Enrolment for Money Back Life Assurance
Underwritten by Mayban Life Assurance Berhad (235175-H)
IMPORTANT NOTE: Pursuant to Section 149(4) of the Insurance Act 1996, you are to disclose fully and faithfully all the facts which you know or ought to know otherwise the policy may be invalidated.
Proof of age will be required by providing a copy of your I/C.
YES
Please enrol me in this Plan and send my policy document as soon as possible.
Please complete Step 1 to 6. Please enter the details on the screen and all the information will be displayed when you print the form out. No information will be transmitted over the Internet at any time.
Sex: Male Female
Race: Citizenship: Malaysian
Others (Please specify)
Date of Birth:
DD
/
MM
/
YYYY
ID Description:
ID Number (Old IC/ Birth Cert / Army ID / Police ID / Passport)
New IC Number: - -
Residential Address:
Town/City: Postcode:
State: Country:
Mailing Address: (If different from Residental Address)
Town/City: Postcode:
State: Country:
Telephone:
Office
House
H/Phone
Fax
Country of Permanent Residence:
(Applicable to foreigners only)
Email Address:
Marital Status:
Number of Children: (Please Indicate)
Single
Married
Others
0 to 12 years
> 12 to 18 years
Preferred Language: B. Malaysia
English
Mandarin
Tamil
Others
Occupation:
Occupation Sector:
Monthly Personal Income:
Step 3
Complete Details of Nominee
Nominee 1
Name:
Address:
Postcode: State:
I/C No: (Old) or (New)
Date of Birth: // Share (%):
Relationship:
Please ensure that the sum of the share for the nominee(s) adds up to 100%. For more than 1 nominee, please click here.
The Accountholder will be the named nominee for Spouse enrolments.
Notes on Nomination
-
If your intention is for the nominee(s) named herein other than your spouse, child or parent (where there is no spouse or child living at the time of nomination) to receive the policy benefits beneficially and not as an executor, then you must assign the benefits of the policy to such person(s).
-
A nominee of a Muslim Policy Owner on receipt of the policy moneys shall distribute in accordance with Islamic Law.
For more information regarding nomination, please click here.
STEP 4
Payment Authorisation (Select One Only)
Credit Card Payment Authorisation Please charge the monthly premium for the plan I have selected to my credit card as detailed below.
Name that appears on card
Card Number
Issuing Bank
Expiry Date: /
MM YYYY
Direct Debit Authorisation I authorise Malayan Banking Berhad to debit my account an amount not exceeding the monthly premium as billed by Mayban Life Assurance Berhad for the credit of their account with you. I agree to abide by the Terms and Conditions as specified in the Direct Debit Leaflet which will be attached with the insurance policy document.
Name of Accountholder
I/C No: (Old) or (New)
Maybank/Mayban Finance Current/Savings Account Number
- - -
Authorisation Signature
X
(Signature of Accountholder / Credit Card holder)
Date
STEP 5
Declaration
I/We declare as follows:-
I agree that the information provided in this enrolment form are true and complete and the stipulations of the policy to be issued shall be the basis of the contract between myself and Mayban Life Assurance Berhad.
I/We have not withheld any information which is material and which might influence the acceptance by the Company of the proposal.
That I/we understand and agree that the assurance I/we have applied for shall only commence on the date the policy has been issued by the Company provided always that the first premium has been paid during my/our lifetime and that prior to or as at the date of issue of the policy, there has been no alterations as to my/our health and/or my/our family history.
I declare that I have not:
Suffered from high blood pressure, heart disease, stroke, epilepsy, kidney disease, asthma or other respiratory or lung diseases, diabetes, hepatitis or other liver diseases, mental disorder, blood disorders e.g. leukaemia, cancer, tumour or any other serious disorders;
Tested for, or received medica; advice, counselling or treatementin connection with transmitted disease, AIDS or infection with any Human Immunodeficiency Virus (HIV);
Medically treated for any ailment for a continuous period of more than 2 weeks, hospitalised or been advised to have any surgical operation within the last 5 years.
Have any proposal for insurance on your life ever been declined, deferred, rated or in any way modified or is now being considered by any insurer; and
Do not or intend to engage in any hazardous pursuits, pastime or hobby pursuit such as aviation, motor racing, underwater activities, hang-gliding, etc.
I understand that this Enrolment Form will be accepted upon receipt by Mayban Life Assurance Berhad.
I hereby authorise Maybank / Mayban Life Assurance Berhad to debit my credit card / account.
I hereby authorised Mayban Life Assurance Berhad to increase/decrease the Auto Debit Payment Limit in accordance to total premium if there is a discrepancy between the Auto Debit Payment Limit and total premium payable.
X
(Signature of Life Assured)
Date
STEP 6
Sending the Enrolment Form
On completion, please PRINT and SIGN the Money Back Life Enrolment Form and either fax or mail the form to:
17th Floor, Marketing Division
Mayban Life Assurance Berhad
MaybanLife Tower, Dataran Maybank
No.1, Jalan Maarof
59000 Kuala Lumpur
Fax Number: 03 - 2283 2937
