This document Information Security class is CONFIDENTIAL and is meant for servicing agent

only and not for Customer / Life Assured. Please dispose by shredding if information is no longer
required

Date : 08/12/2020

Agent Name : NUR ATHIRAH BINTI JOHARI

Agent Code : 80102004013666

Proposal No : 502-3938706

Application rated or accepted as substandard due to:

Blindness of right eye

If the applicant would like to have a copy of the blood tests / medical reports, a request should be made in
writing by the applicant, to Underwriting Department, AXA AFFIN Life. The test results / reports will be
sent to the applicant’s residence unless otherwise directed.

AXA AFFIN Life Insurance Berhad 200601003992 (723739-W)

8th Floor, Chulan Tower, No.3 Jalan Conlay, 50450 Kuala Lumpur Telephone: 03-2117 6688 Fax: 03-2117 3698
Customer Service: 1300 88 1616 Medical Card: 1300 80 0200 [email protected] www.axa.com.my
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AXA AFFIN Life Insurance Berhad 200601003992 (723739-W)

8th Floor, Chulan Tower, No.3 Jalan Conlay, 50450 Kuala Lumpur Telephone: 03-2117 6688 Fax: 03-2117 3698
Customer Service: 1300 88 1616 Medical Card: 1300 80 0200 [email protected] www.axa.com.my
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 LETTER OF COUNTER OFFER
SEMAKAN SEMULA SURAT TAWARAN

Date/ Tarikh: 08/12/2020

MUHAMMAD RAMDHAN AIDIL

NO 2A JALAN 7/153A
TAMAN ANGKASA
JALAN PUCHONG
58200 W.P.KUALA LUMPUR

Dear Sir/Madam
Tuan/Puan yang dihormati,

Ref No/ No rujukan : 502-3938706

MUHAMMAD RAMDHAN AIDIL
980102-14-5953

Thank you for choosing us as your insurance carrier. We have the pleasure in informing you that
your proposal for insurance has been accepted by the Company on a revised terms and conditions.
The particulars of the revised terms and conditions are stated overleaf.
Terima kasih kerana memilih kami sebagai pelindung insurans tuan/puan. Kami dengan besar hati
ingin memaklumkan bahawa cadangan insurans tuan/puan telah diterima, walaubagaimanapun
terdapat beberapa terma bagi cadangan tersebut telah diubah. Terma-terma tersebut adalah
sebagaimana yang tercatat di lampiran yang seterusnya.

We would be grateful if you could sign and return the attached copy of the Letter of Consent of our
counter offer within fourteen (14) days from the date hereof, indicating your acceptance of the
offer. The cover will commence upon receipt of your confirmation of acceptance and additional
premium (if any), provided there has been no change in the particulars previously stated in the
proposal. We shall be entitled to accept or reject the proposal on receiving such information.
Kami sangat berbesar hati sekiranya tuan/puan dapat menandatangai dan memulangkan lampiran
Semakan Semula Surat Tawaran tersebut dalam tempoh empat belas (14) hari dari dari tarikh
tersebut, yang menyatakan persetujuan tuan/puan dengan tawaran terma-terma tersebut.
Perlindungan hanya akan berkuatkuasa setelah penerimaan Semakan Semula Surat Tawaran,
dengan syarat tiada perubahan terhadap kenyataan yang dicatatkan sebelum ini di dalam borang
cadangan. Kami berhak untuk menerima atau membatalkan cadangan apabila menerima informasi
tersebut

AXA AFFIN Life Insurance Berhad (200601003992)

8th Floor, Chulan Tower, No.3 Jalan Conlay, 50450 Kuala Lumpur Telephone: 03-2117 6688 Fax: 03-2117 3698
Customer Service: 1300 88 1616 Medical Card: 1300 80 0200 [email protected] www.axa.com.my

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Your investment link policy provides insurance protection through deduction of cost of insurance on
the basic benefits, attached riders and policy fee from the available invested funds under the policy.
As the values of these units of invested funds do change with market condition and cost of insurance
does increase with age or occupation class, it is prudent to have sufficient excess of available funds
on the policy. Hence, we do advise and recommend that you make periodic reviews of the available
funds and make regular top up payment if necessary, to increase the values of funds available to
support such monthly deductions.
Polisi berkaitan pelaburan anda menyediakan perlindungan insurans melalui potongan kos insurans
bagi manfaat asas, rider yang dilampirkan dan fi polisi daripada dana yang dilaburkan di bawah
polisi ini. Oleh sebab nilai unit dana yang dilaburkan melalui perubahan mengikut keadaan pasaran,
dan kos insurans akan meningkat mengikut umur atau kelas pekerjaan, adalah bijak untuk
mempunyai lebihan yang mencukupi di dalam dana polisi. Oleh itu, kami menasihati dan
menyarankan bahawa anda membuat kajian berkala ke atas dana yang ada dan membuat tambah
nilai berkala, jika perlu, untuk meningkatkan nilai dana yang ada untuk mendokong apa-apa
potongan bulanan sepertinya.

If we do not hear from you within fourteen (14) days from the date of thereof, we shall assume that
our counter offer is not acceptable to you and will proceed to close this matter accordingly.
Sekiranya kami tidak menerima berita dari tuan/puan dalam tempuh empatbelas (14) hari dari
tarikh tersebut, kami beranggapan bahawa Semakan Semula Surat Tawaran kami telah tidak
diterima dan kami akan seterusnya membatalkan dan menutup cadangan tersebut.

We look forward to a long and lasting relationship.

