh pengumpulan nilai tunai untuk sijil baharu anda memerlukan masa yang lebih panjang

HEALTH QUESTIONS/SOALAN-SOALAN KESIHATAN

Note: The questions below must be answered by Participant.

Nota: Soalan-soalan di bawah mesti dijawab oleh Peserta. Yes/

Ya

No/

Tidak

1. Smoker Status/Status merokok Are you a smoker?/Adakah anda seorang perokok?

2. Have you ever been diagnosed with Cancer*, Heart Disease, Stroke* or HIV/AIDS*? Adakah anda pernah didiagnosis dengan Kanser*, Penyakit Jantung*, Strok* atau HIV/AIDS*?

3. Have you been diagnosed with or suffered from Diabetes* or any medical condition affecting your lung, kidney, blood, brain, heart, liver, eye, ear or limbs for which you require continuous treatment* or have consulted medical doctor within the last 5 years?

Adakah anda pernah didiagnosis atau menghidap Diabetes* atau sebarang keadaan perubatan yang memberi kesan kepada paru-paru, buah pinggang, darah, otak, jantung hati, mata, telinga atau anggota badan dimana anda memerlukan rawatan berterusan* atau pernah merujuk kepada doktor perubatan dalam tempoh 5 tahun yang lalu?

4. In the past 12 months, have you consulted or do you intend to consult a medical practitioner or specialist for investigations*, medical referrals, surgical operation or treatment on any medical conditions*? Dalam tempoh 12 bulan yang lepas, adakah anda pernah atau berhasrat merujuk kepada pengamal perubatan atau pakar untuk pemeriksaan*, rujukan perubatan, pembedahan atau rawatan bagi sebarang keadaan perubatan? *Except for these conditions:

Common cold or flu, uncomplicated pregnancy and caesarean section, contraception, inoculation or injuries/fractures from which you have fully recovered. *Keadaan perubatan yang dikecualikan: Demam atau selsema, kehamilan yang tidak rumit dan pembedahan Caesarean, kontrasepsi, inokulasi atau kecederaan/patah tulang yang mana anda telah pulih sepenuhnya.

5. In your job or leisure time, do you take part in any dangerous activities* as part of your occupation or leisure pursuits?

Dalam pekerjaan atau masa lapang anda, adakah anda mengambil bahagian dalam sebarang aktiviti-aktiviti berbahaya* sebagai sebahagian daripada pekerjaan atau aktiviti masa lapang anda?

6. Have any of your family takaful/life insurance application been rejected by HSBC Amanah Takaful (Malaysia) Berhad or any other insurers/Takaful operators? Pernahkah permohonan anda dalam pelan insuran nyawa atau takaful keluarga, ditolak oleh HSBC Amanah Takaful (Malaysia) Berhad atau syarikat insuran/pengendali Takaful yang lain?

* Explanatory Notes on information: * Nota Penjelasan mengenai maklumat:

Cancer/Kanser Abnormal and uncontrolled cell growth in any part of the body that becomes malignant./Pertumbuhan sel yang tidak normal dan tidak terkawal di mana-mana bahagian badan yang menjadi malignan.

Stroke/Strok A cerebro-vascular accident (CVA) caused by a vascular event in the brain which results in any side effects or disorder./ Kejadian cerebro-vaskular (CVA) disebabkan oleh kejadian vaskular di otak yang mengakibatkan sebarang kesan sampingan atau gangguan.

HIV/AIDS If you have ever tested positive for HIV or AIDS./Jika anda pernah diuji positif untuk HIV atau AIDS.

Diabetes Usually defined as Diabetes Mellitus Type 1 or Type 2 which have resulted in raised blood sugar./Biasanya ditakrifkan sebagai Diabetes Mellitus Type 1 atau Type 2 yang mengakibatkan gula darah meningkat.

Treatment/Rawatan Undergoing surgical operation, physiotherapy, medical therapy or taking medicine./Dalam operasi pembedahan, fisioterapi, terapi perubatan atau mengambil ubat.

Investigation/Pemeriksaan Mammogram, X- Ray, MRI, CT Scan, Blood test./Mamogram, X-Ray, MRI, Imbas CT, Ujian darah.

Hereditary condition/Penyakit Keturunan A disease or disorder that is inherited genetically, for e.g. Huntington's disease, Motor Neurone disease or Muscular Dystrophy./ Penyakit atau gangguan yang diwariskan secara genetik, misalnya. Penyakit Huntington, Penyakit Motor Neurone atau Dystrophy Muscular.

Dangerous activities/ Aktiviti-aktiviti merbahaya

Working at heights, working underground, using explosives, motor racing, flying other than as a fare paying passenger on a commercial airline, diving below 30m or mountain climbing (4,000m and above)./Bekerja di tinggi, di bawah tanah, menggunakan bahan peledak, perlumbaan motor, terbang selain sebagai penumpang tambang berbayar di syarikat penerbangan komersil, menyelam di bawah 30m atau mendaki gunung (4,000m dan ke atas).

GENERAL INFORMATION/MAKLUMAT UMUM

Yes/

Ya No/

Tidak

Do you or have you ever had any criminal conviction or legal proceeding including bankruptcy filed against you? If Yes, please provide full details./Adakah anda atau pernahkah anda mempunyai apa-apa sabitan jenayah atau prosiding undang-undang termasuk kebankrapan yang difailkan terhadap anda? Jika Ya, sila berikan butir-butir lengkap. ………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………..

NOMINATION/PENAMAAN

1. Nomination applies only to a family Takaful Certificate effected by you on your own life. If you are not the Covered Person, nomination does not apply./Penamaan ini

hanya boleh digunapakai ke atas Sijil Takaful keluarga yang anda sertai atas nyawa anda sendiri. Jika anda bukan Orang Yang Dilindungi, penamaan ini tidak akan dilaksanakan.

2. You may/Anda boleh : (a) nominate a person to receive the benefits payable under your Takaful Certificate as a beneficiary under conditional hibah (gift); or/menamakan seseorang untuk

menerima manfaat yang akan dibayar di bawah Sijil Takaful anda sebagai penerima manfaat melalui hibah bersyarat; atau (b) nominate a person to receive the benefits as an executor; or/menamakan seseorang untuk menerima manfaat sebagai wasi; atau (c) assign the benefits payable under your Takaful Certificate./menyerah hak manfaat yang akan dibayar di bawah Sijil Takaful anda.

3. If the nominee is/Jika penama adalah : (a) a beneficiary under a conditional hibah, ownership of the takaful benefits transfers to the nominee upon your death and will not form part of your estate or be

subject to your debts./seorang penerima manfaat di bawah hibah bersyarat, hak milik manfaat takaful dipindahkan kepada penama selepas kematian anda dan tidak akan menjadi sebahagian daripada estet atau tertakluk kepada hutang anda.

(b) an executor, he must distribute the takaful benefits in the due course of the administration of your estate according to your wills or applicable distribution law./wasi, dia mesti mengagihkan manfaat takaful mengikut perjalanan wajar pentadbiran estet anda mengikut wasiat anda atau undang-undang pengagihan yang berkenaan.

4. If the takaful benefits have been pledged as security or assigned to any other person (including a corporation) prior to or after this nomination and we have notice of such security or assignment, this nomination will be subject to the rights of the security holder or assignee. Subject to the rights under the security or assignment being preserved, we shall pay the balance of the takaful benefits, if any, to your nominee./Sekiranya manfaat takaful tersebut telah disandar sebagai sekuriti atau diserah hak kepada orang lain (termasuk perbadanan) sebelum atau selepas penamaan ini dan kami mempunyai notis mengenai sekuriti atau serahan hak tersebut, penamaan ini akan tertakluk kepada hak-hak pemegang sekuriti atau orang yang diserah hak tersebut. Tertakluk kepada pemeliharaan hak-hak di bawah sekuriti atau serahan hak tersebut, kami akan membayar baki manfaat takaful, sekiranya ada, kepada penama anda.

5. If there is more than one nominee and you have not specified the share of each nominee, the takaful benefits will be divided equally between the nominees./Jika terdapat lebih daripada satu penama dan anda tidak menyatakan syer untuk setiap penama, manfaat takaful akan dibahagikan sama rata antara penama-penama tersebut.

6. If a nominee predeceases you, the nomination in respect of such nominee shall be automatically revoked. You may also revoke a nomination by written notice to us or by making a subsequent nomination./Jika penama meninggal dunia sebelum anda, penamaan berhubung penama tersebut akan dibatalkan secara automatik. Anda juga boleh membatalkan penamaan melalui notis bertulis kepada kami atau dengan membuat penamaan yang lain.

7. If a nominee dies after you but before the takaful benefits have been paid, we shall pay such benefits to:/Jika penama meninggal dunia selepas anda tetapi sebelum manfaat takaful dibayar, kami akan membayar manfaat tersebut kepada :

(a) your estate if the nominee is an executor;/estet anda jika penama adalah wasi;

(b) the nominee’s estate if the nominee is a beneficiary under a conditional hibah./estet penama jika penama adalah penerima manfaat di bawah hibah bersyarat. 6. Payment to your nominee(s) discharges us from all liabilities in respect of such payment./Pembayaran kepada penama-penama melepaskan kami daripada segala liabiliti

berkenaan dengan pembayaran tersebut.

7. If a nominee who is a beneficiary is incompetent to contract at the time of payment, we shall pay the takaful benefits to his parent. If there is no surviving parent and such benefits:/Jika penama adalah penerima manfaat yang tidak kompeten untuk berkontrak pada masa pembayaran, kami akan membayar manfaat takaful tersebut kepada

ibu bapanya. Jika tiada ibu bapa yang masih hidup dan manfaat tersebut:

(a) do not exceed RM50,000 or other amounts prescribed under the law, we may pay such benefits to a proper claimant;/tidak melebihi RM50,000 atau jumlah lain yang ditetapkan di bawah undang-undang, kami akan membayar manfaat tersebut kepada pihak penuntut yang wajar;

(b) exceed RM50,000 or other amounts prescribed under the law, we shall pay such benefits to the Public Trustee or trust company appointed by you./melebihi

RM50,000 atau jumlah lain yang ditetapkan di bawah undang-undang, kami akan membayar manfaat tersebut kepada Pemegang Amanah Raya atau syarikat amanah yang dilantik oleh anda.

We shall be discharged from all liabilities in respect of such payment./Kami akan dilepaskan daripada semua liabiliti berkenaan dengan pembayaran tersebut.

8. Please ensure that the nominee(s) is aware of your participation in this Takaful Certificate/plan and that you inform us of any change in the contact details, including address of the nominee(s)/trust company./Sila pastikan bahawa penama-penama tersebut mengetahui tentang penyertaan anda di dalam Sijil/pelan Takaful ini dan anda

memaklumkan kepada kami jika terdapat sebarang perubahan mengenai butiran hubungan, termasuk alamat penama-penama/syarikat amanah.

I hereby nominate the following person to receive the takaful benefits under/Saya dengan ini melantik penama dibawah untuk menerima manfaat takaful sebagai : (please select one/sila pilih satu)

Beneficiary under conditional Hibah/Penerima Manfaat melalui hibah bersyarat Executor/Wasi

Details of Nominee(s)/ Butiran Penama-penama

Nominee 1/ Penama 1

Nominee 2/ Penama 2

Nominee 3/ Penama 3

Nominee 4/ Penama 4

Name of Nominee/ Nama Penama

NRIC/Birth Cert/ Passport/Other ID No./ No. K.P. Baru/Sijil Lahir/ Pasport/No. Pengenalan Lain

Date of Birth & Age/ Tarikh Lahir & Umur

Relationship with Participant/ Hubungan dengan Peserta

Share %/% Syer

DECLARATION BY PARTICIPANT/PENGISYTIHARAN OLEH PESERTA

I declare, in my capacity as the Participant that:/Sesungguhnya saya sebagai Peserta mengisytiharkan bahawa: 1. All information and documents I provide pursuant to this proposal form are full, accurate and true./Segala maklumat dan dokumen-dokumen yang saya berikan

menurut borang cadangan ini adalah penuh, tepat dan benar. 2. I agree to participate in this takaful plan managed by the Takaful Operator. The Takaful Operator shall manage this plan based on a Wakalah contract and in

accordance with principles of Syariah. In return, the Takaful Operator is to be paid Wakalah fee disclosed to me and which shall be provided in the Takaful Certificate to be issued to me./Saya bersetuju untuk menyertai pelan Takaful ini yang diuruskan oleh Pengendali Takaful. Pengendali Takaful akan menguruskan pelan ini berasaskan kontrak Wakalah dan mengikut prinsip-prinsip Syariah. Sebagai ganjaran, Pengendali Takaful akan dibayar fi Wakalah yang telah didedahkan kepada saya dan terkandung dalam Sijil Takaful yang akan dikeluarkan kepada saya.

3. I agree that the Takaful Operator may appoint a third party(ies) or agent(s) it deems fit to execute part of its operational role under this Wakalah contract. In the event of the appointment, the Takaful Operator shall bear any cost and expense incurred./Saya bersetuju bahawa Pengendali Takaful boleh melantik pihak ketiga atau ejen-ejen yang sesuai untuk melaksanakan sebahagian daripada tugasan operasi di bawah kontrak Wakalah ini. Sekiranya berlaku perlantikan, sebarang kos dan perbelanjaan akan ditanggung oleh Pengendali Takaful.

4. I agree that my contribution after deducting Wakalah Fee shall be credited as Tabarru’(donation) into the Family Risk Fund for the purpose of helping other participants in need. I also permit the Takaful Operator to make payment for claims/Takaful benefits from the Family Risk Fund in accordance with the terms and conditions of the Takaful coverage./Saya bersetuju bahawa sumbangan saya selepas ditolak fi wakalah akan dimasukkan ke dalam Dana Risiko Keluarga sebagai Tabarru’(derma) untuk membantu peserta-peserta lain yang memerlukan. Saya juga membenarkan Pengendali Takaful untuk membuat bayaran tuntutan/manfaat Takaful daripada Dana Risiko Keluarga mengikut syarat-syarat perlindungan takaful.

