ZURICH LIFE INSURANCE MALAYSIA BERHAD

Date :

NEHRU A/L SUBRAMANIAM

Dear Sir/Madam

RE: APPLICATION NO.

INSURED'S NAME

APPLICANT'S NAME NEHRU A/L SUBRAMANIAM

7210320193

THURGHASINI A/P NEHRU

NO 5 JALAN VILLA LAKSAMANA

TAMAN VILLA LAKSAMANA

68100 BATU CAVES

We thank you for your application for a life/investment/health insurance policy with our Company. For the

consideration of issuing you a policy, we require additional tests /reports/investigations/forms as indicated in the

attached Outstanding Requirement Advice.

Please be advised that any initial/subsequent premiums paid shall be deemed invalid null and void and the

Company shall not be liable in any manner whatsoever for any claims made there from unless and until the

requirements indicated in the attached Outstanding Requirement Advice have been attended to, application has

been duly approved and policy contract has been duly issued.

By copy of this letter, we are also requesting our sales advisor to assist you in this matter.

Thank you.

ZURICH LIFE INSURANCE MALAYSIA BERHAD

[email protected]

(Computer Generated Advice - No Signature Is Required

c.c. - SALES ADVISOR

GROUP AGENCY MANAGER

AA02-03-JS71 V.SUJATA VALLASAMY

AA02-06-K469 LALMUHUNTHAN S/O NAGAPPON

From Life & Family New Business

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04 Oct 2021

eCOPY

Application No. 7210320193

Insured's Name

Applicant's Name NEHRU A/L SUBRAMANIAM

THURGHASINI A/P NEHRU

Please accomplish the requirement (s) indicated below for assessment of the above numbered application:

1)Kindly be informed, physical appearance in NRIC does

not fit with build declared.

Please proceed Medical Examination on APPLICANT

(RM80)- to be done at panel clinics.

(Please refer to the list of panel clinics in the iAdvisor).

Otherwise, APPLICANT can opt to go to the nearest

branch to measure the height and weight. Further

requirements will be needed subject to exact build.

If Medical Examination is done at non panel clinic,

the fee will not be reimbursed and a repeat

medical examination done at panel clinic is

required for us to finalize the underwriting

decision.

NOTE: If non panel clinic is really necessary,

please get our approval first before proceeding.

2)Accident Questionnaire to be completed by the applicant

3)Blood Test - Liver Function Test:-

Total Protein,Albumin,Globulin,A/G Ratio,Total Bilirubin,

Alkaline Phosphatase,Gamma GT,SGOT, SGPT & Alpha-fetoprotein

4)Urine FEME (MU)

Remarks :

On applicant

1.MER is requested due to physical appearance in NRIC does not fit with build declared.

2. Please complete accident questionnaire pertaining to accident in 2020

On insured

1. Blood test - liver functiont test

2. Urine FEME

Note:

-Further test or report maybe called for/requested if necessary.

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Date :04 Oct 2021

eCOPY

Dear Dr.

Re: Medical Examination Reimbursement Letter

Please proceed to examine the above-mentioned applicant/insured as per the requirement stated in our deferment letter.

Once the required examination is completed, kindly ensure that the completed forms are duly signed by both the doctor and the applicant/insured. We are pleased to announce that we will be introducing a hassle-free way to you to send the following document to us, just scan it and attach the softcopy to [email protected]

i. Medical examination, blood and urine test.

ii. Medical bill (to exclude BP Lab bill if any).

Please make sure that item i & ii are completed before emailing us the document. Upon full document received for both items, we will reimburse the medical bills (as per Zurich’s guideline) to your bank account within 7 working days. We will inform you on the status of reimbursement within 7 working days as well.

Also please take note that Zurich will pay direct to BP Lab if there is any payment due in lieu of the above medical examination. If you still prefer to send us physical documents, please be informed that the turnaround time for reimbursement will be much longer, depending on the postal service and the additional time taken for the document to reach our department.

Best regards, Life New Business Zurich Life Insurance Malaysia Berhad Note: This is a computer-generated document. No signature is required.

