TRIPCARE 360 CONTRACT OF TAKAFUL APPLICATION FORM

Etiqa General Takaful Berhad (“Etiqa General Takaful”) is licensed under the Islamic Financial Services Act 2013 to transact general business in
Malaysia and is regulated by Bank Negara Malaysia (BNM).
INSTRUCTIONS: Before you provide answers and the declaration in this application form, please read the following IMPORTANT NOTICE.
IMPORTANT NOTICE:
1. In this application form, the words “I/ We”, “you”,”your”, “me” or “My/ Our”, means the Applicant unless the section instructions indicates
otherwise.
2. Pursuant to Paragraph 5 of Schedule 9 of the Islamic Financial Services Act 2013, if you are applying for this takaful wholly for the purposes
unrelated to your trade, business or profession, you have a duty to take reasonable care not to make a misrepresentation in answering the
questions in this Application Form. You must answer all questions in this Application Form fully and accurately.
3. In addition to answering the questions in this Application Form, you are required to disclose any other matter that you know to be relevant to our
decision in accepting the risks and determining the rates and terms to be applied.
4. Please seek clarification from the agent should you not understand any of the terms and conditions, which relate to the benefits and your duties
under the contract of takaful.
5. You may nominate a person as beneficiary to receive the money to be paid under the certificate at the time when you applied for the Personal
Accident certificate or at any time after the certificate is issued. You should ensure that your nominee is aware that he/she has been nominated
for the certificate that you have participated. You can obtain a copy of the nomination form from our agent or visit our website at
www.etiqa.com.my and submit the duly completed form to our nearest branch.
6. Please notify the agent or us of any change in your correspondence address, or other contact details. If you have an enquiry or require further
information, please contact Etiqa Oneline by calling 1300 13 8888 or 03 2297 3888, or write to Etiqa General Takaful Berhad (201701025031),
Level 13, Tower B, Dataran Maybank, No 1, Jalan Maarof, 59000 Kuala Lumpur, or by facsimile to 03 2297 3800, or e-mail at
info@etiqa.com.my
7. If you have a complaint, dispute or feedback in connection with this application, please contact our Complaints Unit via e-mail at
complaint_cmu@etiqa.com.my, by calling 1300 13 8888 within Malaysia or +603 2780 4500 from overseas, by facsimile to 03 2297 1919, or by
post to Complaints Management Unit, Level 6, Tower B, Dataran Maybank, No. 1 Jalan Maarof, 59000 Kuala Lumpur.
8. If you are dissatisfied with our conduct, you may refer to Bank Negara Malaysia via e-mail at bnmtelelink@bnm.gov.my, by calling 1300 88 5465,
by facsimile to 03 2174 1515, or by post to Director, Jabatan LINK & Pejabat Wilayah, Bank Negara Malaysia, Jalan Dato’ Onn, 50480 Kuala
Lumpur. If you dispute a decision made by us, you may refer to the Ombudsman for Financial Services via e-mail at enquiry@ofs.org.my, by
facsimile to +603 2272 1577, or by post to Chief Executive Officer, Ombudsman for Financial Services, (Formerly known as Financial Mediation
Bureau) Level 14, Main Block, Menara Takaful Malaysia, No 4, Jalan Sultan Sulaiman, 50000 Kuala Lumpur.
9. Please answer the form in black ink using block letters or ticking one (1) of the options, as is applicable.
INSTRUCTIONS: Please answer all questions in Section A.
A. INDIVIDUAL DETAILS
Title
 Mr  Datuk Seri  Datuk  Dato’  Tan Sri  Tun  Others

 Ms  Datin Seri  Datin  Dr  Puan Sri  Toh Puan ___________

*Name
(As per
NRIC/Passport)
*Date of Birth
(dd/mm/yyyy) // Gender  Male  Female

*ID Type  New NRIC  Old Identity Card  Others _______________

*ID Number

*Nationality  Malaysian  Other _______________

*Marital Status  Single  Married  Others _______________

*Occupation
 Manager/Senior
Executive  Pensioner  Self-employed  Housewife  Student

 Officer/Executive  Business Owner  Skilled Worker  Teacher/Lecturer  Clerical

 Others ________________
*Nature of Self
Employment

*Mailing Address

Town/City Postcode
State Country
*Telephone
Mobile House Office
Numbers
Email Address
* Mandatory fields to be completed

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INSTRUCTIONS: Please provide details of the Covered Person in Section B.
B. TAKAFUL RISK DETAILS
1. Period of Takaful
(dd/mm/yyyy)
From // To //
2. Country(ies) to Visit

3. Type of Certificate  Per Trip  Annual

4. Type of Plan  Individual  Senior Citizen
 Individual & Spouse  Family
Note: Senior Citizen are allowed for Individual Plan only.

 Domestic  International (Silver)  International (Gold)  International (Platinum)

Optional Cover:
1. Adventurous Activities Cover  Yes  No
2. COVID-19 Cover  Yes  No
Note: Please refer to the table of benefits and contribution table in the Product Disclosure Sheet for further details.

3. Number of children Please indicate number of children within the age band.
in family where
family
required
plan is  0 - 12 years  12 - 18 years  Above 18 years
4. Other Applicants Please declare separately if the space is insufficient.

ID Number/ Other
No. Full Name Date of Birth Gender Relationship
Identification
1 M/F
2 M/F
3 M/F
4 M/F
5 M/F

5. Under Schedule 10 Does the Applicant wish to make a nomination?

of the Islamic
Financial Services
Act 2013, the
 Yes  No
Covered Person If Yes, please complete the Nomination Form as provided together with the certificate document.
who has attained the
age of 16 years may
nominate a natural
person to receive
certificate benefits
payable upon his
death.
INSTRUCTIONS: Please provide us with your bank account details, for the purpose of crediting refund of contribution or claims, if any.
C. BANK ACCOUNT DETAILS FOR CREDITING ANY REFUNDS OR CLAIM PAYMENT
Bank Name

Account Type  Saving  Current

Account Number 

Name as used for Account

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INSTRUCTIONS: Please provide us your credit card or cheque details for payment of contribution. Please only select one (1) option.
D. PAYMENT METHOD
I wish to pay my contribution RM Payment date //
By:  Cash
 Cheque (Please cross the cheque and made payable to ‘Etiqa General Takaful Berhad’)

Bank Cheque Number Cheque Date Amount (RM)

 Credit Card
Cardholder’s Name

 Visa  Master Card

Credit Card Number

    Credit Card Expiry Date /(mm/yy)