5. I agree that at the end of each financial year, the Takaful Operator will receive 50% of surplus distributable, if any, from the Family Risk Fund as an incentive while the balance 50% will be distributed amongst the eligible participants and my entitlement will be credited into my bank account or credit card account, depending on the contribution payment method I have chosen in the proposal form, on a yearly basis. One attempt will be made to credit the surplus into my account and if the attempt fails, the amount will be donated for charitable purposes as approved by Takaful Operator’s Syariah Committee./Saya bersetuju bahawa pada penghujung setiap tahun kewangan, Pengendali Takaful akan menerima 50% lebihan pendapatan boleh agih jika ada daripada Dana Risiko Keluarga tersebut, sebagai insentif manakala baki 50% akan diagihkan dikalangan peserta-peserta yang layak menerimanya dan lebihan pendapatan berhak keatas saya akan dikreditkan ke dalam akaun bank atau akaun kad kredit saya, bergantung kepada kaedah pembayaran sumbangan yang telah saya nyatakan didalam borang cadangan secara tahunan. Satu percubaan akan dibuat untuk mengkreditkan lebihan pendapatan ke dalam akaun saya dan jika percubaan gagal, jumlah tersebut akan didermakan untuk tujuan kebajikan yang diluluskan oleh Jawatankuasa Syariah Pengendali Takaful.

6. If the Takaful Operator discovers or has reasonable suspicion that this Takaful coverage is exploited for money laundering activities or to finance terrorism, or if any instruction/request given may lead to a breach of any sanction/law, the Takaful Operator reserves the right to reject any instruction/request given or terminate this Takaful coverage immediately. The Takaful Operator shall deal with all contributions paid and all benefits/sums payable in respect of this Takaful coverage in any manner which the Takaful Operator deems appropriate, including but not limited to handing it over to the relevant authorities./Jika Pengendali Takaful mengetahui atau mempunyai syak wasangka yang berasas, bahawa perlindungan Takaful ini digunakan untuk aktiviti penggubahan wang haram atau untuk membiayai keganasan atau jika sebarang arahan/permintaan yang diberi akan melanggar mana-mana sekatan/undang-undang, Pengendali Takaful berhak untuk menolak sebarang arahan/permintaan atau menamatkan perlindungan Takaful ini dengan serta-merta. Pengendali Takaful akan menguruskan semua sumbangan yang telah dibayar dan semua manfaat/jumlah yang kena dibayar berkenaan perlindungan Takaful ini melalui apa cara yang difikirkan sesuai, termasuk tetapi tidak terhad kepada menyerahkannya kepada pihak berkuasa yang berkaitan.

7. I agree that if the Takaful Operator does not receive the contribution for the Takaful Coverage for this Certificate within Sixty (60) days from the contribution due date as stated in Takaful Schedule, the Certificate will be lapsed. I also agree for the Takaful Operator to deduct any outstanding contributions from the sum covered payable to the claimant if the contributions remain unpaid when a claim is submitted. Saya bersetuju bahawa jika Pengendali Takaful tidak menerima sumbangan bagi Perlindungan Takaful bagi Sijil ini dalam tempoh enam puluh (60) hari dari tarikh sumbangan perlu dibayar seperti yang dinyatakan dalam Jadual Takaful, Sijil Takaful akan luput. Saya juga bersetuju untuk Pengendali Takaful menolak sumbangan yang tertunggak daripada jumlah perlindungan yang akan dibayar kepada penuntut jika sumbangan masih tidak dibayar semasa tuntutan diserahkan.

8. I have read and understood the Product Disclosure Sheet and Product Illustration, in respect of this Takaful Plan provided to me./Saya telah membaca dan memahami Lampiran Pendedahan Produk dan Ilustrasi Produk yang berkaitan dengan Pelan Takaful ini yang diberikan kepada saya.

9. The English terms of this document shall prevail over the Bahasa Malaysia terms if there is any inconsistency between the two. Please seek our Customer Service’s assistance if you have any query regarding this Proposal Form./Terma-terma Bahasa Inggeris dokumen ini akan diguna pakai sekiranya terdapat sebarang percanggahan antara terma Bahasa Inggeris dan Bahasa Malaysia. Sila rujuk kepada Perkhidmatan Pelanggan kami sekiranya anda mempunyai sebarang pertanyaan mengenai Borang Cadangan ini.

10. The Takaful Operator will refund my contribution (if payment was made before the Takaful Certificate was issued), less any fees for medical examination the Takaful Operator may have incurred, if I withdraw my consent before my takaful application is accepted by the Takaful Operator, or the surrender value of my Takaful Certificate, if any, as if I am surrendering my takaful certificate, after the Takaful Certificate has been issued./Pengendali Takaful akan memulangkan sumbangan takaful saya (sekiranya pembayaran telah dibuat sebelum Sijil Takaful dikeluarkan) ditolak pembayaran pemeriksaan perubatan yang telah ditanggung oleh Pengendali Takaful, sekiranya saya menarik balik kebenaran untuk memproses data peribadi saya sebelum permohonan takaful saya diterima oleh Pengendali Takaful, atau nilai serahan Sijil Takaful saya, jika ada, sebagaimana saya telah menyerahkan Sijil Takaful saya selepas Sijil Takaful dikeluarkan.

PERSONAL DATA PROTECTION/PERLINDUNGAN MAKLUMAT PERIBADI

1. I consent and hereby authorise: (a) the Takaful Operator (or any of its appointed service providers) 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 and has records on me, or my health and (c) HSBC Bank Malaysia Berhad or HSBC Amanah Malaysia Berhad, to provide, relevant information and documents required by the Takaful Operator 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 authorisation will be as effective and valid as the original./Saya memberi izin dan memberi kuasa kepada (a) Pengendali Takaful (atau mana-mana pembekal perkhidmatan yang dilantik) untuk memperolehi dan memproses; dan (b) mana-mana pengamal perubatan, hospital, pusat perubatan, sebarang individu atau institusi perubatan (sama ada diperbadankan atau tidak) yang pernah merawat saya dan memiliki rekod keatas saya atau kesihatan saya dan (c) HSBC Bank Malaysia Berhad atau HSBC Amanah Malaysia Berhad, untuk memberikan maklumat yang relevan dan dokumen-dokumen yang diperlukan oleh Pengendali Takaful untuk menentukan sama ada untuk menerima cadangan 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.

