1. PECAHAN PREMIUM YANG DITERIMA / TOTAL PREMIUM RECEIVED BREAKDOWN
KATEGORI
Category
60% LAYAK DI BAWAH
PELEPASAN PERUBATAN
60% Eligibility under Medical Relief
PENDIDIKAN
Education
DEWASA
Adult
Insurans Asas
Basic Insurance
RM
Faedah Tambahan / Additional Rider
100% Kelayakan mengikut kategori / Eligibility by category
60% Kelayakan di bawah peruntukan pelepasan perubatan / Eligibility under medical relief
100% Kelayakan di bawah peruntukan pelepasan perubatan / Eligibility under medical relief
Tidak layak / Not Eligible for exemption
RM
RM
RM
RM
Penyata ini mengandungi butir-butir premium yang telah diterima bermula dari 1hb Januari sehingga 31hb Disember
dalam tahun yang dinyatakan.
Bagi premium yang jatuh dalam tahun ini tetapi diterima dalam tahun lain, maka bayaran tersebut akan dimasukkan ke
dalam penyata tahun tersebut dan bukannya di dalam penyata ini. Lazimnya ini berlaku kepada premium yang dibayar
melalui potongan gaji atau menerusi Bank. (Contohnya : Bayaran premium untuk bulan Disember hanya akan diterima
pada bulan Januari tahun berikutnya).
Mengikut AKTA INSURANS 1996, pemegang Polisi Insurans Hayat perlu membuat penamaan bagi memudahkan
pembayaran pampasan jika berlaku kematian. Bagi yang belum membuat penamaan sila dapatkan borang penamaan di
cawangan kami yang berdekatan.
Note:
This statement shows premiums received from 1 January to 31 December of the year stated.
Premiums due within this year but received in another year shall be reflected in the premium statement of the respective
year in which the premiums are received, and not in this statement.This normally applies to premiums remitted through
monthly deductions of salary or bank standing instructions. (Example : Premium due in December may only be received
in January the following year).
In accordance with the Insurance Act 1996, Life Insurance policyholders are required to make a nomination to ease
death benefit payments. You may obtain the nomination form at our nearest branch office.
Nota:
003973831 / 06990022 / 21132
CUSM15B-CAPSIL-ISY-2012 (BONUS)
ENCIK KENNEDY B ALIP
SMK APIN APIN
PETI SURAT 464
89008 KENINGAU SABAH
SABAH
Tarikh : 12/03/2013
SEMUA TARIKH TERTERA ADALAH
BETUL SETAKAT 31 DISEMBER 2012
ALL THE FIGURES ARE CORRECT
AS AT 31 DECEMBER 2012
PENYATA PEMBAYARAN INSURANS HAYAT
LIFE INSURANCE PREMIUM STATEMENT
2012
BUTIR-BUTIR POLISI / POLICY DETAILS
UNTUK DIKEMUKAKAN KEPADA JABATAN HASIL DALAM NEGERI
FOR SUBMISSION TO THE INLAND REVENUE BOARD
Diri yang Diinsuranskan : KHAIRUNNISA FIFFY BT KENNEDY @ KHAI
Life Assured
Pemilik Polisi : KENNEDY B ALIP
Owner of Policy
Nombor Polisi : 003973831
Policy Number
Harga Polisi : RM 10,000.00
Sum Assured
Jenis Polisi
Type of Policy
: ALONG
Premium : RM 126.14
Premium
Nombor Kad Pengenalan : 720608-12-5641
Identity Card Number
Tarikh Kuatkuasa : 28MAY2004
Commencement Date
Status Polisi
Policy Status
: KUATKUASA
INFORCE
Frekuensi Bayaran
Frequency of Payment
: BULANAN
MONTHLY
1,299.96 0.00 0.00
26.40
0.00
101.52
85.80
12614 - 37840

2. CUSTOMER UPDATE FORM
For your convenient, you are encouraged to verify your contact detail as in this form. If there are any
changes, please update your latest information below.
1) Fax the completed form to 03-27856161 / 03-27856111 ; or
2) E-mail completed form to info@etiqa.com.my ; or
3) Contact Etiqa Oneline at 1300 13 8888 ; or
4) Mail the completed form to Policy Servicing Department - Life Operations, Etiqa Insurance Berhad,
Level 16 Tower B, Dataran Maybank, No. 1 Jalan Maarof, 59000 Kuala Lumpur
Policy No.
Policy Owner
New IC No.
Old IC No. / Others
New IC No.
Old IC No. / Others
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
Mailing Address
Postcode
Town / City
Mailing Address
Postcode
Town / City
State
Handphone No.
Home/Office Tel.
State
Handphone No. H/O
Maybank
Others
E-mail Address
Bank Name
Bank Account No.
E-mail Address
Bank Name
(please tick)
Bank Account No.
- -
- -
:
:
Policy Owner's signature Date (dd/mm/yyyy)
Current Policy Owner Details
Policy Owner Details to be Updated (only fill in the fields to be updated)
Please ensure the above mentioned account still active and keep updating us for any changes.
Bank account information is for future policy benefit payment (if any).
1.
2.
Important:
(Please refer to the list of banks at the back of this form)
0 0 3 9 7 3 8 3 1
ENCIK KENNEDY B ALIP
7 2 0 6 0 8 - 1 2 - 5 6 4 1
S M K A P I N A P I N
P E T I S U R A T 4 6 4
8 9 0 0 8 K E N I N G A U S A B A H
8 9 0 0 8
S A B A H
0 8 3 - 3 3 9 0 4 9
0 8 7 - 3 3 2 3 6 3
12614 - 37841

3. BANK LIST
No.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
Bank Name
AFFIN BANK BERHAD
AGRO BANK
ALLIANCE BANK BERHAD
ARAB MALAYSIA BANK BERHAD
BANK ISLAM MALAYSIA BERHAD
BANK KERJASAMA RAKYAT MALAYSIA
BANK MUAMALAT MALAYSIA BERHAD
BANK OF AMERICA
BANK SIMPANAN NASIONAL
BANK UTAMA MALAYSIA BERHAD
CIMB BANK BERHAD
CITIBANK BERHAD
DEUTSCHE BANK
EON BANK BERHAD
HONG LEONG BANK BERHAD
HONGKONG & SHANGHAI BANK CORP
J.P. MORGAN CHASE BANK BERHAD
KUWAIT FINANCE HOUSE
MALAYAN BANKING BERHAD
OVERSEAS CHINESE BANKING CORP
PUBLIC BANK BERHAD
ROYAL BANK OF SCOTLAND
RHB BANK BERHAD
STANDARD CHARTERED BANK BERHAD
SOUTHERN BANK BERHAD
UOB BANK
12614 - 37842