Address: Level 36, Menara Bangkok Bank, 105, Jalan Ampang, 50450 Kuala Lumpur.

Address: Xxxxx 00, Xxxxxx Xxxxxxx Bank, 000, Xxxxx Xxxxxx, 00000 Xxxxx Xxxxxx.

Toll Free: 0-000-000-000 Tel.: 00-0000 0000 Fax: 00-0000 0000 E-mail: xxxx@xxxxxx.xxx.xx Website: xxx.xxxxxxxxxxxx.xxx.xx

Postcode

LIVING CARE CRITICAL ILLNESS INSURANCE PROPOSAL FORM

Berjaya Sompo Insurance Berhad (62605-U) (BSIB) is licensed under the Financial Services Act 2013 and regulated by Bank Negara Malaysia.
IMPORTANT NOTICE
Consumer Insurance Contract Pursuant to Paragraph 5 of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance wholly for 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 proposal form. You must answer the questions in this proposal form fully and accurately, otherwise it may result in avoidance of your contract of insurance, refusal or reduction of your claim(s), change of terms or termination of your contract of insurance. The above duty of disclosure for Consumer Insurance Contract shall continue until the time your contract of insurance is entered into, varied or renewed with us. In addition to answering the questions in this proposal 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. You also have a duty to tell us immediately if at any time after your contract of insurance has been entered into, varied or renewed with us any of the information given in this proposal form is inaccurate or has changed.
PLEASE USE BLOCK LETTERS AND CROSS (X) IN APPROPRIATE BOX
Agency : Account No. :
YOUR PERSONAL PARTICULARS
Name of Proposer (in full) :
Address (Postal):
Tel. No. :		Email :
NRIC No :		Date Of Birth :
Sex : ⬜ Male ⬜ Female		Nationality :
Race : ⬜ Malay ⬜ Chinese ⬜ Indian ⬜ Other		Weight :      kg
		Height : cm
Occupation :		Nature of Work :
YOUR SPOUSE'S PARTICULARS/ MAKLUMAT PASANGAN ANDA
Name :
NRIC No :	Date Of Birth :
Sex : ⬜ Male ⬜ Female	Nationality :
Weight :   kg	Height :   cm
Occupation :	Nature of Work :
YOUR CHILDREN'S PARTICULARS
Name :
NRIC No :	Date Of Birth :
Sex : ⬜ Male ⬜ Female	Nationality :
Weight :   kg	Height :   cm
Occupation :	Nature of Work:
Name :

(LC/PF092018) 1

NRIC No :	Date Of Birth :
Sex : ⬜ Male ⬜ Female	Nationality :
Weight :   kg	Height :   cm
Occupation :	Nature of Work :
Name :
NRIC No :	Date Of Birth :
Sex : ⬜ Male ⬜ Female	Nationality :
Weight :   kg	Height :   cm
Occupation :	Nature of Work :
Name :
NRIC No :	Date Of Birth :
Sex : ⬜ Male ⬜ Female	Nationality :
Weight :       kg	Height :   cm
Occupation :	Nature of Work :
Name :
NRIC No :	Date Of Birth :
Sex : ⬜ Male ⬜ Female	Nationality :
Weight :   kg	Height :   cm
Occupation :	Nature of Work :
Name :
NRIC No :	Date Of Birth :
Sex : ⬜ Male ⬜ Female	Nationality :
Weight :   kg	Height :   cm
Occupation :	Nature of Work :
QUESTIONNAIRES
Have you or your dependents :
1. Ever suffered from or been treated, told by or consulted a medical practitioner for any of the following ⬜ Yes ⬜ No
(a) Persistent stomach, abdominal or gastric pain, ulcer or disorder of the stomach, pancreas, intestines, ⬜ Yes ⬜ No haemorrhoids or rectal disorder?
(b) Heart disorder, Chest pain or discomfort or tightness, Heart Attack, Stroke, Paralysis, High Blood Pressure, Rheumatic Fever, Palpitation or other diseases of the Heart of Blood vessels or any form of Circulatory ⬜ Yes ⬜ No Disorder?
(c) Disease of Eyes, Ears, Nose, Mouth or Throat? ⬜ Yes ⬜ No
(d) Arthritis Sciatica, Rheumatism, Gout, disorder of the muscles or joints, Spinal disorder or back pain ⬜ Yes ⬜ No Bone, Joint, Muscle or skin disorder?
(e) Cancer, Enlarged Lymph Nodes,Thyroid conditions or disorders, Tumors, Cysts, Nodules, Polyps or growth and lumps of any kinds including malignant Blood/Leukemia? ⬜ Yes ⬜ No
(f) Persistent Cough, Asthma or shortness of breath, Bronchitis, Pleurisy,Tuberculosis or other Respiratory ⬜ Yes ⬜ No Disorders or Lung Disease?
(g) Epilepsy, Fits, recurrent dizziness or headaches, fainting, Sclerosis, Depression, Anxiety, Psychiatric or Psychological Disorder, Mental or Nervous Disorder, blackout or of any kind? ⬜ Yes ⬜ No
(h) Skin Lesions, HIV,AIDS or AIDS related conditions or other Sexually Transmitted Diseases? ⬜ Yes ⬜ No
(i) Anemia, Blood disorder, Varicose Veins, Deep Vein Thrombosis? ⬜ Yes ⬜ No
(j) Disease of the Breast, Ovary, Uterus or other female organs, Menstrual disorder, abnormal ⬜ Yes ⬜ No Pap Smear(s), pregnancy complications or complications at child-birth?
(k) High Cholesterol, Hypercholesterolemia, Hyperlipidemia, Hyperuricemia, Hyperglycemia or abnormal lipid Profile? ⬜ Yes ⬜ No