2. I consent and agree that the Takaful Operator may disclose and process my personal data including medical records for purposes as provided for in the Takaful Operator’s Notice to Customers relating to the Personal Data Protection Act 2010 ("the Notice”), a copy of which is attached to this proposal form. I also confirm that I have received, read and agree to the contents and terms of the Notice which is also available for download from http://www.takaful.hsbcamanah.com.my. /Saya memberi kebenaran dan bersetuju bahawa Pengendali Takaful boleh mendedahkan dan memproses maklumat peribadi saya termasuk rekod perubatan untuk tujuan seperti yang dinyatakan dalam Notis Pengendali Takaful kepada Pelanggan berkenaan dengan Akta Perlindungan Data Peribadi 2010 ("Notis tersebut"), di mana satu salinan Notis tersebut dilampirkan bersama borang cadangan ini. Saya juga mengesahkan bahawa saya telah menerima satu salinan Notis tersebut, membaca dan bersetuju dengan kandungan dan terma Notis tersebut, yang juga boleh dimuat turun dari http://www.takaful.hsbcamanah.com.my.

COLLECTION AND USE OF CUSTOMER INFORMATION, FINANCIAL CRIME RISK MANAGEMENT ACTIVITY AND TAX

COMPLIANCE/KUTIPAN DAN PENGGUNAAN MAKLUMAT PELANGGAN, AKTIVITI PENGURUSAN RISIKO JENAYAH KEWANGAN DAN

PEMATUHAN CUKAI

1. I and any Connected Person (as defined in the Global Clause) consent and agree that the Takaful Operator may disclose and process my and/or the Connected Person’s

personal data for purposes as provided for in the notice on Collection and Use of Customer Information, Financial Crime Risk Management Activity and Tax Compliance (“the Global Clause”), a copy of which is attached to this proposal form. I further confirm and warrant that every Connected Person whose information (including

personal data or tax information) has been (or will be) provided to the Takaful Operator has been informed of (or will be informed) and agreed to the processing,

disclosure and transfer of their information as set out in the Global Clause./Saya dan Orang Yang Berhubungkait (seperti yang dinyatakan dalam Klausa Global) memberi kebenaran dan bersetuju bahawa Pengendali Takaful boleh mendedahkan dan memproses maklumat peribadi saya dan sesiapa yang berkaitan bagi tujuan yang

dinyatakan dalam Notis berkenaan Kutipan dan Penggunaan Maklumat Pelangan, Aktiviti Pengurusan Risiko Jenayah Kewangan dan Pematuhan Cukai (“Klausa

Global”), satu salinan telah dilampirkan bersama dengan borang cadangan ini. Saya juga mengesahkan bahawa Orang Yang Berhubung kait di mana maklumat (termasuk maklumat peribadi atau cukai) telah (atau akan) diberikan kepada Pengendali Takaful, telah dimaklumkan (atau akan diberitahu) dan bersetuju untuk

pemprosesan, pendedahan dan pemindahan maklumat mereka seperti yang dinyatakan dalam Klausa Global.

2. I also confirm that I have received, read and agree to the contents and terms of the Global Clause, which is also available for download from http://www.takaful.hsbcamanah.com.my./Saya juga mengesahkan bahawa saya telah menerima, membaca dan bersetuju dengan kandungan dan syarat-syarat dalam

Klausa Global, yang juga boleh dimuat turun dari http://www.takaful.hsbcamanah.com.my.

3. I am aware that if I or a Connected Person refuse or fail to comply with the Global Clause, the Takaful Operator may:-/Saya sedar bahawa sekiranya saya atau Orang

Yang Berhubungkait enggan atau gagal mematuhi Klausa Global, Pengendali Takaful boleh:-

a) be unable to provide new services to me, or carry out any of my instructions in relation to my Takaful Certificate; and/or/tidak dapat menyediakan perkhidmatan

baru kepada saya, atau menjalankan sebarang arahan yang berhubung dengan Sijil Takaful saya; dan/atau

b) take actions necessary for Takaful Operator or a member of the HSBC Group to meet the Compliance Obligations (as defined in the Global Clause)/mengambil tindakan yang sewajarnya untuk Pengendali Takaful atau ahli kumpulan HSBC untuk memenuhi Kewajipan Pematuhan (seperti yang dinyatakan dalam Klausa

Global.

This includes the Takaful Operator making its own decision with respect to my status or a Connected Person’s, including whether to report me or a Connected Person to a

Tax Authority (as defined in the Global Clause), and may require the Takaful Operator or other persons to withhold amounts as may be legally required by any Tax

Authority and paying such amounts to the Tax Authority, where necessary./Ini termasuk Pengendali Takaful mengambil keputusan sendiri berkenaan dengan status saya atau Orang yang Berhubungkait, termasuk sama ada melaporkan saya atau Orang Yang Berhubungkait kepada Pihak Berkuasa Cukai (seperti yang dinyatakan dalam

Klausa Global), dan mungkin menghendaki Pengendali Takaful atau orang lain untuk menahan jumlah yang dikehendaki dari segi undang-undang oleh Pihak Berkuasa

Cukai dan membayar jumlah ini kepada Pihak Berkuasa Cukai, di mana yang berkenaan.

RESTRICTION ON CERTIFICATE/PENYEKATAN KE ATAS SIJIL

I understand that the issuance of the Takaful Certificate is intended for distribution only in Malaysia and governed by the laws of Malaysia. If you, or anyone else with authority over or otherwise connected to this Certificate (such as the Covered Person or the beneficiary) is, temporarily or permanently/ Saya faham bahawa Sijil Takaful

yang akan dikeluarkan hanya untuk pengedaran di Malaysia sahaja dan tertakluk kepada undang-undang Malaysia. Jikalau anda, atau sesiapa sahaja yang mempunyai

kuasa atau sebaliknya berkait dengan Sijil ini (seperti Orang yang Dilindungi atau benefisiari) berada buat sementara waktu atau secara tetap:

(a) outside of Malaysia; or/ di luar Malaysia; atau

(b) otherwise subject to the laws of any other place/ sebaliknya tertakluk kepada undang-undang tempat lain;

such that we reasonably believe that by complying with a particular term or condition of this Certificate we would breach any laws of Malaysia or such other place, then we are entitled not to comply with such term or condition for any period of time we deem necessary, regardless of what such term or condition may provide. This might include

declining to service some of your requests related to this Certificate. You agree we will not be liable for any losses, damages, claims, liabilities or costs you or any other

relevant person may suffer from our exercise of our rights under this clause. The prior sentence continues to apply even if this Certificate terminates for any reason./ yang kami percaya jika kami mematuhi terma atau syarat tertentu Sijil ini kami akan melanggar sebarang undang-undang Malaysia atau tempat lain tersebut, maka kami berhak

untuk tidak mematuhi terma atau syarat tersebut untuk tempoh masa yang kami fikirkan perlu, tanpa mengira peruntukan terma atau syarat itu. Ini mungkin termasuk

menolak untuk memberi perkhidmatan terhadap permintaan anda berkaitan Sijil ini. Anda bersetuju kami tidak akan bertanggungjawab ke atas sebarang kerugian, kerosakan, tuntutan, liabiliti atau kos yang anda atau orang berkenaan alami disebabkan oleh tindakan kami berkenaan hak kami di bawah klausa ini. Ayat di atas akan

terus digunapakai walaupun Sijil ini ditamatkan atas sebarang sebab.