INSTRUCTIONS. Please confirm your agreement to the following declarations by signing below. All declarations are mandatory except
item 12 below where you must select the option to agree (Yes) or disagree (No).
E. DECLARATIONS
1. I/ We have read and understand the contents of the application, including all notices therein.
2. I/ We am not travelling for the purpose of obtaining medical treatment or travelling against the advice of any medical practitioner.
3. I/ We understand and agree that the contract of takaful that I/ We have applied for shall only take effect on the date the contract of takaful has
been issued by Etiqa General Takaful. I/ We understand that the contract of takaful will only be issued following the assessment by Etiqa
General Takaful, and provided that the full contribution has been received by Etiqa General Takaful. I/ We understand that if the initial
contribution is paid by cheque, the contract of takaful will only take effect once the cheque has been cleared.
4. I/ We understand that failure to take reasonable care in answering the questions may result in avoidance of My/ Our contract of takaful,
refusal or reduction of My/ Our claim(s), change of terms or termination of My/ Our contract of takaful.
5. I/ We understand that the above duty of disclosure shall continue until the time My/ Our contract of takaful is entered into, varied or renewed
with Etiqa General Takaful.
6. I/ We understand that I/ We have a duty to tell Etiqa General Takaful immediately that this contract of takaful has been entered into, varied or
renewed, whether any of the information given in this application is inaccurate or has changed.
7. I/ We agree to notify Etiqa General Takaful of any change in My/ Our occupation and personal pursuits (example hobbies, sport activities)
which would affect the risk profile during the period of takaful.
8. I/ We confirm that the agent has fully explained the terms and conditions of the contract of takaful in a language that I/ We understand and
has presented and provided me with a Product Disclosure Sheet.
9. I/ We agree that any payment by Etiqa General Takaful to the account details provided by me in Section C of this application, will be deemed
as full payment and Etiqa General Takaful shall be released and fully discharged from further liability and demand in relation to the payment.
I/ We confirm that the bank account details in Section C are active and maintained in Malaysia.
10. I/ We understand that contributions will be subjected to relevant charges or taxes, as deemed necessary by the Malaysian tax authorities.
11. I/ We agree to participate in this General Takaful scheme based on the principle of takaful. I/ We agree to pay the contribution on the basis of
Tabarru’ (donation) for the purpose of mutual support of other participants and with this contribution, I/ We am/ are entitled to the takaful cover
expressed in the terms and conditions of the Takaful Certificate. Payment of sum covered to participants is payable from the General Takaful
Fund (Fund) based on the concept of Tabarru’.
This scheme also applies the Wakalah (agency) concept, I/ We agree to appoint Etiqa General Takaful to act on My/ Our behalf to invest and
manage the Fund. The Fund is collectively owned by the Participants where Tabarru' portion of the contribution is placed for the purpose of
takaful. Accordingly, I/ We agree to pay the Wakalah Fee (as shown in the Product Disclosure Sheet) to Etiqa General Takaful, as a
deduction from contributions, to cover the expenses of investing and managing the Fund.
I/ We agree to authorize Etiqa General Takaful to delegate its rights, duties and obligations to any third party as Etiqa General Takaful deems
fit for the purpose of achieving the objective to invest and manage the Fund, provided that, Etiqa General Takaful will remain liable and
responsible for all such rights, duties and obligations towards Me/ Us.
I/ We understand that at the end of each financial year, the distributable surplus (if any) from the General Takaful Fund will be determined by
Etiqa General Takaful and will only be payable for annual Certificate. The distribution, if any, makes allowance for contingency provisions, and
is subject to the surplus policy approved by the Shariah Committee of Etiqa General Takaful. I/ We agree that fifty percent (50%) of the
distributable surplus (if any) will be paid to Etiqa General Takaful for operating and managing the Fund, based on the contract of Ju’alah
(wage), and the balance of fifty percent (50%) will be shared amongst participants whose certificates have not terminated and who have not
made any claim within the financial year.
I/ We further agree that if the surplus or any sum payable is less than Ringgit Malaysia Ten (RM10.00), it will automatically be credited into
charitable fund which will be utilized as ‘Amal Jariah’ on behalf of the participants. The Fund will be distributed to eligible recipients as
approved by Shariah Committee of Etiqa General Takaful for charitable purposes.
Definitions:
“Tabarru” means contribution, donation or gift. In relation to the Takaful contract, it means Contribution for the purpose of Takaful. This
portion is placed in the General Takaful Fund.
“Ju’alah” is a wage contract. It is an exchange contract for a known or unknown task, that is difficult to precisely determine and for which
payment is due only once the work has been completed. In relation to the Takaful Contract, it refers to the reward given to the Takaful
Operator (EGTB) agreed upfront by the Participant and the Takaful Operator for good management of the fund.
“Wakalah” refers to a contract where a party, as principal authorizes another party as his agent to perform a particular task on matters that

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 may be delegated with or without imposition of a fee. In relation to the Takaful Contract, it means that the Participant have appointed Etiqa
General Takaful to invest and manage the General Takaful Fund on his/her behalf.
12. PERSONAL DATA PROTECTION ACT 2010
I/ We agree to allow Etiqa General Takaful to process My/ Our personal data, including sensitive personal data, with the intention of entering
into a contract of takaful in compliance with the provisions of the Personal Data Protection Act 2010.
I/ We agree that any personal data collected or held by Etiqa General Takaful, whether contained in this application or subsequently
obtained, may be held, used, processed and disclosed by Etiqa General Takaful to individuals or organizations related to and associated with
Etiqa General Takaful, or any selected third parties (within or outside Malaysia, including medical institutions, retakaful, claim adjusters, claim
investigators, solicitors, industry associations, regulators, statutory bodies, and government authorities), for the purpose of processing this
application, providing subsequent service related to it, and to communicate with me for such purposes.
I/ We understand that I/ We have a right to obtain access to, and to request correction of any personal data held by Etiqa General Takaful
concerning me. I understand that such request can be made by completing the Access Request Form available at all Etiqa General Takaful
branches or contacting Etiqa General Takaful via email at PDPA@etiqa.com.my. I understand that in accordance with the provisions of the
PDPA, I may contact the Customer Service Centre at Etiqa General Takaful Oneline 1300 13 8888 for the details of My/ Our personal data
and that such information shall only be granted upon verification of My/ Our identification.

I agree that Etiqa General Takaful share My/ Our personal data within the Maybank Group and selected third parties, as Etiqa General
Takaful deems fit, and I may receive marketing communication from Etiqa General Takaful or from these other third parties about products
and services that may be of interest to me.

 Yes  No

________________________________________ _________________________________
Signature of Applicant Date

FOR OFFICE USE

HQ/Branch Name Sales Channel Code

Channel Sales Channel Name

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