Page 1 of 1

PENYATA KEPADA PEMERIKSA PERUBATAN

STATEMENT TO THE MEDICAL EXAMINER

Kenyataan Penting : Sila ambil perhatian bahawa menurut Jadual 9 Akta Perkhidmatan Kewangan 2013, anda adalah dengan ini diingatkan bahawa: Important Notice : Please take note that pursuant to Schedule 9 of the Financial Services Act 2013, you are hereby reminded that:

a. Anda dikehendaki untuk mengambil perhatian yang wajar agar tidak membuat sebarang salah nyata apabila menjawap setiap pertanyaan yang diajukan oleh kami iaitu anda perlu menjawab soalan dengan lengkap dan tepat/betul. Sila ambil perhatian bahawa semua soalan-soalan yang diminta oleh kami adalah berkaitan dengan keputusan kami sama ada untuk menerima risiko atau tidak, serta kadar dan terma yang terpakai. You are required to take reasonable care not to make any misrepresentation when answering any questions asked by us i.e. you should answer the questions fully and accurately/correctly. Please note that all the questions that are asked by us are relevant to our decision whether to accept the risk or not and the rates and terms to be applied.

b. Jika terdapat sebarang perubahan kepada jawapan yang diberikan di dalam borang permohonan/cadangan dalam jarak masa antara borang permohonan/cadangan dikemukakan dan masa

kontrak bermula, anda juga perlu mengisytiharkan perubahan tersebut dengan penuh dan tepat/betul. If there are any changes to the answers given in the application/proposal form between the time of submission of the application/proposal form and the time the contract is entered into, you are also required to disclose to us fully and accurately/correctly such changes.

c. Selain dari menjawab soalan-soalan dalam borang cadangan dengan penuh dan tepat/betul, anda juga perlu mengambil perhatian sewajarnya untuk mengisytiharkan dengan tepat/betul sebarang hal lain yang anda tahu ianya berkaitan dengan keputusan kami untuk menerima risiko atau tidak serta kadar dan terma yang terpakai. In addition to answering the questions in the proposal form fully and accurately/correctly, you are also required to take reasonable care to disclose to us fully and accurately/correctly any other matters which you know to be relevant to our decision on whether to accept the risk or not and the rates and terms to be applied.

d. Kegagalan anda memberikan jawapan yang lengkap dan tepat boleh menyebabkan polisi anda tidak diproses, tuntutan tidak dibayar atau dikurangkan, atau syarat-syarat polisi diubah; Your failure to give answers that are full and accurate may result in your policy being avoided, a claim not being paid or reduced, or the terms of the policy being changed;

e. Jika anda tidak memahami kewajiban/tugas anda seperti yang dinyatakan di atas atau jika anda memerlukan sebarang penjelasan, anda boleh menghubungi kami atau perunding jualan

kami. lf you do not understand your obligation/duty as stated above or if you need any further explanation, you can contact us or our sales advisor.

Nama Penuh Pemohon Insurans Hayat Full Name of Proposed Life No. KP/PP Tarikh Lahir Umur Lelaki Perempuan NRIC/PP No. Date of Birth Age Male Female Nama Perunding Jualan dan No. Kod Pekerjaan Name of Sales Advisor and Code No. Occupation Jumlah Insurans dipohon Insurans sedia ada Amount of Insurance applied for now Existing Insurance Nama dan Alamat doktor peribadi anda atau doktor yang kerap memeriksa anda Name and Address of your personal doctor or doctor that you frequent most Adakah anda mengambil sebarang ubat sekarang? Ya Tidak Are you on any medication at present? Yes No Jika “Ya”, nyatakan sebab dan jenis-jenis ubat If “Yes”, state reason and type of medication Tarikh Pemeriksaan Terakhir Nama Doktor Yang Memeriksa Date of Last Consultation Name of Doctor Consulted Sebab Pemeriksaan Reasons for this Consultation Pernahkah anda diperiksa oleh PAKAR SAKIR JIWA pada BILA-BILA MASA? Ya Tidak Have you at ANYTIME consulted a PSYCHIATRIST? Yes No Jika “Ya”, sila berikan butir-butir dan tarikhnya If “Yes”, give details and dates

