This document is an application form for a participant to request a top-up, switch, withdrawal, surrender or contribution redirection for their takaful certificate. The participant provides their personal details and certificate information. They then select the type of request and provide additional details such as amounts or fund types. Some requests require a signature and date. The form also includes terms and conditions for the different request types as well as guidelines for completing the form.

1. Agency Code/ Kod Agensi :
Agent’s Name/ Nama Ejen :
Name of Participant/ Nama Peserta :
Name of Person Covered/ Nama Orang Dilindungi :Certificate Number/ Nombor Sijil :
Application for Top-up/ switching/ Withdrawal/ Surrender/ Contribution-redirection / Permohonan untuk Penambahan/ Pertukaran/
Pengeluaran/ Penyerahan/ Alih arah caruman
I/We .......................................................The owner / Assignees in the title of the above mentioned certificate authorise and request Prudential
BSN Takaful Berhad (PruBSN) to (please cross (x) where applicable):-
Saya/Kami.................................................Pemilik / Penerima Hak hak milik Sijil tersebut di atas membenarkan dan memohon Prudential BSN
Takaful Berhad (PruBSN) melakukan (sila tandakan (x) pada tempat yang sesuai):-
Top-Up of / Penambahan RM ......................................
Fund Type
Jenis Dana
Percentage
Peratusan (%)
*Withdrawal / Pengeluaran
Switch / Pertukaran To Re-direct current Contribution Direction of my certificate to/
Mengalih arah Arah Caruman Semasa Sijil saya ke:
* Pay the Surrender value in full discharge of the liability of Prudential BSN Takaful Berhad (PruBSN) under the said certificate.
Bayar Nilai Serahan dengan discaj dari liabiliti sepenuhnya kepada Prudential BSN Takaful Berhad (PruBSN) di bawah sijil ini.
Fund Type
Jenis Dana
Amount (RM) / Units
Jumlah (RM) / Unit
Fund Type
Jenis Dana
Percentage
Peratusan (%)
From Fund Type
Dari Dana Jenis
To Fund Type
Ke Dana Jenis
RM
RM
* IMPORTANT NOTE / NOTA PENTING
Payment for withdrawal or surrender requests shall be subjected to the clearance of the last top-up and/or contribution payments made prior to such
withdrawal or surrender requests. The Company reserves the right to defer such payment until we receive confirmation from our Banker on the
clearance of such contribution payment.
Bayaran untuk permohonan pengeluaran atau penyerahan adalah tertakluk kepada penjelasan bayaran penambahan dan/atau bayaran caruman
terakhir yang dibuat sebelum permohonan untuk pengeluaran atau penyerahan tersebut. Syarikat juga berhak untuk menangguhkan pembayaran
tersebut sehingga pengesahan dari pihak Bank diterima.
DECLARATION/PENGAKUAN
I/We futher understand that at my request :-
(1)
(2)
(3)
(4)
Saya/Kami seterusnya memahami bahawa atas permintaan saya/kami :-
(1)
(2)
(3)
(4)
My application will not take effect until my application is accepted and notified to me by Prudential BSN Takaful Berhad.
My application must reach Prudential BSN Takaful Berhad at Its Principal Office in Kuala Lumpur by 3:00 pm on the day before a Valuation Date as
described in the certificate document.
Prudential BSN Takaful Berhad will not accept faxed copy of this application.
I/We further declare that I/We am/are not in bankruptcy(s) and that I/we have committed no act of bankruptcy within the last twelve months and that
no receiving order or adjudication in bankruptcy has been made against me/us during that period.
Permohonan saya tidak akan berkuatkuasa sehingga permohonan saya diterima dan dimaklumkan kepada saya oleh Prudential BSN Takaful Berhad.
Permohonan saya mestilah sampai ke Prudential BSN Takaful Berhad di Ibu Pejabat di Kuala Lumpur pada pukul 3:00 petang pada sebelum Tarikh
Penilaian seperti yang dinyatakan dalam dokumen sijil.
Prudential BSN Takaful Berhad tidak akan menerima salinan faks permohonan ini.
Saya/ Kami seterusnya mengaku bahawa saya/kami bukan muflis dan saya/kami tiada tindakan muflis dalam tempoh dua belas bulan yang lalu dan
tiada arahan penerimaan atau penghukuman muflis telah dibuat ke atas saya/ kami dalam tempoh tersebut.
Signature of Participant
Tandatangan Peserta
Date / Tarikh: ......................................................................
Telephone No. / No. Telefon: ................................................
I/C Number / No. K/P: ..........................................................
Signature of Participant
Tandatangan Peserta
Date / Tarikh: ......................................................................
Telephone No. / No. Telefon: ................................................
I/C Number / No. K/P: ..........................................................
For Office Use Only / Untuk Kegunaan Pejabat Sahaja :
Page / Mukasurat 1/2
Form ID 61001008

2. TERMS AND CONDITIONS / SYARAT-SYARAT DAN TERMA-TERMA GUIDELINE FOR FORM COMPLETION / PANDUAN MELENGKAPKAN BORANG
SWITCHING / PERTUKARAN
Switching fee of 1% of the total amount to be switched, maximum of RM100, will be
charged for each application. Prudential BSN Takaful Berhad will waive this
charge for my first application in each certificate year. No carry forward of
“unused” switches to another year would be allowed.
Yuran pertukaran sebanyak 1% daripada jumlah yang mahu ditukarkan, sehingga
maksimum RM100 akan dikenakan pada setiap permohonan. Prudential BSN Takaful
Berhad akan mengenepikan bayaran ini untuk permohonan pertama saya pada setiap
tahun Sijil. Membawa ke hadapan pertukaran “yang tidak digunakan” ke tahun satu lagi
tidak dibenarkan.
The minimum amount that can be switched is RM1,000 and it may be varied from
time to time.
Jumlah minimum yang boleh ditukarkan ialah RM1,000 dan jumlah ini boleh diubah dari
semasa ke semasa.
Prudential BSN Takaful Berhad reserves the right to vary the amount of switching fee.
Prudential BSN Takaful Berhad berhak untuk mengubah yuran pertukaran.
If the future contribution is to be re-directed, to indicate the new direction of the
fund and the percentage, else the current contribution re-direction will remain.
Jika caruman yang akan datang akan dialih arah, tunjukkan arah baru dana dan
peratusan, jika tidak, arah semasa caruman akan dikekalkan.
(1)
(2)
(3)
(4)
(1)
(2)
(3)
(4)
(1)
(2)
(3)
(4)
(5)
(1)
(2)
(3)
(4)
(1)
(2)
CONTRIBUTION RE-DIRECTION / CARUMAN ALIH ARAH
The contribution redirection for regular contribution investment (must be in
multiple of 5%).
Alih arah caruman untuk caruman tetap pelaburan (mestilah dalam gandaan 5%).
The contribution redirection will supersede any previous instruction and will apply
for the total contribution paid on this certificate for the purchase of units.
Alih arah akan menggantikan mana-mana arahan sebelumnya dan akan
diaplikasikan untuk jumlah penuh caruman yang dibayar terhadap sijil, bagi pembelian
unit.
Switch / Pertukaran(A)
(A)
(A)
From Fund / Dari Dana To Fund / Ke Dana Units / Unit
(B) (C) (D)
Fund Type / Jenis Dana Percentage (%) / Peratusan (%)
(B) (C)
Fund Type / Jenis Dana Percentage (%) / Peratusan (%)
(C) (D)
Fund Type / Jenis Dana Amount (RM)/Units / Jumlah (RM)/Unit
(B) (C)
Fund Type / Jenis Dana Amount (RM)/Units / Jumlah (RM)/Unit
Takafulink Dana Bon 1000 units
Takafulink Dana Ekuiti 2000 units
Fund Type / Jenis Dana Percentage (%) / Peratusan (%)
Takafulink Dana Bon 100%
From Fund / Dari Dana To Fund / Ke Dana Units / Unit
Takafulink Dana Ekuiti Takafulink Dana Bon
To cross (x) in the box provided / Tandakan (x) dalam ruang yang disediakan.
The Fund Type of which the Units are to be switched out from.
Jenis dana yang Unitnya mahu ditukarkan daripada.
The Fund Type of which the Units are to be switched to.
Jenis dana yang unitnya mahu ditukarkan kepada.
The number of Units to be switched.
Bilangan unit yang mahu ditukarkan.
Example: Switch 5000 units from Takafulink Dana Ekuiti fund to Takafulink Dana
Bon.
Contohnya: Tukarkan 5000 unit dari Takaful Dana Ekuiti ke Takaful Dana Bon.
To indicate the following / Dengan menyatakan seperti berikut:
(A)
(B)
(C)
(D)
(A)
(B)
(C)
(A)
(B)
(C)
(A)
(B)
(C) & (D)
(C) & (D)
(A)
To Re-direct current Contribution Direction of my Certificate to
Mengalih arah Arah Caruman Semasa Sijil saya ke:
To cross (x) in the box provided / Tandakan (x) dalam ruang yang disediakan.
The Fund Type of which subsequently contribution payment be re-directed.
Jenis Dana yang bayaran caruman berikutnya mahu dialih arah.
The percentage of the re-direction. / Peratusan alih arah.
Example: Re-direction of contribution from Takafulink Dana Ekuiti to Takafulink Dana
Bon.
Contohnya: Alih arah caruman dari dana Takafulink Dana Ekuiti ke Takafulink Dana Bon.
WITHDRAWAL / PENGELUARAN
The minimum withdrawal is RM1,000 and the minimum value of the remaining units
after a withdrawal is RM4,000. This minimum amount may be varied from time to time.
Pengeluaran minimum ialah RM1,000 dan nilai minimum unit yang tinggal selepas
pengeluaran ialah RM4,000. Jumlah minimum ini boleh diubah dari semasa ke
semasa.
Withdrawal of top-ups is upon clearance of the top-up cheque.
Pengeluaran penambahan boleh dibuat apabila cek penambahan dijelaskan.
The withdrawals of the cancelled units will be determined in accordance with the
Provisions of the said certificate and other such documentation required by
Prudential BSN Takaful Berhad to prove the title of the person claiming payment.
Pengeluaran unit yang dibatalkan akan ditentukan menurut Peruntukan sijil tersebut
dan dokumen lain yang dikehendaki oleh Prudential BSN Takaful Berhad bagi
mengesahkan hak milik individu yang menuntut bayaran.
No reinstatement of withdrawal is allowed.
Pengembalian semula pengeluaran tidak dibenarkan.
Withdrawal / Pengeluaran
(A) Pay the Surrender Value / Bayaran Nilai Serahan
(A) Top-Up of / Penambahan RM .....................(2)......................
To cross (x) in the box provided / Tandakan (x) dalam ruang yang disediakan.
The Fund Type where the withdrawal is to be initiated.
Nyatakan jumlah penambahan.
The Amount or the number of Units to be withdrawn. Only indicate either amount or
units to be withdrawn.
Jumlah atau bilangan Unit yang mahu dikeluarkan. Tunjukkan hanya jumlah atau unit
yang mahu dikeluarkan.
Example: Withdraw 2000 units from Takafulink Dana Ekuiti and 1000 units from
Takafulink Dana Bon. To indicate the following :
Contohnya: Pengeluaran 2000 unit dari Dana Ekuiti Takaful dan 1000 unit dari Dana
Bon Takaful. Dengan menyatakan seperti berikut :
SURRENDER / SERAHAN
The Surrender Value will be determined in accordance with the Provisions of
the said Certificate and other such documentation required by Prudential BSN
Takaful Berhad to prove title of the person claiming payment.
Nilai Serahan akan ditentukan menurut Peruntukan Sijil tersebut dan dokumen lain
yang dikehendaki oleh Prudential BSN Takaful Berhad bagi mengesahkan hak milik
individu yang menuntut bayaran.
No reinstatement of surrender is allowed.
Pengembalian semula serahan tidak dibenarkan.
The original Certificate Document must be enclosed.
Dokumen Sijil yang asal mesti disertakan.
If the certificate has been assigned, the original Assignment Deed must be enclosed.
Jika sijil sudah diserahkan hak, Surat Ikatan Serah Hak mestilah disertakan.
The certificate terminates upon surrender.
Sijil tamat setelah serahan.
In full discharge of the liability of Prudential BSN Takaful Berhad under the
said certificate.
Dengan memberikan discaj dari liabiliti sepenuhnya kepada Prudential BSN Takaful
Berhad di bawah sijil ini.
To cross (x) in the box provided
Tandakan (x) dalam ruang yang disediakan.
TOP-UP / PENAMBAHAN
The minimum amount of top-up is RM1,000.
Jumlah minimum penambahan ialah RM1,000.
Initial charge of 5% per top-up and administration fees of RM25.00 (subject
to change from time to time) is charged for every top-up.
Caj permulaan sebanyak 5% dari jumlah penambahan dan yuran pentadbiran
sebanyak RM25 (bergantung kepada perubahan dari masa ke semasa) akan
dikenakan untuk setiap penambahan.
Top-ups will be used to buy unit at the next pricing date of receipt of payment.
Penambahan akan digunakan untuk membeli unit pada harga tarikh hadapan selepas
tarikh bayaran diterima.
Full payment must be submitted together with this application.
Bayaran penuh mestilah dilampirkan bersama-sama permohonan ini.
To cross (x) in the box provided / Tandakan (x) dalam ruang yang disediakan.
To state the amount for Top-up / Nyatakan jumlah penambahan.
To state the fund type where the Top-up amount is to be directed to
Indicate each fund type and percentage of the fund Top-up to be directed to
that specified fund type.
Example: Top-up RM10,000 to Dana Ekuiti fund 60% and Dana Bon fund 40%.
Nyatakan jenis dana di mana Jumlah Penambahan mahu diarahkan. Jika
terdapat lebih daripada satu dana ke mana Penambahan mahu diarahkan, sila
tunjukkan jenis dana dan peratusan Penambahan yang mahu diarahkan kepada
jenis dana yang tertentu.
Contohnya: Tambahkan RM10,000 kepada Dana Ekuiti 60% dan Dana Bon 40%.
To indicate the following / Dengan menyatakan seperti berikut:
Top-Up of RM10,000 / Penambahan RM10,000
Fund Type / Jenis Dana Percentage (%) / Peratusan (%)
Dana Ekuiti 60%
Dana Bon 40%
Prudential BSN Takaful Berhad (740651-H)
Level 8A, Menara Prudential, No.10, Jalan Sultan Ismail,
50250 Kuala Lumpur. P.O.Box 10073, 50704, Kuala Lumpur.
Customer Service Hotline: 603-2053 7188 Fax: 603-2072 6188 E-mail: customer@prubsn.com.my
www.prubsn.com.my
Page / Mukasurat 2/2