Opt-Out Section/Bahagian Pengecualian

Intention to opt-out from use of personal data for direct marketing and/or cross selling./Niat untuk dikecualikan daripada penggunaan data peribadi untuk jualan langsung dan/atau jualan silang.

□ Tick (“”) this box if you do not wish HSBC Amanah Takaful (Malaysia) Berhad to use your personal data in direct marketing and cross selling within HSBC

Group of companies/Sila tanda (“”) kotak ini jika anda tidak membenarkan HSBC Amanah Takaful (Malaysia) Berhad untuk menggunakan data peribadi anda

untuk jualan langsung dan jualan silang dalam Kumpulan Syarikat HSBC.

The above represents my present choice whether or not to receive direct marketing and/or cross selling contact or information and replaces any prior choice communicated

by me to the Takaful Operator./Perkara di atas mewakili pilihan terkini saya sama ada atau tidak untuk dihubungi atau dimaklumkan mengenai jualan langsung dan/atau jualan silang dan menggantikan pilihan saya yang dimaklumkan kepada Pengendali Takaful sebelum ini.

Please note that your above choice applies to the direct marketing and/or cross selling of other products and services offered by the Takaful Operator and/or other HSBC Group members./Sila maklum bahawa pilihan anda di atas terpakai kepada jualan langsung dan/atau jualan silang produk-produk dan perkhidmatan-perkhidmatan yang

ditawarkan oleh Pengendali Takaful dan/atau mana-mana ahli Kumpulan HSBC.

Participant/Peserta Witness/Saksi

Signature/Tandatangan

Name/ Nama

NRIC/Passport/Other ID No./ No. K.P Baru/Pasport / No. Pengenalan Lain

Date/Tarikh

Note: The Takaful Certificate will be issued within 7 working days from the date of the Takaful Operator’s acceptance of the proposal, receipt of all the relevant documentation and full contribution in respect of this proposal whichever is later. The Takaful cover shall only be effective from the date the Takaful Certificate is issued. Nota: Sijil Takaful akan dikeluarkan dalam masa 7 hari bekerja dari tarikh penerimaan cadangan, semua dokumen yang berkenaan dan penerimaan sumbangan penuh berhubung dengan cadangan ini, yang mana terkemudian oleh Pengendali Takaful. Perlindungan takaful ini akan berkuatkuasa dari tarikh Sijil Takaful dikeluarkan.

Takaful Operator: HSBC Amanah Takaful (Malaysia) Berhad (Company No./No. Syarikat : 731530-M) Pengendali Takaful: P.O. Box 13343, 50806 Kuala Lumpur, Malaysia. Toll Free/Bebas Tol: 1-800-88-9659

HSBC Amanah Takaful (Malaysia) Berhad is registered under Islamic Financial Services Act 2013 and is regulated by Bank Negara Malaysia./HSBC Amanah Takaful (Malaysia) Berhad adalah didaftarkan di bawah Akta Perkhidmatan Kewangan Islam 2013 dan dikawal selia oleh Bank Negara Malaysia

NB/FTETT/18/000001

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HSBC Amanah Takaful (Malaysia) Berhad. (Company No. 731530-M) P.O.Box 13343, 50806 Kuala Lumpur, Malaysia.Toll Free: 1-800-88-9659. www.takaful.hsbcamanah.com.my

Notice to Customers Relating to the Personal Data Protection Act 2010 (the Act)

1. HSBC Amanah Takaful (Malaysia) Berhad. (“HSBC Amanah Takaful”) views your personal data and privacy seriously. This

Notice is issued pursuant to the requirements of the Personal Data Protection Act 2010.

2. It is necessary for individuals to supply their personal data to HSBC Amanah Takaful for the provision, continuation and

administration of Takaful contracts and Takaful services or to comply with any laws, guidelines or request issued by regulatory

or other authority. Apart from the data provided by you, HSBC Amanah Takaful may obtain and/or verify data on you from or

with any third party (whether incorporated or otherwise) including but not limited to risk surveyors, medical practitioners,

hospitals or medical institutions that has attended to you and/or any member of the HSBC Group. Failure to supply such

personal data or to agree to HSBC Amanah Takaful’s collection of such personal data may result in HSBC Amanah Takaful

being unable to provide or continue to provide Takaful coverage under the Takaful contract, including the termination of the

Takaful contract, and related Takaful services to you or comply with any laws or guidelines issued by regulatory or other

authorities.

3. Such personal data may include information concerning your personal details (such as name, age, identity card number,

passport number, gender, date of birth, race, nationality, citizenship and marital status) contact details (such as address, email

and phone numbers), family information (such as marital status, name of spouse or child or immediate family member),

occupation details (such as employer name, annual income, job title, nature and description of job) and financial details (such

as bank account number and credit card number).

4. In addition, HSBC Amanah Takaful may from time to time request for:-

(i) information relating to a customer’s medical records or health condition in general from the customer or any medical

practitioner, hospital, medical institution or any person (whether incorporated or not) who has ever attended to the

customer or has records regarding such customer’s health or medical condition; and/or

(ii) certain other personal information that may be relevant for HSBC Amanah Takaful to consider your application for

Takaful cover or the continuous provision of the Takaful certificate and/or Takaful services under a Takaful certificate

issued by HSBC Amanah Takaful. This includes but is not limited to tax information about a customer, a beneficiary

or any person entitled to any benefits/payment under the Takaful certificate.

5. It is also the case that personal data are collected from (i) customers and other sources in the ordinary course of the

continuation of the Takaful relationship for example, when customers write cheques or provide their credit card or bank

account details to HSBC Amanah Takaful for contribution payment of the Takaful coverage or when a customer nominates a

nominee to receive Takaful benefits payable under a Takaful certificate (ii) a person acting on behalf of the individual whose

data are provided and (iii) from other sources (including from publicly available information) . Data may also be generated or

combined with other information available to HSBC Amanah Takaful or any member of the HSBC Group (“HSBC Group”

means HSBC Holdings plc, its affiliates, subsidiaries, associated entities and any of their branches and offices (together or

individually) and “member of the HSBC Group” has the same meaning).

6. The purposes for which data may be used and/or processed are as follows:

(i) Considering applications for Takaful product and services and offering, providing, maintaining and managing Takaful

products and services to customers;

(ii) the operation and administration of Takaful products and services provided to customers which may include, without

limitation, underwriting, administration or evaluation of a Takaful application or any requests;

(iii) for all ancillary purposes relating to the offering, providing, maintaining and managing Takaful contracts and/or

related Takaful services including the provision of computer, telecommunications, storage and technology services;

(iv) for the daily operation and administration of the Takaful contracts and/or Takaful services provided to customers;

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(v) the Takaful Operator’s internal operational requirements or those of the HSBC Group (including credit and risk

management, system or product development and planning, insurance, audit and administrative purposes);

(vi) maintenance of databases, statistical analysis, claim verification, audit, customer complaints handling and resolution,

and operational matters;

(vii) conducting identity and/or medical checks with any medical practitioner, hospital, medical institution or any person

(whether incorporated or not) who has ever attended to you or has records on your health;

(viii) conducting risk survey on the proposed covered property and/or proposed covered contents in a property and all

associated risk thereunder;

(ix) for making enquiries or investigations as to whether or not the customer or person whose data is collected, used

and/or processed by HSBC Amanah Takaful is actually a sanctioned person, or is otherwise howsoever related to, or

associated with, a sanctioned person or entity; and also for the reporting or the taking of any remedial or preventive

action in relation thereto;

(x) processing, assessing and determining any proposal or request made by a customer for Takaful products or services,

issuing or arranging Takaful contracts and maintaining the customer’s record with HSBC Amanah Takaful;

(xi) purposes related to any claims made by or against or otherwise involving a customer in respect of Takaful contracts

and/or Takaful related services provided by HSBC Amanah Takaful including, without limitation, making, defending,

analyzing, investigating, processing, assessing, determining responding to, resolving or settling such claims;

(xii) promoting products and/or services by HSBC Amanah Takaful or any member of the HSBC Group to you. If you do

not wish to receive any promotional information from HSBC Amanah Takaful and/or any member of the

HSBC Group, please indicate so in our proposal form;

(xiii) improving the products and/or services provided by HSBC Amanah Takaful and to facilitate the provision of products

and/or services by any member of the HSBC Group to the customer;

(xiv) determining the amount of indebtedness owed to or by a customer and collecting amounts outstanding from a

customer;

(xv) exercising any rights HSBC Amanah Takaful or a member of the HSBC Group may have in connection with the

Takaful contract and/or services provided to a customer;

(xvi) matching any data held by HSBC Amanah Takaful or a member of the HSBC Group relating to a data subject from

time to time for any of the purposes listed in this paragraph (6);

(xvii) meeting obligations, requirements or arrangements, whether compulsory or voluntary, of HSBC Amanah Takaful or

any member of the HSBC Group to comply with, or in connection with:

a) any law, regulation, judgment, court order, voluntary code, sanctions regime, within or outside Malaysia existing

currently and in the future (“Laws”);

b) any guidelines, guidance or requests given or issued by any legal, regulatory, governmental, tax, law

enforcement or other authorities, or self-regulatory or industry bodies or associations of financial services

providers within or outside Malaysia existing currently or in the future and any international guidance, internal

policies or procedures;

c) any present or future contractual or other commitment with local or foreign legal, regulatory, judicial,

administrative, public or law enforcement body, or governmental, tax, revenue, monetary, securities or futures

exchange, court, central bank or other authorities, or self-regulatory or industry bodies or associations of

financial service providers or any of their agents with jurisdiction over all or any part of the HSBC Group

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(together the “Authorities” and each an “Authority”) that is assumed by, imposed on or applicable to HSBC

Amanah Takaful or any member of the HSBC Group; or

d) any agreement or treaty between Authorities;

(xviii) complying with any obligations, requirements, policies, procedures, measures or arrangements for sharing data and

information within the HSBC Group and/or any other use of data and information in accordance with any programmes

for compliance with sanctions or prevention or detection of money laundering, terrorist financing or other unlawful

activities;

(xix) conducting any action to meet obligations of HSBC Amanah Takaful or any member of the HSBC Group to comply

with Laws or international guidance or regulatory requests relating to or in connection with the detection, investigation

and prevention of money laundering, terrorist financing, bribery, corruption, tax evasion, fraud, evasion of economic

or trade sanctions and/or any acts or attempts to circumvent or violate any Laws relating to these matters;

(xx) meeting obligations of HSBC Amanah Takaful or any member of the HSBC Group to comply with any demand or

request from the Authorities;

(xxi) enabling an actual or proposed assignee or transferee of HSBC Amanah Takaful or any member of the HSBC Group,

or participant or sub-participant of HSBC Amanah Takaful’s or any member of the HSBC Group companies’ rights to

evaluate and/or undertake due diligence in relation to the transaction intended to be the subject of the assignment,

transfer, participation or sub-participation;

(xxii) to support the Group’s business, financial and risk monitoring, planning and decision making;

(xxiii) for any purpose required by law or regulation;

(xxiv) for the purpose of enforcing its legal rights and/or obtaining legal advice; and/or

(xxv) purposes relating thereto.

(7) Data held by HSBC Amanah Takaful or a member of the HSBC Group relating to an individual will be kept confidential but

HSBC Amanah Takaful or a member of the HSBC Group may provide or disclose such information to the following parties

(whether within or outside Malaysia) for the purposes set out in paragraph (6) (who may also subsequently process, transfer

and disclose such data for the purposes set out in paragraph 6):

(i) any member of the HSBC Group;

(ii) any agents, contractors, sub-contractors, service providers or associates of the HSBC Group (including their

employees, directors, officers, agents, contractors, service providers and professional advisers);

(iii) any third party service provider who provides administrative, telecommunications, computer, payment, telemarketing,

call centre, data processing,storage services or other services to HSBC Amanah Takaful in connection with the

operation of its business (including their employees, directors and officers)

(iv) any Authorities;

(v) any persons acting on behalf of an individual whose data are provided, payment recipients, beneficiaries, account

nominees, intermediary, correspondent and agent banks, clearing houses, clearing or settlement systems, market

counterparties, upstream withholding agents, swap or trade repositories, stock exchanges, companies in which the

customer has an interest in securities (where such securities are held by the Takaful Operator us or any member of

the HSBC Group) or a person making payment into the customer’s account;

(vi) any party to a transaction or potential transaction acquiring interest in, or assuming or bearing risk in, or in connection

with a Takaful certificate including without limitation, reinsurance / retakaful operators;

(vii) any other person in the context of the sale or transfer by HSBC Amanah Takaful or any member of the HSBC Group

of all or part of its business or portfolio of products, Takaful certificates or other assets or any proposed or confirmed

transaction relating to such a sale or transfer provided that such person is under a duty of confidentiality to HSBC

Amanah Takaful or to any member of the HSBC Group which has undertaken to keep such information confidential;

4 Version 3.0


(viii) co-insurance / co-takaful operators for the purposes of underwriting, administration or evaluation of a Takaful

contract;

(ix) any purposes in connection with any claims made by or against or otherwise involving a customer in respect of any

Takaful products and/or services provided by HSBC Amanah Takaful or a member of the HSBC Group including,

without limitation, making, defending, analysing, investigating, processing, assessing, determining, responding to,

resolving or settling such claims;

(x) any person to whom HSBC Amanah Takaful or any member of the HSBC Group is under an obligation or required or

expected to make disclosure for the purposes set out, or in connection with paragraph 6 (xvii), 6 (xviii), 6 (xix) or 6

(xx);

(xi) any actual or proposed assignee or transferee of HSBC Amanah Takaful or any member of the HSBC Group or

participant or sub-participant of HSBC Amanah Takaful’s or any member of the HSBC Group’s rights in respect of a

customer;

(xii) any person under a duty of confidentiality to HSBC Amanah Takaful including any HSBC Group member which has

undertaken to keep such information confidential;

and

(ix) hospitals, clinics, medical practitioners, laboratories, technicians, risk surveyors loss adjustors, risk intelligence

providers, legal advisers or private investigators that may be engaged by HSBC Amanah Takaful or on behalf of

HSBC Amanah Takaful.

