Agensi Mohd Azhar Bin Mohd Jaafar (Kod Agensi : GG 09825)
AZHARJAAFAR RESOURCES (001798245-W)

Application Form for Motor Takaful

Insured Particulars

* Name

* IC Number (new)

IC Number (old)

* Driving Experience (years)

* Full Address

* Phone Number (mobile)

Phone Number (office)

Phone Number (house)

* Valid Email Address

Vehicle Particulars

* Vehicle Reg. No.

* Vehicle Type

* Vehicle Registration

For Motorcycle only

Single Rider

All Rider

* Vehicle Reg. Card No.
(No. At Right Top)

Attach a copy of Reg. Card (if possible)
-Front page

-Back Page

* Engine No

* Chassis No

* Make (Buatan)

* Model

* Engine Capacity (cc)

* Use of Vehicle
(Kelas Kegunaan)

* Body (Jenis Badan)

* Year Of Manufactured
(Tahun Dibuat)

* Market Value Of Vehicle
(Desired Sum Insured)

* Current NCD (%)

For Motorcycle only
Current NCD

0.00

* Road Tax End Date

Hire Purchase Company
(Hak Milik Dituntut Oleh)

Previous Insurer Particulars

* Insurance Company

* NCD on Policy

* Policy Start Date

* Policy End Date

Add Extra Benefit (optional)

Windscreen (RM)

Driver 2; Full Name, IC No, Driving Experience (year)

Driver 3; Full Name, IC No, Driving Experience (year)

Extra Services

* Road Tax Renewal (private car only)

Yes

If 'Yes', please give address for the road tax to be send

Declaration And Authorisation

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 Sdn Bhd (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 placed in the General Risk Investment Account (GRIA) and the Company be appointed to manage and invest My/Our GRIA to the expertise of the Company based on the Al-Wakalah principle as defined by the Company and in accordance to Syariah. In return, I/We agree to allow the Company to deduct 25% of the contribution as Wakalah Fee. I/We further agree that a portion of My/Our contribution shall be allocated on monthly basis as Tabarru’ (donation) into the Risk Fund and Special Fund and be used to help other Participants in time of misfortune. The remainder of the Takaful Contribution in the GRIA shall be invested by the Company and the profit arising out of this investment, if any, shall be returned to Me/Us after deducting an Investment Performance Fee of 40% from the profit. I/We also understand that the net surplus arising from the Risk Fund, if any, shall be managed by the Company according to the method and allocation in accordance to the Syariah Principle that will benefit the Participant and the Special Fund.

I/We currently holding a valid certificate/policy from My/Our previous Takaful/Insurance Company as stated in this proposal form.

I/We intend to transfer or claims My/Our NCD entitlement to a vehicle to be covered with your Company.

I/We hereby confirm that :
a) The NCD state on the documents (original Certificate/Policy Schedule/Renewal Notice/Endorsement/Certificate of Takaful/Insurance) is TRUE and CORRECT.
b ) To the best of My/Our knowledge no claim or action has been lodged/pending or is likely to be taken against Me/Us under the Certificate/Policy.
c) There is no breach of any Certificate/Policy condition which affects My/Our NCD entitlement.
d) I/We have not and shall not use this entitlement of NCD for any other vehicle/cetificate/policy.
e) If the NCD is incorrect, I/We undertaken to pay the difference of premium within 14 working days, failing which I/We agreed the certificate/policy may be cancelled by the Company.
Enclosed is a copy of (Original Certificate/Policy Schedule/Renewal Notice/Endorsement/Certificate of Takaful/Insurance) issued by the Insurance Company as evidence of my entitlement.

* Indicates Response Required