BORANG PERMOHONAN PERKHIDMATAN/ SERVICE REQUEST FORM

No. Polisi / Policy No. : ________________________________ No. KP Baru/ New NRIC No. : _____________________________

No.KP Lama/ Sijil Kelahiran/ Paspot/ Old IC/ BC/ Passport No : __________________________________

Nama Pemegang Polisi/ Name of Assured : __________________________________________________________________________

A. PERTUKARAN MAKLUMAT INFORMASI PERHUBUNGAN/ CHANGE OF CONTACT INFORMATION

Alamat/ Address: _______________________________________________________________ No. Tel / Tel No. : _________________

______________________________________________________________________________ E-mel / E-mail : __________________

___________________________________________ Poskod/ Postcode: __________________

Sila tandakan kotak yang sesuai/ Please tick box where appropriate

B. PERUBAHAN KONTRAK/ CONTRACTUAL CHANGES

Butiran/ Particular Dari/ From Kepada/ To

Pertukaran Pelan Asas/ Change of Basic Plan _______________________ ________________________

Pindaan Harga Polisi Asas/ Alteration of Basic Sum Assured _______________________ ________________________

* Perubahan-perubahan adalah tertakluk kepada terma dan syarat polisi/ amalan MCIS LIFE. / Changes are subjected to policy terms and
conditions/ MCIS LIFE practices.

Pertukaran Cara Bayaran/ Change Mode of Payment

Bulanan/ Monthly Suku tahunan/ Quarterly Setengah tahunan/ Half-yearly Tahunan/ Annually

Pertukaran Jenis Bayaran/ Change Method of Payment

Master/ Visa Card Banker’s Order Bayaran Terus/ Direct Bayaran Auto/ Auto-debit

Angkasa Swasta/ Private Lain-lain/ Others

*Sila hantar dengan Borang potongan/ Please submit with Deduction authority form

Pindaan Jumlah Faedah Rider/ Manfaat Tambahan/ Alteration of Riders Sum Assured/ Supplementary Benefits

Nama Faedah/ Rider name Dari/ From Kepada/ To

Hospital/ Hospitalization ______________________ _____________________ ____________________

Kemalangan/ Accident ______________________ _____________________ ____________________

Perubatan&Kesihatan/ Medical&Health ______________________ _____________________ ____________________

Lain-lain/ Others ______________________ _____________________ ____________________

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C. PEMBATALAN/ PENAMBAHAN RIDER/MANFAAT TAMBAHAN/ CANCELLATION/ ADDITION OF RIDERS/ SUPPLEMENTARY
BENEFITS

Hospital/ Hospitalization : ___________________ Kemalangan/ Accident: __________________

Perubatan & Kesihatan/ Medical & Health: ___________________ Lain-lain/ Others : __________________

D. PINDAAN BUTIR-BUTIR PERIBADI/ CORRECTION OF PERSONAL PARTICULARS

Butiran / Particular of Kepada / To

Nama/ Name : Pemegang polisi/ Assured :____________________________________________

No. KP/ Sijil Kelahiran/ Paspot/ Hayat yang Diinsuranskan/

NRIC/ BC No./ Passport No. Life Assured

Tarikh Lahir/ Date of Birth

(HH/ DD BB/ MM TTTT/ YYYY)
Jantina/ Sex Lelaki/ Male Perempuan/ Female

Pekerjaan/ Occupation : ___________________________________________

Taraf Perkahwinan/ Marital Status : ___________________________________________

Agama/ Religion : ___________________________________________

Bangsa/ Race : ___________________________________________

*Salinan Surat Beranak, Kad Pengenalan, Paspot, atau Sijil Kerakyatan perlu dilampirkan./ Copy of Birth Certificate, Identity Card,
Passport or Citizenship Certificate must be submitted.

E. PERTUKARAN TANDATANGAN/ CHANGE OF SIGNATURE

Spesimen Tandatangan Lama/ Old Specimen Signature’s Spesimen Tandatangan Baru/ New Specimen Signature’s

F. PERTUKARAN PILIHAN DIVIDEN(Semua plan)/ CHANGE OF DIVIDEND OPTION (All plan)

Pilihan 1/ Option 1 Menerima dividen secara tunai/ Receive dividend in cash

Pilihan 2/ Option 2 Meninggalkan keseluruhan dividen yang didepositkan dengan Syarikat/ Leave the entire dividend on
deposit with the Company

G. PERTUKARAN PILIHAN DIVIDEN UNTUK PELAN MZ MUDAH BAYAR SAHAJA/ CHANGE OF DIVIDEND OPTION FOR
MZ FLEXIPAY PLAN ONLY

Pilihan 1/ Option 1 Menerima dividen secara tunai/ Receive dividend in cash

Pilihan 2/ Option 2 Meninggalkan keseluruhan dividen yang didepositkan dengan Syarikat/ Leave the entire dividend on
deposit with the Company

Pilihan 3/ Option 3 Menggunakan dividen untuk membayar premium/ Apply the dividend to pay premium