KENYATAAN PERIBADI KEPADA PEMERIKSA PERUBATAN PERSONAL STATEMENT TO MEDICAL EXAMINER 1. Pernahkah anda mengalami atau diberitahu bahawa anda mengalami atau pernah dirawat

kerana/ Have you EVER had or been told you had or been treated for

a. Epilepsi, pitam, serangan sawan, gangguan saraf atau mental, neuritis, lumpuh atau sebarang penyakit atau masalah otak atau sistem saraf yang lain? Epilepsy, fainting, spells seizure, nervous or mental condition, neuritis, paralysis or any disease or abnormality of the brain or nervous system?

b. Kepeningan, hilang kesedaran, sesak nafas, sakit dada, tekanan darah tinggi, debaran atau sebarang penyakit jantung, darah atau saluran darah? Giddiness, loss of consciousness, breathlessness, chest pain, high blood pressure, palpitation or any disease of the heart, blood or blood vessel?

c. Ludah berdarah, batuk kering, lelah, batuk-batuk, pluresi atau sebarang penyakit pernafasan atau paru-paru yang lain? Blood spitting, tuberculosis, asthma, habitual cough, pleurisy or any respiratory or lung disease?

Ya Tidak Yes No

Butir-butir jawapan “Ya”. (NYATAKAN NOMBOR SOALAN DAN BULATKAN PERKARA BERKENAAN. Sertakan diagnosis, tarikh, keputusan, tempoh, nama dan alamat semua doktor dan pusat perubatan yang memeriksanya). Details of “Yes” answers. (IDENTIFY QUESTION NUMBER AND CIRCLE APPLICABLE ITEMS. Include diagnosis, dates, results, duration, names and addresses of all attending doctors and medical facilities).

QF-LUW-041/REV0

HIGHLY CONFIDENTIAL

Page 1 of 6

d. Masalah penghadaman berulang, ulser, hernia atau penyakit hepar, pundi hempedu, perut atau usus? Recurrent indigestion, ulcer, hernia or disease of liver, gallbladder, stomach or intestine?

e. Gula/albumin/batu karang dalam kencing, penyakit kelamin, masalah haid atau penyakit buah pinggang, prostate, saluran kencing atau sistem genital? Urinary sugar/albumin/stones, venereal disease, menstrual disorder or disease of the kidney, prostate, urinary or genital system?

f. Kencing manis, goiter atau sebarang penyakit atau masalah kelenjar tiroid atau kelenjar endokrin lain? Diabetes, goiter or any disease or abnormality of the thyroid or other endocrine glands?

g. Penyakit mata, telinga, hidung (termasuk hidung berdarah) atau kerongkong? Disease of eyes, ears, nose (including nose bleeds) or throat?

h. Kanser, tumor, sista atau sebarang ketumbuhan? Cancer, tumour, cyst or any growth?

i. Jaundis, Hepatitis, sebarang penyakit hepar atau menjadi pembawa Hepatitis? Jaundice, Hepatitis, any disease of the liver or been a Hepatitis carrier?

j. Malaria, disentri atau sebarang penyakit tropika? Malaria, dysentery or any tropical diseases?

k. Demam reumatik, artritis, gout atau sebarang penyakit tulang belakang, disk antara vertebra tergelincir, tulang, sendi, otot, tisu perantara, nodus limfa atau kulit? Rheumatic fever, arthritis, gout or any disease of the spine, prolapsed intervertebral disc, bone, joint, muscle, connective tissue, lymph nodes or skin?

Butir-butir jawapan “Ya”. (NYATAKAN NOMBOR SOALAN DAN BULATKAN PERKARA BERKENAAN. Sertakan diagnosis, tarikh, keputusan, tempoh, nama dan alamat semua doktor dan pusat perubatan yang memeriksanya). Details of “Yes” answers. (IDENTIFY QUESTION NUMBER AND CIRCLE APPLICABLE ITEMS. Include diagnosis, dates, results, duration, names and addresses of all attending doctors and medical facilities).

