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Nota Sila rujuk kepada Notis Privasi Etiqa yang boleh didapati dari laman web kami di www. etiqa.com.my yang memaparkan mengenai cara Etiqa Takaful Berhad mengumpul menggunakan mendedahkan melindungi dan menyimpan Data Peribadi anda. Certificate Details/ Butiran Sijil Certificate Holder/ Pemegang Sijil Certificate No./ No. Sijil Vehicle No./ No. Kenderaan Financing Account No. if any / No. Akaun Pembiayaan jika ada A Amendment on Personal Details/ Pertukaran Butiran Peribadi Name/ Company Name Nama/ Nama Syarikat MyKad No./ Other Identification No. Please attach copy of identification document No. MyKad/ Lain-lain No. Pengenalan Sila sertakan salinan dokumen pengenalan Correspondence Address/ Alamat Surat-Menyurat Postcode/ Poskod Contact Details Talian untuk Dihubungi Mobile No./ No. Tel Bimbit House Tel. No./ No. Tel. Rumah Fax No./ No. Faks Office Tel. No./ No. Tel. Pejabat Email/ Emel Current Occupation/ Nature of Business Pekerjaan Terkini/ Jenis Perniagaan B Amendment to Certificate Details/ Pertukaran Maklumat Sijil To amend Certificate with effect from/ Pindaan Sijil mulai / dd/mm/yyyy / hh/bb/tttt Extension of Period of Takaful POT until dd/mm/yyyy Tempoh Lanjutan Sijil sehingga hh/bb/tttt Increase or decrease the Sum Covered/ Penambahan atau pengurangan Jumlah Perlindungan From/ Dari RM to/ ke RM Withdraw No Claim Discount NCD / Pembatalan Kelayakan Diskaun Tanpa Tuntutan NCD Transfer of NCD to Vehicle No. Pemindahan NCD kepada kenderaan bernombor Transfer Ownership to/ Pemindahan Hak Sijil Kepada Inclusion of Extension Benefits for Motor Perlindungan Tambahan untuk Motor Windscreen/ Cermin Kenderaan Flood/ Banjir All Drivers/ Semua Pemandu for Company Vehicle only/ untuk Kenderaan Syarikat sahaja Additional Drivers/ Penambahan Nama Pemandu Name/ Nama MyKad No./ No. MyKad Others/ Lain- I/We hereby authorise MyKad No. to collect the NCD/ Cancellation letter on my behalf. Please provide a copy of Certificate Holder s MyKad/ Passport/ identification document Pembatalan sijil bagi pihak saya. Sila sertakan salinan MyKad / Pasport / dokumen pengenalan diri Pemegang Sijil Building Occupation/ Kegunaan Premis Deletion of mortgage chargee clause/ Pembatalan fasal penerima gadai janji Nature of Business/ Jenis Perniagaan New location of premise to be covered/ Lokasi baru premis yang ingin dilindungi New Address/ Alamat Baru Others/ Lain-lain For amendments of Motor details please provide a copy of the Vehicle Registration Card / Sila sertakan salinan Kad Pendaftaran Kenderaan untuk pertukaran maklumat Polisi Motor C Cancellation of Certificate/ Pembatalan Sijil To cancel Certificate with effect from/ Pembatalan Sijl mulai Property or Vehicle sold/ Harta benda atau Kereta telah dijual Refinancing/ Pembiayaan Semula For Motor please attach Original Certificate of Takaful / Untuk Sijil Motor sila sertakan Sijil Asal Please attach a copy of the Certificate/ Sila sertakan salinan Sijil D Auto Debit Arrangement/ Arahan Bayaran Auto Debit I/We authorise Etiqa Takaful Berhad to debit my / our Bank Account or Credit Card for the contribution as billed by Etiqa Takaful Berhad. Credit Card/ Kad Kredit Name of Credit Card holder/ Nama Pemegang Kad Kredit Visa or Master Card No./ No. Kad Visa atau Master Credit Card Expiry Date/ Tarikh Luput Kad Kredit mm/yy / bb/tt Maybank Current or Savings Account/ Akaun Semasa atau Simpanan Maybank Account Holder s Name/ Nama Pemegang Akaun Current or Savings Account No./ No. Akaun Semasa atau Simpanan E Update e-Payment Bank Account Information/ Kemaskini Maklumat Akaun Bank e-Bayar Note Nota Kindly provide us your bank account to credit payment of surplus distribution refund of contribution or claims if any. Please ensure that the account is active and belongs to the Certificate Holder. Sila nyatakan butiran akaun bank untuk bayaran pengagihan lebihan bayaran balik sumbangan atau tuntutan secara elektronik jika ada. Sila pastikan akaun bank adalah aktif dan dimiliki oleh Pemegang Sijil. Bank Name/ Nama Bank The Payment which has been made based on the account details provided by You will be deemed as full payment and We shall be discharged from any existing and future claim and demand in relation to it. Bayaran yang telah dibuat berdasarkan maklumat akaun yang diberikan oleh Anda akan dianggap sebagai bayaran penuh dan Kami berhak untuk pelepasan dari sebarang tuntutan sedia ada akan datang dan permintaan yang berkaitan dengannya. Declaration/ Pengakuan I/We declare that the above statements and particulars are correct and complete in every aspect and I/We have not concealed misrepresented any material fact in relation to this Endorsement Instruction Form otherwise it may lead to the Policy between us being set aside My/Our claim being refused or the terms of the Policy