Such information may be transferred to a place outside Malaysia.

(8) Under and in accordance with the provisions of the Act, any individual may:

(i) check whether HSBC Amanah Takaful holds data about him/her and of access to such data;

(ii) request HSBC Amanah Takaful to correct any data relating to him/her which is inaccurate; and

(iii) request for clarification of HSBC Amanah Takaful’s policies and practices in relation to data and to be informed of the

kind of personal data held by HSBC Amanah Takaful.

(9) In accordance with the terms of the Act, HSBC Amanah Takaful has the right to charge a fee for the processing of any data

access request.

(10) The individual can request access to data or correction of data or for information regarding policies and practices and kinds of

data held by filling and returning a Data Access Request form available at the following internet address

http://www.takaful.hsbcamanah.com.my. or any HSBC Bank Malaysia Bhd / HSBC Amanah Malaysia Bhd branches to:_

The Personal Data Protection Officer

HSBC Amanah Takaful (Malaysia) Berhad

P.O. Box 13343

50806 Kuala Lumpur

Tel: 1-800-88-9659

Email: [email protected]

(11) If customers have any queries or complaints regarding this Notice or otherwise relating to misuse or suspected misuse of their personal information, you may send an email to [email protected] or call HSBC Amanah Takaful’s call centre at 1-800-88-9659.

(12) For existing customers, if you do not want us to process and further disclose any of your personal data to any company within

the HSBC Group member for the purposes of direct selling and/or cross selling, please notify us in writing by filling the Opt-

http://www.takaful.hsbcamanah.com.my./

mailto:[email protected]

5 Version 3.0


Out Form, which forms part of our Alteration Form, available for download at http://www.takaful.hsbcamanah.com.my or any

HSBC Bank Malaysia Bhd / HSBC Amanah Malaysia Bhd branches.

(13) HSBC Amanah Takaful reserves the right to amend this Notice at any time and will place notice of such amendments on

HSBC Amanah Takaful’s website or via any other mode HSBC Amanah Takaful views suitable.

(14) Where the customer is a partnership (that is not registered under the Limited Liability Partnerships Act 2012) or other

unincorporated body of persons, the giving of this Notice addressed to the partnership or the unincorporated body of persons

shall be deemed as notice given to all the partners or the office bearers (as the case maybe) of such customer whose data are

collected and/or processed by HSBC Amanah Takaful for the purposes as stated herein. In this regard, the customer warrants

that the customer has obtained the consent of all such individuals to the provision of their data to HSBC Amanah Takaful for

the foregoing purposes and for disclosure to such parties as stipulated above and the customer undertakes to extend a copy

of this Notice to all such individuals, which expression shall include all such existing and new partners or office-bearers (as the

case maybe) of the customer from time to time.

(15) Aside from customers, this Notice shall also apply (as the context shall require) in relation to the usage, processing and

disclosure of the data of any other individual who is not a customer but whose data is required to be collected by HSBC

Amanah Takaful by reason of, or incidental to, a Takaful contract and/or the provision of Takaful services by HSBC Amanah

Takaful to its customers, whether the customer concerned is another individual(s) or is a company, business entity,

organization or unincorporated body. In this regard, the customer confirms and warrants that the customer has obtained the

consent of such individuals to the provision of such data to HSBC Amanah Takaful for the foregoing purposes and for

disclosure to such parties as stipulated above. For the foregoing purpose, such expression shall include but is not limited to

beneficiaries, recipient of Takaful payments, the corporate customer’s authorized signatories or the corporate customer’s

employees,

(16) Nothing in this Notice shall limit the rights of customers or HSBC Amanah Takaful under the Act.

1 Version 1.0 HSBC Amanah Takaful (Malaysia) Berhad (Company No. 731530-M) P.O.Box 13343, 50806 Kuala Lumpur, Malaysia.Toll Free: 1-800-88-9659. www.takaful.hsbcamanah.com.my

COLLECTION AND USE OF CUSTOMER INFORMATION, FINANCIAL CRIME RISK MANAGEMENT ACTIVITY AND TAX COMPLIANCE

DEFINITIONS

Capitalised terms used in this Clause shall have the following meanings, unless the context otherwise requires:

“Authorities” means any local or foreign judicial, administrative, public or regulatory body, any government, or public or government agency or authority, any Tax Authority, securities or futures exchange, court, central bank or law enforcement body, self-regulatory or industry bodies or associations of financial service providers or any agents thereof having jurisdiction over any part of HSBC Group.

“Compliance Obligations” means obligations of any member of the HSBC Group to comply with: (a) Laws or international guidance and internal policies or procedures relating thereto, (b) any demand or request from Authorities or reporting, regulatory trade reporting, disclosure or other obligations under Laws, or (c) Laws requiring us to verify the identity of our customers and Connected Persons.

"Connected Person" means a person or entity other than you whose information (including Personal Data or Tax Information) is provided by you, or on your behalf , to any member of the HSBC Group or otherwise received by any member of the HSBC Group in connection with the provision of the Services. A Connected Person may include, but is not limited to, any person identified as a beneficiary under a Takaful certificate, any person who is, or may be, entitled to receive a payment under a Takaful certificate, a director or officer of a company, partners or members of a partnership, any “substantial owner”, “controlling person”, or beneficial owner, trustee, settler or protector of a trust holding or controlling (directly or indirectly) the Takaful certificate, any of your representatives, agents or nominees, or any other persons or entities with whom you have a relationship that is relevant to your relationship with the HSBC Group. “controlling persons” generally means individuals who exercise control over an entity (for a trust, these are the settlor, the trustees, the protector, the beneficiaries or class of beneficiaries, and any other individual who exercises ultimate effective control over the trust, and in the case of a legal entity other than a trust, such term means persons in equivalent or similar positions of control).

“Customer Information” means all or any of the following terms relating to you or a Connected Person, where applicable: (i) Personal Data, (ii) any information about you and derived from and relating to a Takaful certificate, account value, transactions, use of our Takaful products, services and your relationship with the HSBC Group, and (iii) Tax Information.

“Financial Crime” means money laundering, terrorist financing, bribery, corruption, tax evasion, fraud, evasion of economic or trade sanctions, and/or violations, or attempts to circumvent or violate any Laws or regulations relating to these matters. “HSBC Group” means HSBC Holdings plc, and/or any of its affiliates, subsidiaries, associated entities and any of their branches and offices, and “any member of the HSBC Group” has the same meaning.


“Laws” include any law, regulation, rule, judgment, voluntary code, directive, sanctions regime, court order, agreement between any member of the HSBC Group and an Authority, or agreement or treaty between Authorities and applicable to us or a member of the HSBC Group. “Personal Data” means any data relating to an individual from which the individual can be identified, including, without limitation, sensitive personal data.

“Services” means, without limitation, (a) the provision of Takaful cover(s) under and maintaining of a Takaful certificate (b) the provision of any services relating to a Takaful certificate and its termination or expiry, and (c) the maintenance of our overall relationship with you. “substantial owners” means any individuals entitled to more than 10% of the profits of or with an interest of more than 10% in an entity either directly or indirectly. “Tax Authorities” means Malaysia or foreign tax, revenue, fiscal or monetary authorities.

"Tax Information" means any documentation or information (and accompanying statements, waivers and consents) relating, directly or indirectly, to your tax status or a Connected Person , “controlling person”, “substantial owner” or beneficial owner of a Connected Person. “Tax Information” includes, but is not limited to, information about: tax residence and/or place of organisation (as applicable), tax domicile, tax identification number, Tax Certification Forms, certain Personal Data (including name(s), residential address(es), age, date of birth, place of birth, nationality, citizenship).

“Tax Certification Forms” means any forms or other documentation as may be issued or required by a Tax Authority or by us from time to time to confirm your tax status or of a Connected Person. 1. COLLECTION, PROCESSING AND SHARING OF CUSTOMER INFORMATION This Clause explains how we will use information about you and Connected Persons. This Clause is to be read in conjunction with the Notice to Customers Relating to the Personal Data Protection Act 2010 (which may be amended or supplemented from time to time) (“the Notice”), which has been given to you. By using the Services, you agree that we and members of the HSBC Group shall use Customer Information in accordance with this Clause and the Notice.

COLLECTION 1.1. We and other members of the HSBC Group may collect, use and share Customer Information. Customer Information may be requested from you or a Connected Person (or a person acting on your behalf or a Connected Person), or may also be collected by or on behalf of us, or members of the HSBC Group, from other sources (including from publically available information), and it may be generated or combined with other information available to us or any member of the HSBC Group. PROCESSING 1.2. We and members of the HSBC Group will process, transfer and disclose Customer Information in connection with the purposes stated in the Notice and/or any purposes in relation thereto (“the Purposes”). SHARING


1.3. By using the Services, you agree that we may transfer and disclose any Customer Information to the recipients stated in the Notice (who may also subsequently process, transfer and disclose such Customer Information for the Purposes).

YOUR OBLIGATIONS 1.4 You agree to inform us promptly, in writing if there are any changes to Customer Information supplied to us or a member of the HSBC Group from time to time, and to promptly respond to any request from, us, or a member of the HSBC Group. 1.5. You confirm that every Connected Person whose information (including Personal Data or Tax Information) has been (or will be) provided to us or a member of the HSBC Group has been notified of (or will be notified) and agreed to the processing, disclosure and transfer of their information as set out in this Clause and the Notice (which may be amended or supplemented from time to time). You and every Connected Person have (or will at the relevant time have) read and understand the Notice. You shall advise such Connected Persons that they have rights of access to, and correction of, their Personal Data. 1.6 You consent and shall take such steps as are required from time to time for the purposes of the Personal Data Protection Act 2010 or any secrecy law to permit us to use, store, disclose, process and transfer all Customer Information in the manner described in this Clause and the Notice. You agree to inform us promptly in writing if you are not able or have failed to comply with the obligations set out in paragraphs 1.5 and 1.6 in any respect. 1.7. Where:

you or a Connected Person fails to provide Customer Information that we reasonably request, or

you or a Connected Person withholds or withdraws any consents that we may need to process, transfer or disclose Customer Information for the Purposes, or

we or a member of the HSBC Group has reasonable suspicions regarding the possible commission of Financial Crime or an associated risk, We may: a. be unable to provide new Services, or carry out any of your instructions in relation to a Takaful certificate; and/or b. take actions necessary for us or a member of the HSBC Group to meet the Compliance Obligations. In addition, your or a Connected Person’s failure to supply promptly your or a Connected Person’s Tax Information and accompanying statements, waivers and consents when requested, may result in us making our own decision with respect to your status or a Connected Person’s, including whether to report you or a Connected Person to a Tax Authority, and may require us or other persons to withhold amounts as may be legally required by any Tax Authority and paying such amounts to the Tax Authority.


2. FINANCIAL CRIME RISK MANAGEMENT ACTIVITY

2.1 We, and members of the HSBC Group, are required, and may take any action we consider appropriate, to meet Compliance Obligations in connection with the detection, investigation and prevention of Financial Crime (“Financial Crime Risk Management Activity”). Such action may include, but is not limited to: (a) screening, intercepting and investigating any instruction or communication by you or on your behalf or by a Connected Person or on their behalf, (b) investigating the source of or intended recipient of funds (c) combining Customer Information with other related information in the possession of the HSBC Group, and/or (d) making further enquiries as to the status of a person or entity, whether they are subject to a sanctions regime, or confirming your or Connected Person’s identity and status. 2.2 To the extent permissible by law, neither we nor any other member of HSBC Group shall be liable to you or any third party in respect of any loss (however it arose) whether incurred by you or a third party, caused in whole or in part in connection with the delaying, blocking or refusing of any payment or the provision of all or part of the Services or otherwise as a result of Financial Crime Risk Management Activity. 3. TAX COMPLIANCE

You acknowledge you are solely responsible for understanding and complying with your tax obligations (including but not limited to, tax payment or filing of returns or other required documentation relating to the payment of all relevant taxes) in all jurisdictions in which those obligations arise and relating to Takaful certificate and/or Services provided by us and/or members of the HSBC Group. Certain countries may have tax legislation with extra-territorial effect regardless of the Customer’s place of domicile, residence, citizenship or incorporation. We and/or any member of the HSBC Group do not provide tax advice. You are advised to seek independent legal and/or tax advice. We and/or any member of the HSBC Group have no responsibility in respect of your tax obligations in any jurisdiction which they may arise including, without limitation, any that may relate specifically to a Takaful certificate and/or Services provided by us and/or members of the HSBC Group. 4. MISCELLANEOUS

4.1.In the event of any conflict or inconsistency between any of this Clause and the terms contained in any Takaful certificate or endorsement(s) issued thereunder (if any) between you and us, this Clause shall prevail. 4.2.If all or any part of the provisions of the terms of this Clause becomes illegal, invalid or unenforceable in any respect under the law of any jurisdiction, that shall not affect or impair the legality, validity or enforceability of such provision in any other jurisdictions or the remainder of the terms in that jurisdiction. 5. SURVIVAL UPON TERMINATION This Clause shall continue to apply notwithstanding the termination of the Services or the expiry of a Takaful certificate.