2. Pernahkah anda/ Have you ever

Menerima sebarang nasihat perubatan, kaunseling atau rawatan berkaitan AIDS, masalah berkaitan AIDS; atau sebarang keadaan lain berkaitan AIDS atau diberitahu menghidapinya; ATAU menjalani ujian HIV (Sila nyatakan keputusan), ATAU dalam 3 bulan lalu mengalami mana-mana gejala berikut terus-menerus selama lebih seminggu: keletihan, kehilangan berat badan, cirit birit, nodus limfa bengkak atau lelas kulit luar biasa? Received any medical advice, counselling or treatment in connection with AIDS, AIDS Related Complex or any other AIDS related condition; or been told you had any of these; OR that you had HIV testing done (please state result), OR in the last 3 months had any of the following symptoms for more than one week continuously: fatigue, weight loss, diarrhoea, enlarged lymph nodes or unusual skin lesions?

3. Dalam 5 TAHUN YANG LALU, pernahkah anda In the PAST 5 YEARS, have you had any

a. Menjalani ujian diagnostik seperti X-Ray, mamografi, elektrokardiogram, imbasan CT, echo, ultrasonogram, ujian darah atau air kencing? Diagnostic test such as X-Ray, mammography, electrocardiogram, CT scanning, echo or ultrasonogram, blood or urine studies?

b. Mengalami kesakitan, kecederaan, pembedahan, menerima nasihat perubatan, menjalani rawatan di hospital atau pemeriksaan fizikal yang tidak tersebut di atas? Illness, injury, operation, medical advice, hospital treatment or physical check-up not mentioned above?

4 a. Adakah anda menghisap rokok, paip, cerut dan sebagainya? Do you smoke cigarettes, pipes, cigar etc? Jika ya, dalam bentuk apa, jumlahnya dan sudah berapa lama? If so, in what form, quantity and duration?

b. Adakah anda minum bir, wain atau arak? Do you drink beer, wine or spirits? Jika ya, dalam bentuk apa, dan jumlahnya? If so, in what form, quantity? c. Pernahkah anda ketagih minum lebih banyak daripada sekarang?

Have you at any time been in the habit of drinking more heavily than you do now? Jika ya, sila berikan butir-butir. If so, please give details.

d. Pernahkah anda menggunakan dadah atau narkotik yang menyebabkan ketagihan atau dirawat kerana ketagihan arak atau dadah? Have you ever used habit forming drugs or narcotics or been treated for alcoholism or drug habit

e. Adakah anda mengalami kecacatan fizikal atau masalah kesihatan lain?

Have you any other physical defects or health impairments?

Page 2 of 6

5a. Sejauh yang anda ketahui atau percayai, pernahkah mana-mana anggota keluarga terdekat anda menghidap atau mati akibat kanser, batuk kering, kencing manis, penyakit jantung, darah tinggi, penyakit mental, penyakit buah pinggang atau sebarang penyakit keturunan yang lain? To the best of your knowledge and belief, has any of your immediate family ever had or died from cancer, tuberculosis, diabetes, heart disease, hypertension, mental disease, kidney disease or any other hereditary disease?

b. Pernahkah pasangan anda menghidapi sebarang penyakit berkaitan dengan AIDS atau didapati positif dalam ujian HIV? Has your spouse suffered from any AIDS related condition or been tested HIV positive?

6. Rekod Keluarga Family Record

Usia jika Hidup Age if Living

Sebab Kematian Cause of Death

Usia Ketika Kematian Age at Death

Bapa Father

Ibu Mother

Adik beradik Brothers/Sisters

7a. Adakah berat badan anda berubah lebih daripada 5 kg dalam setahun yang lalu? Jika ya, mengapa?

Has your weight changed more than 5 kg in the past years? If yes, why? b. Pernahkah permohonan insurans hayat anda ditolak, ditarik balik, ditangguh, dipersoal,

dihidupkan semula atau diubahsuai dalam sebarang cara? Has any application for insurance on your life ever been declined, withdrawn, postponed,

rated, reinstated or modified in any way?

8. WANITA SAHAJA FEMALE ONLY

a. Pernahkah anda menghidap sebarang penyakit payu dara atau organ kelamin atau mengalami kesulitan sewaktu melahirkan anak? Have you ever had any disease of the breast or female organs or complications at child-birth?

b. Adakah anda hamil sekarang? Jika ya, berapa bulan? Are you now pregnant? If so, how many months?

PERAKUAN & KEBENARAN DECLARATION & CONSENT

Saya, yang menurunkan tandatangan, dengan ini mengesahkan bahawa jawapan yang saya berikan di atas adalah penuh, lengkap dan benar dan bersetuju bahawa ia akan menjadi sebahagian daripada sebarang polisi, dalam mana jawapan ini akan atau mungkin menjadi asas tindakan Syarikat.

Setelah membaca dan memahami kandungan borang ini, saya dengan ini seterusnya memberikan kebenaran kepada mana-mana pemeriksa perubatan yang dilantik oleh Syarikat atau makmal yang ditetapkan untuk menjalankan atau melakukan ujian darah dan/atau air kencing, seperti yang diperlukan untuk meluluskan permohonan perlindungan insurans saya. Ini boleh meliputi, tetapi tidak terhad kepada, ujian-ujian kolesterol dan lipid darah berkaitan, diabetes, masalah hepar atau buah pinggang, jangkitan virus AIDS, masalah daya tahan penyakit, atau kehadiran ubat, dadah, nikotin atau metabolitnya.

Dengan syarat bahawa, kecuali kebenaran saya diperolehi terlebih dahulu, Syarikat pada setiap masa hendaklah merahsiakan segala keputusan ujian sedemikian dan hanya menggunakannya untuk tujuan permohonan saya atau permohonan insurans selanjutnya daripada Syarikat, melainkan jika perlu dimaklumkan mengikut kehendak Persatuan Insurans Hayat Malaysia, mana-mana Pihak Berkuasa Kerajaan atau oleh Undang-undang dan dengan syarat selanjutnya bahawa Syarikat hendaklah sentiasa berhati-hati dalam menjalankan sebarang ujian sedemikian, tetapi tidak akan bertanggungjawab terhadap sebarang kejadian, tindakan atau kegagalan di luar jangkaan, melainkan Syarikat telah melakukan kecuaian.

Saya dengan ini, seterusnya membenarkan mana-mana doktor, hospital, klinik, syarikat insurans atau pertubuhan, institusi atau orang lain yang mempunyai rekod atau pengetahuan mengenai saya atau kesihatan saya, untuk memaklumkan kepada Syarikat atau wakil sebarang dan segala maklumat berkaitan dengan kesihatan dan sejarah perubatan saya, dan sebarang kemasukan ke hospital, nasihat, rawatan, penyakit atau kesakitan. Salinan fotostat kebenaran ini hendaklah dianggap sah dan sama seperti yang asal.

I, the undersigned, hereby confirm that the above answers given by me, are full, complete and true and agreed that they form part of any policy, where these answers are or may be, relied upon the Company.

Having read and understood the contents hereof, I also, hereby authorize any of the Company’s appointed medical examiners or designated laboratories to conduct or perform blood and/or urine tests, as may be necessary to underwrite my application for Insurance coverage. These may include, but are not limited to, tests for cholesterol and related blood lipids, diabetes, liver or kidney disorders, infection by the AIDS virus, immune disorders or the presence of medication, drugs, nicotine or their metabolites.

Provided that, unless my prior consent has been obtained, the Company shall, at all times, keep all results of any such tests confidential and the use thereof shall only be for the purpose of my application or further application for insurance with the Company except to such an extent that disclosure is required by the Life Insurance Association of Malaysia, any proper Government Authority or by Law and further provide that the Company shall use all care in carrying out any such test, but shall not be liable for any unforeseen occurrences, act or omission, unless the Company has been negligent.

I hereby further authorize any physician, hospital, clinic, insurance company or other organization, institution or person, that has any records or knowledge of me or my health, to disclose to the Company or its representative any and all information about me with reference to my health and medical history and any hospitalization, advice, treatment, disease or ailment. A photostat copy of this authorization shall be as effective and valid as the original. Bertarikh pada haribulan 20 Dated at on Disaksikan oleh (Pemeriksa Perubatan) Tandatangan Pemohon Witnessed by (Medical Examiner) Signature of Proposed Insured

Page 3 of 6

LAPORAN SULIT OLEH PEMERIKSA PERUBATAN MEDICAL EXAMINER’S CONFIDENTIAL REPORT

PEMERIKSAAN INI HENDAKLAH DIJALANKAN SECARA SULIT. PIHAK KETIGA TIDAK BOLEH HADIR THIS EXAMINATION SHOULD BE MADE IN PRIVATE. NO THIRD PERSON SHOULD BE PRESENT

9. Pernahkah tuan/puan menemui pemohon insurans hayat secara profesional sebelum ini?

Jika “Ya”, sila semak rekod tuan/puan untuk mengesahkan bahawa segala perkara dalam sejarah fizikal pemohon insurans hayat telah diisytiharkan di muka sebelah. Jika tidak, sila berikan butir-butir mengenai sebarang perkara yang tertinggal atau tidak tepat. Have you ever seen the proposed life professionally before? If “Yes”, we would appreciate if you would review your records to confirm that all items of the proposed life’s physical history have been declared overleaf. If not, please give details of any omissions or inaccuracies.

10. Adakah tuan/puan mempunyai apa-apa pertalian persaudaraan dengan Pemohon Insurans Hayat atau Perunding Jualannya? Are you in any way related to the Proposed Life or to the Sales Advisor?

11 a. Adakah terdapat apa-apa bukti mengenai ulser, hernia, buasir, fistula atau vena varikos?

Is there any evidence of ulcers, hernia, piles, fistula or varicose veins?

b. Adakah wajahnya menunjukkan masalah kesihatan? Does appearance indicate poor health?

c. Adakah beliau kelihatan lebih tua daripada usia yang dinyatakan? Does he/she appear older than stated age?

Ya Tidak Yes No

BUTIR-BUTIR – SILA BERIKAN BUTIR-BUTIR PENUH MENGENAI HASIL DAN PENDAPAT NEGATIF. DETAILS – PLEASE GIVE FULL DETAILS OF ADVERSE FINDINGS AND OPINIONS.

Ketinggian (sm) Height (cm)

Berat (kg) Weight (kg)

UNTUK LELAKI SAHAJA FOR MALES ONLY

Dada (sm) / Chest (cm) (tarik nafas) / (forced

inspiration)

Dada (sm) / Chest (cm) (hembus nafas) / (forced

expiration)

Tahap penglihatan Visual acuity

belum dibetulkan uncorrected

dibetulkan corrected

Mata kanan Right eye Mata kiri Left eye

12. Adakah tuan/puan menemui sebarang bukti penyakit atau masalah lama atau sekarang, meliputi Do you find any evidence of past or present disease or abnormality of

a. Sistem pernafasan (paru-paru, pleura, dinding dada)? Respiratory system (lungs, pleura, chest wall)?

b. Sistem saraf pusat atau sampingan (termasuk refleks, cara jalan, lumpuh)? Central or peripheral nervous system (including reflexes, gait, paralysis)?

c. Sistem genitourinary? Genito-urinary system?

d. Sistem gastrousus? Gastrointestinal system?

e. Kulit, tulang atau sendi (termasuk vena varikos, kecacatan, tempang, pemotongan anggota, parut/tanda pengenalan)? Skin, bones or joints (including varicose veins, deformities, lameness, amputations, scars/identifying marks)?

f. Mata, telinga, hidung, kerongkong dan mulut (termasuk masalah penglihatan atau pendengaran)? Eyes, ears, nose, throat and mouth (including impairment of sight or hearing)?

g. Kelenjar tiroid atau kelenjar endokrin lain atau sistem metabolik atau hematopoiesis? Thyroid or other endocrine glands or metabolic and haemopoietic system?

h. Sistem Limfatik? Lymphatic system?

i. Payu dara? Breasts?

Page 4 of 6

13. (A) ANALISIS AIR KENCING URINALYSIS Nota : Jumlah surih mesti dicatit N.B : “Trace” amount must be noted

Darah* Blood*

Gula Sugar

Albumin Albumin

Graviti Spesifik Specific Gravity

BUTIR-BUTIR – SILA BERIKAN BUTIR-BUTIR PENUH MENGENAI HASIL DAN PENDAPAT NEGATIF. DETAILS – PLEASE GIVE FULL DETAILS OF ADVERSE FINDINGS AND OPINIONS.

Hantar spesimen untuk analisis air kencing mikroskopik jika Send specimen for microscopic urinalysis if

a. Tekanan darah melebihi 140/90 Blood pressure is 140/90

b. Albumin, darah atau gula dikesan Albumin, blood or sugar is present

c. Terdapat tanda-tanda atau sejarah penyakit saluran kencing There are any findings or history of urinary disease

d. Pemohon menghidapi kencing manis atau sedang dirawat kerana tekanan darah tinggi Applicant is a diabetic or under treatment for blood pressure

e. Sejarah kencing manis dalam keluarga Family history of diabetes

*Untuk pemohon wanita nyatakan LMP jika darah dikesan. *Female clients to indicate LMP when blood is present.

(B) Adakah darahnya dihantar untuk analisis? Is blood specimen sent for analysis? Jika “Ya”, profil mana? If “Yes”, which profile?

Ya Tidak Yes No

14. TEKANAN DARAH (jika tahap sistolik melebihi 140 atau diastolik melebihi 90 atau mempunyai sejarah hipertensi, catatkan 3 bacaan). BLOOD PRESSURE (if over 140 systolic or 90 diastolic or with history of hypertension, record 3 readings)

Sistolik Systolic

mmHg

mmHg

mmHg

Diastolik (Fasa ke-5) Diastolic (5

th phase)

mmHg

mmHg

mmHg

15. NADI PULSE

Semasa Rehat At Rest

Kadar Seminit Rate Per Minute

Denyutan Tidak Tetap Seminit Irregularities Per Minute

16. JANTUNG: Degupan Apeks terletak di ruang interkostal HEART: Apex Beat located in intercostals space

iaitu sm ke Kiri Kanan GARIS TENGAH STERNUM. cm to the Left Right of the MIDSTERNAL line.

Adakah jantungnya bengkak? Is the heart enlarged?

Adakah apa-apa tanda Is there any

a. Arteriosklerosis atau aneurism? Arteriosclerosis or aneurysm

b. Hipertrofi atau edema? Hypertrophy or oedema?

c. Deruan (jika terdapat deruan, huraikan di bawah) Murmur (if murmur is present, describe below)

Lokasi dekat sternum apeks kawasan aortik Location parasternal apex aortic area

tapak kawasan pulmonari base pulmonary area

Page 5 of 6

Jangka sistolik diastolik prestolik Timing systolic diastolic presytolic

panastolik panystolic

Tahap perlahan sederhana kuat Intensity soft moderate loud

Penyaluran tiada aksilia skapula Transmission none axilia scapula

Lepas senaman hilang berkurangan tidak berubah After exercise absent decreased unchanged

bertambah increased

Diagnosis Diagnosis

Adakah berlaku dispnea berlebihan selepas senaman? Is there excessive dyspnea after exercise?

BUTIR-BUTIR – SILA BERIKAN BUTIR-BUTIR PENUH MENGENAI HASIL DAN PENDAPAT NEGATIF. DETAILS – PLEASE GIVE FULL DETAILS OF ADVERSE FINDINGS AND OPINIONS.

17. Selepas menyemak seluruh hasil siasatan, adakah tuan/puan mengesyaki sebarang masalah jantung atau sistem vaskularnya? Do you suspect any abnormality in the heart or vascular system upon review of your overall findings?

