Form for clients who are not Malaysians but want to but insurance policy in Malaysia

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FOREIGNER’S QUESTIONNAIRE (To be completed by Assured)
SOALSELIDIK WARGANEGARA ASING ((Untuk diisi oleh Hayat Diinsuranskan)
Proposal Number /Nombor Cadangan Agency No / No Agensi Agent's Name/Nama Agen
______________________ ____________________ ________________________
Full name of Assured / Nama penuh Hayat yang diinsurankan :
_________________________________________________________________________________
Passport Number / Nombor Pasport Nationality / Kewarganegaraan City of origin /Bandar Asal
________________________ ____________________ ____________________
_______________________________________________________________________________
1. Currently, where is your permanent place of residence?/Pada masa ini, dimanakah tempat tinggal
tetap anda?
2. (a) When did you arrive in Malaysia? Month/ Year/
Bilakah anda tiba di Malaysia? Bulan: Tahun:
(b) How long do you intend to stay in Malaysia?
Berapa lamakah anda bercadang untuk tinggal di Malaysia?
3. What is your official status in Malaysia?/Apakah status rasmi anda di Malaysia?
[ ] Employment Pass/Pas perkerjaan [ ] Dependant’s Pass/Pas tanggungan
[ ] Student’s Pass/Pas pelajar [ ] Social Pass/Pas sosial
[ ] Holder of "Malaysia-My Second Home" program/Pemegang program "Malaysia-My
Second Home"
4. (a) Name of your present employer/Nama majikan anda sekarang:
(b) Address of employer/Alamat majikan:
(c) Current position you hold within this company:
Jawatan yang sedang anda pegang di dalam syarikat ini:
(d) Annual Income (RM)/Pendapatan Tahunan (RM):
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5. Do you have the following based in Malaysia?/Adakah anda mempunyai seperti yang berikut di
Malaysia?
Yes/ No/ If yes, state details/
Ya Tidak Jika ya, nyatakan butirannya:
Bank Account/Akaun Bank [ ] [ ] ____________________
Property/Harta [ ] [ ]
Business/Perniagaan [ ] [ ]
Investment (eg. shares)/ [ ] [ ]
Pelaburan (seperti saham)
Family members or relatives/ [ ] [ ]
Ahli keluarga atau saudara mara
6. Where did you reside and what was your occupation during the last 5 years?
Dimana anda tinggal dan apakah pekerjaan anda dalam tempoh 5 tahun yang lepas?
Date/Tarikh
From/Dari To/Ke
Country/Negara City/Bandar Occupation/
Pekerjaan
7. Why do you need a Malaysia class policy?
Mengapa anda memerlukan polisi kelas Malaysia?
8. What do you intend to do with the policy when you leave Malaysia?
Apakah yang anda akan lakukan dengan polisi tersebut bila anda meninggalkan Malaysia?
9. Please provide details of your existing insurance cover including proposals about to be sumitted.
Nyatakan keterangan polisi sedia ada anda termasuk cadangan yang akan dikemukakan.
Year of Purchase Country Type of plan Sum Assured
10. Does your spouse reside with you?
Adakah pasangan anda tinggal bersama anda?
[ ]Yes/Ya [ ]No/Tidak
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11. Is your spouse a Malaysian?
Adakah pasangan anda warganegara Malaysia?
[ ]Yes/Ya [ ]No/Tidak
Occupation/Pekerjaan :
Nationality/Kewarganegaraan :
________________________________________________________________________
I the life proposed, confirm that the entire marketing and selling process is respect of my proposed
insurance application has been conducted in Malaysia, which includes but not limited to :
1. I received all of the insurance related marketing materials in Malaysia.
2. The Agent / Sales staff has explained the details of my proposed insurance plan (s) in
Malaysia
3. I have signed all the documents in respect of my insurance application (including but
not limited to the Proposal Form) in Malaysia.
4. I have paid the initial premium in respect of my proposed insurance application in
Malaysia.
I declare that the answers I have given are, to the best of my knowledge, true and that I have not
withheld any material information that may influence the assessment or acceptance of this proposal.
I agree that this form will constitute part of my proposal for life assurance and that failure to disclos
any material facts known to me may invalidate the contract.
Saya, Hayat yang diinsurankan, mengesahkan bahawa seluruh proses pemasaran dan penjualan
cadangan insuran saya telah dilakukan di Malaysia, termasuk tetapi tidak dihadkan kepada :
1. Saya telah menerima semua bahan pemasaran mengenai insuran di Malaysia
2. Agen/kakitangan jualan telah menjelaskan butir-butir cadangan insuran saya di
Malaysia
3. Saya telah menandatangani semua dokumen-dokumen yang berkaitan dengan
permohonan cadangan insuran saya (termasuk tetapi tidak dihadkan kepada
borang cadangan) di Malaysia
4. Saya telah membayar premium pertama yang berkaitan dengan permohonan
cadangan insuran saya di Malaysia.
Saya mengaku bahawa jawapan yang telah saya berikan adalah, sepanjang pengetahuan saya,
benar dan saya tidak menyembunyikan sebarang maklumat penting yang mungkin akan
mempengaruhi penilaian atau penerimaan cadangan insurans ini. Saya bersetuju bahawa
borang ini akan menjadi sebahagian dari borang cadangan untukinsurans hayat dan
kegagalan untuk mendedahkan sebarang maklumat penting yang saya ketahui berkemungkinan
membatalkan kontrak insurans tersebut.
Signed by/Ditandatangani oleh :______________________ Date/Tarikh :___________________
Name of Life Proposed/
Nama penuh Hayat yang diinsurankan : ______________________________________________
In the presence of / Disaksikan oleh : ______________________________________________
Name of Agent/Sales Staff / Nama Agen : ______________________________________________
Date / Tarikh : _______________________________
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