COVER NOTE

STAMP DUTY PAID

Participant Cover Note No. : 80030694

Account No. : V0006298
NUR IZZAH NAZIRAH BINTI ISA Agent Name : SITI HABSAH BINTI MOHD
NO 161 BATU 10 LEKIR` JOHARI
SITIAWAN
32000 PERAK Product Type : Private Car - Private Use
Period of Takaful from 11/03/2017 To 10/03/2018 (both Dates
Inclusive). Any subsequent period for which the Participant shall pay
and the Takaful Operator shall agree to accept a renewal contribution..

NRIC No : 920124-08-6654 Business Reg No : Vehicle Estimated Value RM 30000.00

Business/Occupation : Office Other ID No : Gross Contribution RM 1027.80
Vehicle Information Add: Loading 0.00% RM 0.00
JPJ Document No : Less: No Claim Discount RM 308.34
30.00%
Vehicle Reg No : AKA3774 Log Book No : 7695838
Windscreen (RM600.00) RM 90.00
Make : PROTON
Named Driver RM 0.00
Model : SAGA FLX EXECUTIVE (A)
______
Engine No : S4PEUM0784 Cover Type : Comprehensive
RM 809.46
Chassis No : PL1BT3STRFB490982 Vehicle Type : Private Car
Less : Discount/Rebate 0.00% RM 0.00
Year of : 2015 License Type : Normal Vehicle
Manufacture Add : Goods and Services Tax RM 48.57
6.00%
Cubic Capacity : 1332 Use For : Private Use
Stamp Duty RM 10.00
Seating Capacity : 5
Financial Interest : NIL
TOTAL AMOUNT DUE RM 868.03
Authorised Driver
1 NUR IZZAH NAZIRAH BINTI ISA 920124-08-6654
2 MAT HAMZI BIN HAMIDI 891009-08-6755 Excess All Claims RM 0.00
Subject to the following warranties, endorsements and clauses incorporated herein and
forming part of the Policy.
Clause Code Clause Name

IMPORTANT NOTICE - APPLICABLE TO ALL CONSUMER PRODUCTS

(Takaful wholly for purposes unrelated to your trade, business or profession)
Where You have applied for this Takaful wholly for purposes unrelated to Your trade, business or profession, You had a duty to take reasonable
care not to make a misrepresentation in answering the questions in the Application Form (or when You applied for this Takaful) i.e. You should
have answered the questions fully and accurately. Failure to have taken reasonable care in answering the questions may result in avoidance of
Your contract of Takaful, refusal or reduction of Your claim(s), change of terms or termination of Your contract of Takaful in accordance with the
remedies in Schedule 9 of the Islamic Financial Services Act 2013. You were also required to disclose any other matter that You knew 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 Takaful has been entered into, varied or renewed with Us any of
the information given in the Application Form (or when You applied for this Takaful) is inaccurate or has changed.

Issue Date : 08-03-2017 For and on behalf of

Issue At : A2 Etiqa Takaful Berhad
Issue By : v0006298

Visit www.etiqa.com.my or our nearest branch to obtain the full policy wordings.
Help preserve the country's natural resources.
 Tax Invoice No: ETBG2017UWFL00163942
Date: 08/03/2017

TAX INVOICE

ETIQA TAKAFUL BERHAD (266243D)

LEVEL 19 TOWER C
DATARAN MAYBANK
NO 1 JALAN MAAROF
59000 KUALA LUMPUR
(GST Reg No: 001192038400)

To Account Number: V0006298

NUR IZZAH NAZIRAH BINTI ISA
NO 161 BATU 10 LEKIR`
SITIAWAN
32000 PERAK

Description Total (RM)

Type of Certificate: Private Car - Private Use
Certificate Number: 80030694
Period of Cover: 11/03/2017 to 10/03/2018

Contribution 809.46
Total (Excluding GST) 809.46
GST payable @ 6.00% 48.57
Stamp Duty 10.00

Total Amount Payable 868.03

This is a computer generated document. Therefore, no signature is required