(l) Diabetes, Liver disorder or Hepatitis of any kind or jaundice, Stones in the Urinary and Biliary systems and Cholecystitis? Stones (Calculi) or any disorder of t he Genitourinary System (Sex organs and Urinary system including Kidneys, Ureters, Bladder, Prostate, etc) ⬜ Yes ⬜ No
2. Have you suffered from any illness, disorder or injury during the past three (3) years which required any form of medical or specialized examination or consultation or hospitalization or that may require treatment in the future? ⬜ Yes ⬜ No
3. Have you suffered from any physical impairment, infirmity or abnormity or congenital conditions? Or are currently receiving medical treatment and/or suffering from physical impairment, congenital abnormality or poor health? ⬜ Yes ⬜ No
4. Are you currently taking any medication or have any medication prescribed? (If "yes", please provide reason including name of medication, daily dosage and length of treatment?)					⬜ Yes ⬜ No
5. Have you seen a doctor/ specialist for medical or surgical advice, diagnostic test or investigation, including test or treatment that has not been performed or completed?					⬜ Yes ⬜ No
6. Do you have other insurance policies in force where a similar benefit maybe payable?					⬜ Yes ⬜ No
7. Have you ever had an application or an insurance coverage declined, postponed, rated up or accepted on special terms? ⬜ Yes ⬜ No
8. Do you have any close relatives who had suffered heart disease, stroke, cancer, kidney disease, or other serious conditions or disease?					⬜ Yes ⬜ No
9. Do you smoke any form of tobacco? ⬜ Yes ⬜ No (if "YES, please advise type and daily consumption. If "NO", please advise how long you have been a non-smoker)
If you have answered " YES" to the above Questions from 1 to 9, please give full details below and number your answers according to the question number.
Question No.	Nature of Illness/Disease	Date Treated / Date Treatment Ended	Present State of Health	Name of Treating Doctor or Hospital
For Question 3	Name of Medication (Prescribed Drugs)	Reason for Therapy	Daily Dosage	Length of Treatment
PREMIUM
NAME		SUM INSURED	RATE	PREMIUM (RM)
Sub Total
Stamp Duty
Service Tax
Total

PAYMENT METHOD
Total Premium Paid: RM		Please select payment method.
⬜ Cash
⬜ JomPay	For payment via JomPay, please provide proof of payment.
⬜ Visa ⬜ MasterCard	Card No. - - -				Expiry Date m m / y y
Cardholder’s Name:
Date:			C	ardholder’s Signature:
PRIVACY NOTICE
The personal information including your personal, policy and financial details ("Personal Data") provided by and collected from you may be used and processed by us and our Group Companies1 (within or outside Malaysia) in order for us to provide our services and to operate and manage our function as an insurance company. By signing on this proposal form, you consent to the use and processing of your Personal Data for the purposes as stated in our Privacy Notice. If you represent a body corporate, you have procured the necessary consent for our use and processing of the Personal Data provided by you for the purposes as stated in our Privacy Notice. Please refer to the Privacy Notice for details of your Personal Data privacy rights and our rights of disclosure, which is also available at our website at xxx.xxxxxxxxxxxx.xxx.xx.
OPTION TO SUBSCRIBE TO CROSS-SELLING ACTIVITIES
You can extend your consent for us to use your Personal Data for cross-selling purposes within/with our Group Companies or our strategic business partners or selected third parties, by selecting: ⬜ Yes ⬜ No Take note that you can always choose to opt out of the cross-selling activities as described above (including marketing campaigns by any of our Group Companies) at any time by contacting BSIB at the contact number stated above. Note: 1Group Companies refer to Sompo Holdings Group and Berjaya Group, of which BSIB is also an affiliate.
DECLARATION BY PROPOSER
I/We declare and warrant that the answers/information provided in this proposal form are true and correct and I/We have not withheld any information or made any misrepresentation likely to affect the acceptance of this proposal and declaration which I/We agree shall be the basis of the contract between myself/ourselves and the Company. I/We shall undertake to notify the Company when there is any subsequent change to the information provided in this proposal form. A copy of the product disclosure sheet (“PDS”) is available at our website xxx.xxxxxxxxxxxx.xxx.xx. Please make sure that you have read and understood the contents of the PDS before purchasing the product.
My regular doctor/Last clinic visited:
Name of clinic:
Address:
Tel. No.:
Date		Proposer’s Signature
		(If the Proposer is a company, authorised signature(s) and chop)
FOR OFFICE USE
Effective Date
Underwriter
Remarks: