Amendment to Proposal for Family Takaful

Pindaaan kepada Cadangan Takaful Keluarga

Proposal Number/Nombor Cadangan :

Name of Proposer/Nama Pencadang :

_______________________________________________________________________________________

I the above named proposer, hereby request that my application for family takaful to be amended as follow:-
Saya, pencadang seperti nama di atas, dengan ini memohon permohonan takaful keluarga saya dipinda seperti berikut:-

I certify that there has been no change in my condition of health and that I have not received any medical attention,
consultation or examination whatsoever, since the date of my application and that all my answers stated in the said
application are still true. I agree that this form will constitute part of my proposal for family takaful and that failure to
disclose any material fact known to me may invalidate the contract.

Saya mengaku bahawa tiada perubahan tentang keadaan kesihatan saya dan saya tidak menerima apa-apa rawatan
perubatan, khidmat pakar atau pemeriksaan sejak tarikh permohonan saya dan semua jawapan saya yang tercatat di
dalam permohonon ini masih benar. Saya bersetuju bahawa borang ini akan menjadi sebahagian cadangan takaful
keluarga saya dan kegagalan mendedahkan fakta yang saya ketahui akan membatalkan kontrak takaful ini.

Signed at _____________________ this ___________________ day of _________________ 200______

Ditandatangani di pada hari

Witnessed by : ______________________________ ________________________________

Disaksikan oleh Signature of Agent Signature of Proposer
Tandatangan Ejen Tandatangan Pencadang
( Agency No / No Agensi : )

[ 60102001 ]