H. PERTUKARAN PILIHAN MANFAAT HIDUP DIJAMIN UNTUK PELAN WEALTH MULTIPLIER SAHAJA /
CHANGE OF GUARANTEED SURVIVAL BENEFIT FOR WEALTH MULTIPLIER PLAN ONLY

Pilihan 1/ Option 1 Menerima Manfaat Hidup 10% setiap 3 tahun / Received Survival Benefit 10% every 3 year

Pilihan 2/ Option 2 Menerima Manfaat Hidup 3% setiap tahun / Received Survival Benefit 3% every year

SRF_V06_Sep2021 Page 2 of 5
 I. PERTUKARAN/ PENGELUARAN I-LINK/ I-LINK ALTERATION/ WITHDRAWAL

Pertukaran Dana/ Switching of Fund Dari/ From ___________________ Kepada/ To ____________________

Penambahan Harga Polisi/ Increase Sum Assured Dari/ From ____________ - ______ Kepada/ To ____________ - ______

Pengurangan Harga Polisi/ Reduce Sum Assured Dari/ From ____________ - ______ Kepada/ To ____________ - ______

Penambahan/ Pengurangan Premium/ Dari/ From ____________ - ______ Kepada/ To ____________ - ______
Increase / Reduce Premium

Pengeluaran Sebahagian/ Partial Withdrawal RM ____________ - ______ Unit/ Units ____________________

Pengeluaran Penuh/ Full Withdrawal

Sebab bagi Pengeluaran Penuh/ Reason for Full Withdrawal

[ ] Masalah Kewangan/ Financial Problem

[ ] Penyalah Jualan/ Mis-selling

[ ] Perkhidmatan tidak memuaskan/ Poor Service

[ ] Berkaitan hukum syarak/ Religious Reasons

[ ] Sila lengkapkan dengan jelas jika sebab yang bukan dari di atas/ Kindly write clearly if the reason is not from the above

* Dengan ini, saya/kami faham bahawa berdasarkan permintaan saya/kami, transaksi diatas adalah berdasarkan kaedah ‘Next Valuation
Day’. Saya/ kami mesti menampilkan buku polisi asal untuk pengeluaran penuh dan saya/ kami juga bersetuju menanggung kos
transaksi wujud. I/We further understand that at my/our request, the transaction above will take effect on Next Valuation Day basis. I/We
must attach the original policy document for a full withdrawal and I/ We also agree to bear the transaction cost incurred.

SRF_V06_Sep2021 Page 3 of 5
 J. MAKLUMAT E_BAYARAN/ E_PAYMENT DETAILS

(PENTING/ IMPORTANT : TULIS DALAM HURUF BESAR/ WRITE IN BLOCK)

Kepada/ To : MCIS INSURANCE BERHAD

Per/ Re : NO POLISI / POLICY NO :

Saya mengizinkan/ memberi kebenaran MCIS INSURANCE BERHAD (merujuk kepada MCIS LIFE) mengkreditkan bayaran insurans saya
ke akaun bank seperti yang dinyatakan dibawah/ I hereby allow/ give consent that payment(s) due to me by MCIS INSURANCE BERHAD
(hereafter referred to as MCIS LIFE) on the abovementioned policy be credited to my bank account as stated below and confirm that: -

1. Saya mengizinkan MCIS LIFE memberi data peribadi saya kepada pihak bank untuk memudahkan pembayaran insurans./ I give consent to
MCIS LIFE releasing the below data to its banker in order to facilitate the payment(s).

2. Saya mengesahkan bahawa maklumat yang dinyatakan oleh saya adalah benar dan tepat. Sekiranya terdapat percanggahan maklumat,
pembayaran akan ditangguhkan. Sila berikan butiran akaun bank yang tepat untuk mengelakkan pengkreditan pembayaran yang tidak tepat/
I confirm the information provided herein are true and accurate and in the event I have made an error or omission, I understand the payment
will be delayed. Please provide the accurate bank account details to avoid any inaccuracy of crediting the said payment.

3. Permintaan saya ini tidak boleh dibatalkan tanpa persetujuan MCIS LIFE. MCIS LIFE boleh pada bila-bila masa menukar cara
pembayaran kepada saya dengan kaedah lain./ My request herein shall be irrevocable without the consent of MCIS LIFE. MCIS LIFE may
at any time in its absolute discretion effect payment(s) to me by other methods.

4. Pilihan akaun bank dan butiran diri saya adalah seperti dinyatakan di bawah./ My preferred bank account and contact details are as stated
below.