being changed. yang salah berkaitan dengan Borang Arahan Endorsemen ini jika tidak ia boleh membawa kepada Polisi diantara kita diketepikan tuntutan Saya/Kami ditolak atau syarat-syarat kontrak diubah. Endorsement Instruction Form/ Borang Arahan Endorsmen I/We agree consent and allow Etiqa Takaful Berhad to process my/our personal data including sensitive personal data herein referred to as Personal Data with the intention of processing this endorsement to the contract of Takaful in compliance with the provisions of the Personal Data Protection Act 2010. Note Please refer to the Etiqa Privacy Notice posted in our website at www. etiqa.com.my that outlines how Etiqa Takaful Berhad collects uses stores discloses secures and retains your Personal Data. Saya/Kami dengan ini bersetuju memberi persetujuan dan membenarkan Etiqa Takaful Berhad untuk memproses data peribadi saya / kami termasuk data peribadi yang sensitif Data Peribadi dengan niat untuk memproses endorsmen ini ke atas kontrak Takaful selaras dengan peruntukan-peruntukan Akta Perlindungan Data Peribadi 2010. Nota Sila rujuk kepada Notis Privasi Etiqa yang boleh didapati dari laman web kami di www. etiqa.com.my yang memaparkan mengenai cara Etiqa Takaful Berhad mengumpul menggunakan mendedahkan melindungi dan menyimpan Data Peribadi anda. Certificate Details/ Butiran Sijil Certificate Holder/ Pemegang Sijil Certificate No./ No. Sijil Vehicle No./ No. Kenderaan Financing Account No. if any / No. Akaun Pembiayaan jika ada A Amendment on Personal Details/ Pertukaran Butiran Peribadi Name/ Company Name Nama/ Nama Syarikat MyKad No./ Other Identification No. Please attach copy of identification document No. MyKad/ Lain-lain No. Pengenalan Sila sertakan salinan dokumen pengenalan Correspondence Address/ Alamat Surat-Menyurat Postcode/ Poskod Contact Details Talian untuk Dihubungi Mobile No./ No. Tel Bimbit House Tel. No./ No. Tel. Rumah Fax No./ No. Faks Office Tel. No./ No. Tel. Pejabat Email/ Emel Current Occupation/ Nature of Business Pekerjaan Terkini/ Jenis Perniagaan B Amendment to Certificate Details/ Pertukaran Maklumat Sijil To amend Certificate with effect from/ Pindaan Sijil mulai / dd/mm/yyyy / hh/bb/tttt Extension of Period of Takaful POT until dd/mm/yyyy Tempoh Lanjutan Sijil sehingga hh/bb/tttt Increase or decrease the Sum Covered/ Penambahan atau pengurangan Jumlah Perlindungan From/ Dari RM to/ ke RM Withdraw No Claim Discount NCD / Pembatalan Kelayakan Diskaun Tanpa Tuntutan NCD Transfer of NCD to Vehicle No. Pemindahan NCD kepada kenderaan bernombor Transfer Ownership to/ Pemindahan Hak Sijil Kepada Inclusion of Extension Benefits for Motor Perlindungan Tambahan untuk Motor Windscreen/ Cermin Kenderaan Flood/ Banjir All Drivers/ Semua Pemandu for Company Vehicle only/ untuk Kenderaan Syarikat sahaja Additional Drivers/ Penambahan Nama Pemandu Name/ Nama MyKad No./ No. MyKad Others/ Lain- I/We hereby authorise MyKad No. to collect the NCD/ Cancellation letter on my behalf. Please provide a copy of Certificate Holder s MyKad/ Passport/ identification document Pembatalan sijil bagi pihak saya. Sila sertakan salinan MyKad / Pasport / dokumen pengenalan diri Pemegang Sijil Building Occupation/ Kegunaan Premis Deletion of mortgage chargee clause/ Pembatalan fasal penerima gadai janji Nature of Business/ Jenis Perniagaan New location of premise to be covered/ Lokasi baru premis yang ingin dilindungi New Address/ Alamat Baru Others/ Lain-lain For amendments of Motor details please provide a copy of the Vehicle Registration Card / Sila sertakan salinan Kad Pendaftaran Kenderaan untuk pertukaran maklumat Polisi Motor C Cancellation of Certificate/ Pembatalan Sijil To cancel Certificate with effect from/ Pembatalan Sijl mulai Property or Vehicle sold/ Harta benda atau Kereta telah dijual Refinancing/ Pembiayaan Semula For Motor please attach Original Certificate of Takaful / Untuk Sijil Motor sila sertakan Sijil Asal Please attach a copy of the Certificate/ Sila sertakan salinan Sijil D Auto Debit Arrangement/ Arahan Bayaran Auto Debit I/We authorise Etiqa Takaful Berhad to debit my / our Bank Account or Credit Card for the contribution as billed by Etiqa Takaful Berhad. Credit Card/ Kad Kredit Name of Credit Card holder/ Nama Pemegang Kad Kredit Visa or Master Card No./ No. Kad Visa atau Master Credit Card Expiry Date/ Tarikh Luput Kad Kredit mm/yy / bb/tt Maybank Current or Savings Account/ Akaun Semasa atau Simpanan Maybank Account Holder s Name/ Nama Pemegang Akaun Current or Savings Account No./ No. Akaun Semasa atau Simpanan E Update e-Payment Bank Account Information/ Kemaskini Maklumat Akaun Bank e-Bayar Note Nota Kindly provide us your bank account to credit payment of surplus distribution refund of contribution or claims if any.

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