Kami berharap hubungan ini akan berpanjangan

Thank you.
Terima kasih.

Yours truly
Yang benar,

__ __________
Underwriting Department
Jabatan Pengunderaitan

Cc NUR ATHIRAH BINTI JOHARI

80102004013666

AXA AFFIN Life Insurance Berhad (200601003992)

8th Floor, Chulan Tower, No.3 Jalan Conlay, 50450 Kuala Lumpur Telephone: 03-2117 6688 Fax: 03-2117 3698
Customer Service: 1300 88 1616 Medical Card: 1300 80 0200 [email protected] www.axa.com.my

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 LETTER OF CONSENT / SURAT PENERIMAAN TAWARAN
(To be signed by the Proposer or Proposed Owner/ Untuk ditandatangani oleh Hayat Diinsuranskan
atau Pemunya Hayat Diinsuranskan)
Proposal Number / Nombor Polisi : 502-3938706
Frequency of Payment / Kekerapan Pembayaran: Monthly

Coverage / Manfaat Sum Insured / Standard Remark / Catatan Total Premium

Perlindungan Jumlah Yang Premium / with extra
Diinsuranskan Premium Standard *Exclusion/Pengecualian premium/ Jumlah
Loading/penambahan Premium dengan
penambahan
premium
AFFIN Flex Protector + 130,000 150.00 *TPD7 150.00

Hospital Cash ( 2 Unit) - 15 1,000 *REYE

Premium Payor 80 1,800 *TPD7 , *WRCI

TopUp / Tambah Nilai 0.00

Total Premium / Jumlah Premium 150.00

*Refer to the Exclusion(s) description in Appendix A (Last page, if any) /Sila Rujuk penerangan
pengecualian di Lampiran A (Halaman terakhir, jika ada)

AXA AFFIN Life Insurance Berhad (200601003992)

8th Floor, Chulan Tower, No.3 Jalan Conlay, 50450 Kuala Lumpur Telephone: 03-2117 6688 Fax: 03-2117 3698
Customer Service: 1300 88 1616 Medical Card: 1300 80 0200 [email protected] www.axa.com.my

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Premium Payable/ Pembayaran Premium : 300.00
Premium Received/ Pembayaran diterima : 300.00
Outstanding Premium Payable/ Premium Tertunggak :0
Excess Premium Payable/ Premium Perbezaan :0

AXA AFFIN Life Insurance Berhad (200601003992)

8th Floor, Chulan Tower, No.3 Jalan Conlay, 50450 Kuala Lumpur Telephone: 03-2117 6688 Fax: 03-2117 3698
Customer Service: 1300 88 1616 Medical Card: 1300 80 0200 [email protected] www.axa.com.my

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502-3938706

OPTION A/ PILIHAN A
( ) I hereby agree to accept the above revised terms and conditions of the offer as stated and
certify that there is no change in health condition since the date the said application/medical
examination was completed.
Saya, sebagaimana di bawah, bersetuju untuk menerima tawaran tersebut dan menerima
segala terma, dan syarat yang telah dikenakan sebagaimana surat tuan. Saya/Kami
mengakui bagi pihak hayat yang diinsuranskan bahawa tiada sebarang perubahan dari segi
kesihatan, dan tiada sebarang perundingan perubatan atau pemeriksaan perubatan yang
diterima sejak tarikh pemohonan/laporan pemeriksaan yang telah dipenuhi.

OPTION B/ PILIHAN B

( ) I do not accept your Offer of Acceptance, and request to have the application cancelled. I
understand that if I have made any payment of premium for this application, such payment
shall be refunded via a cheque in my name.
Saya/ Kami sebagaimana dibawah dengan ini tidak menerima tawaran tersebut dan
dengan ini mengarahkan bahawa permohonan ini dibatalkan. Saya/Kami difahamkan
bahawa sekiranya saya/kami telah membuat sebarang pembayaran bagi permohonan ini,
maka pemulangan kembali pembayaran tersebut akan dibuat melalui cek diatas nama
saya/kami.

__________________________________ ____________________________
Signature of Life Assured/Proposer Owner Signature of Witness
Tandatangan Hayat/Pemunya Dicadangkan Tandatangan Saksi

Name/ Nama: ______________________ Name/ Nama : ____________________

NRIC/ KP : ______________________ NRIC/ KP : ____________________

Date/ Tarikh : ______________________ Date/ Tarikh : ____________________

AXA AFFIN Life Insurance Berhad (200601003992)

8th Floor, Chulan Tower, No.3 Jalan Conlay, 50450 Kuala Lumpur Telephone: 03-2117 6688 Fax: 03-2117 3698
Customer Service: 1300 88 1616 Medical Card: 1300 80 0200 [email protected] www.axa.com.my

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Appendix A/Rujuk Lampiran A

Exclusion / Pengecualian:

TPD7 :
Total and Permanent Disability (TPD) Benefit exclude right eye
REYE :
any investigation and/or follow up treatment caused by or resulted from disease and disorder of
right eye and any complications thereof, treatment or operation therefore, whether directly or
indirectly arising therefrom
WRCI :
Blindness of Right Eye under Critical Illness

AXA AFFIN Life Insurance Berhad (200601003992)

8th Floor, Chulan Tower, No.3 Jalan Conlay, 50450 Kuala Lumpur Telephone: 03-2117 6688 Fax: 03-2117 3698
Customer Service: 1300 88 1616 Medical Card: 1300 80 0200 [email protected] www.axa.com.my

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