Nama Bank/ Bank Name : ________________________________________________________________

No Akaun Bank/ Bank Account No. (*) :

*Nota/ Note: Akaun Bersama tidak
dibenarkan/ Joint Account is not allowed

No. Identiti seperti di Akaun Bank/

Identity No. as per bank A/C : ______________________________________________

No Telefon Bimbit/ Mobile Phone No. : _____________________________________

Alamat E-mel/ E-mail Address : _____________________________________

Nama/ Name : ______________________________________

Tarikh/ Date : ______________________________________ Tandatangan Pemegang Polisi/ Penuntut

Policyowner / Claimant Signature

Pilihan dikenakan kepada/

A Semua Polisi/ Polisi Semasa/
Option apply to : All Policies Current Policy

Senarai adalah untuk rujukan sahaja. Bank lain (dalam Malaysia) yang tiada dalam senarai dibawah juga diterima./ Bank Listed below are for
reference only. Other banks (in Malaysia) not listed are acceptable.

SENARAI BANK DAN BUTIRAN RUJUKAN / LIST OF BANKS AND DETAILS FOR REFERENCE
Nama Bank / Bank Name Angka Nama Bank / Bank Name Angka
Digit Digit
Affin Bank Bhd / Affin Islamic Bank Bhd 12 Agro Bank/Bank Pertanian 16
AmBank (M) Bhd / AmIslamic Bank Bhd 13 Al Rajhi Bank 15
Alliance Bank Malaysia / Alliance Islamic Bank Bhd 15 Bank Islam Malaysia 14
Bank Kerjasama Rakyat 12 Bank Muamalat Malaysia 14
Bank Simpanan National 16 CIMB Bank / CIMB Islamic Bank Berhad 14/10
Citibank Berhad 10 Hong Leong Bank / Hong Leong Islamic Bank Berhad 11
HSBC Bank / HSBC Amanah Malaysia Berhad 12 Kuwait Finance House 12
Maybank Bhd / Maybank Islamic Bhd 12 OCBC Bank Malaysia / OCBC Al-Amin Bank Berhad 10
Public Bank Bhd / Public Islamic Bank Bhd 10 RHB Bank Bhd / RHB Islamic Bank Bhd 14
Standard Chartered Bank / Standard Chartered Saadiq 12 United Oversea Bank 11
Berhad

SRF_V06_Sep2021 Page 4 of 5
 K. PENGISTIHARAN DAN PEMBERIKUASAAN/ DECLARATION AND AUTHORIZATION

Saya/ Kami dengan ini memohon bahawa polisi ini ditukar mengikut butir-butir di atas dengan pemahaman dan persetujuan bahawa
surat atau keratan pindaan MCIS LIFE kepada saya mengesahkan pertukaran yang diminta adalah diakui, atau diubah dan akan
membentuk sebahagian polisi tersebut berkuatkuasa dari tarikh yang dinyatakan/ I/ We hereby request that this policy be changed in
accordance with the above particulars with the understanding and agreement that MCIS LIFE letter or endorsement to me confirming
that the changes requested for are granted, or modified, or varied shall form part of the said policy with effect from the date stated.

Saya/ Kami bersetuju, mengizinkan dan membenarkan Syarikat untuk memproses data peribadi saya/ kami dengan niat untuk
memeterai perjanjian, selaras dengan peruntukan Akta Perlindungan Data Peribadi 2010. I/ We agree, consent and allow the Company
to process my/our personal data with the intention of entering into a contract of Insurance, in compliance with the provisions of the
Personal Data Protection Act 2010.

Ditandatangani di/ Signed at ______________________ pada/ on ____________, bulan/ day of month ___________20/20___________
Tempat/ Place Tarikh/ Date Bulan/ Month Tahun/ Year

_____________________________________________ ______________________________________________
Tandatangan Pemegang Polisi/ Pemegang Serah Hak / Tandatangan Pemegang Amanah / Penama /
Signature of Assured/ Assignee Signature of Trustee / Nominee

Nama/ Name : ______________________________ Nama/ Name : _________________________________

No. KP/ NRIC No. : ______________________________ No. KP/ NRIC No. : _________________________________

____________________________________________________
Tandatangan Saksi/ Signature of Witness

Nama/ Name : _______________________________

No. KP/ NRIC No. : _______________________________

No. Telefon / Contact No. : _______________________________

Alamat/Address : _______________________________

_______________________________

Nota/ Note : *(Saksi mesti telah mencapai 18 tahun / The Witness must have attained the age 0f 18 years)

Mengikut Seksyen 16 (3) Akta Pencegahan Pengubahan Wang Haram, Pembiayaan Anti-Keganasan dan Hasil Kegiatan Tidak Sah
2001 (AMLATFPUAA 2001), dan Akta Suruhanjaya Pencegahan Rasuah Malaysia 2009, MCIS Life berhak untuk menahan atau
menghentikan permohonan perniagaan termasuk pembayaran tuntutan di mana ia dianggap sesuai dan wajar. In compliance with
Section 16(3) of the Anti-Money Laundering, Anti-Terrorism Financing and Proceeds of Unlawful Activities Act 2001 (AMLATFPUAA
2001), and the Malaysian Anti-Corruption Commission Act 2009, MCIS Life reserves its right to withhold or terminate the business
application including claims payment where it deems fit and proper.

SRF_V06_Sep2021 Page 5 of 5