18. Adakah apa-apa sebab untuk tuan/puan mempercayai bahawa pemohon insurans hayat mempunyai risiko menghidap AIDS lebih tinggi daripada biasa? Jika ya, mengapa? Do you have any reason to believe that the proposed insured is a higher than average risk for AIDS? If so, why?

19. a. Adakah tuan/puan menyedari sebarang ciri kurang baik yang mungkin menjejaskan jangka hayatnya Are you aware of any unfavourable features likely to affect his/her longevity

i. Dalam sejarah peribadi atau keluarga? In the personal or family history?

ii. Didedahkan oleh pemeriksa tuan/puan? Disclosed by your medical examination?

b. Adakah tuan/puan mengesyorkan sebarang ujian atau laporan lanjutan?

Do you recommend any additional tests or reports?

c. Adakah tuan/puan mengetahui sebarang fakta mengenai risiko ini yang tidak dinyatakan sebelum ini? Do you know any facts about this risk not brought up earlier?

d. Apakah tanggapan umum tuan/puan mengenai pesakit selepas menjalankan pemeriksaan? What is your general impression of the patient after completing your medical examination?

PERAKUAN DECLARATION

Saya dengan ini mengesahkan bahawa saya telah menjalankan pemeriksaan ini secara sulit di I hereby certify that I have made this examination in private at pada haribulan 20 pada jam pg/ptg/mlm. on the day of at am/pm.

Nama Pemeriksa Tandatangan Pemeriksa Name of Examiner Signature of Examiner

No. Kod Pemeriksa Examiner’s Code Number

No. KP Cop Klinik NRIC No. Clinic Rubber Stamp

DOKTOR – SILA SEMAK LAPORAN SUPAYA TIADA PERKARA YANG TERTINGGAL DOCTOR – PLEASE CHECK YOUR REPORT FOR OMISSIONS

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Page 1 of 3 QF-LUW-092/REV0

CONFIDENTIAL

Soal Selidik Kemalangan

Accident Questionnaire No. Permohonan: Application No.:

Nama Penuh: Full Name:

1. Bilakah kemalangan berlaku?

When did the accident happen?

2.

Bagaimanakah anda mengalami kecederaan? How did you sustain injury?

3.

Adakah anda tidak sedarkan diri? Were you unconscious?

Ya/ Yes Tidak/ No

Jika Ya, untuk berapa lama? If Yes, for how long?

4. Terangkan mengenai kecederaan yang dialami dan bahagian badan manakah yang terlibat. Describe the injuries sustained and on which part of the body.

5.

Dimanakah dan oleh siapakah anda dirawat? Where and by whom were you treated?

6. Jika anda terpaksa ke hospital If you had to go to hospital

a) Hospital mana? Which hospital was it?

b) Berapa lamakah anda tinggal disana? How long did you have to stay there?

c) Adakah anda menjalani x-ray/MRI/imbasan CT? Did you have x-ray/MRI/CT scan?

Ya/ Yes Tidak/ No

Jika Ya, sila berikan keterangan. If Yes, please give details

_______________________________________________ ________________________________________________ ________________________________________________

7. Adakah anda mengalami sakit kepala, pening atau pengsan sejak itu? Have you had any headaches, dizziness or fainting spells since?

Ya/ Yes Tidak/ No

Jika Ya, sila berikan keterangan. If Yes, please give details.

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CONFIDENTIAL

8.

Sebarang kecederaan terhadap organ dalaman? Any injury to the inner or deeper organ?

Ya/ Yes Tidak/ No

Jika Ya, sila berikan keterangan. If Yes, please give details.

9.

a) Sebarang pembedahan dilakukan terhadap kecederaan? Any operation done for the injury?

Ya/ Yes Tidak/ No

Jika Ya, nyatakan tarikh dan bahagian mana badan. If Yes, indicate date and on which part of the body.

b) Sebarang pemasangan dalaman dilakukan? Any internal fixation done?

Ya/ Yes Tidak/ No

Jika Ya, nyatakan tarikh dan bahagian mana badan. If Yes, indicate date and on which part of the body.

Jika pemasangan dalaman telah dilakukan, adakah anda dimaklumkan oleh doktor yang ia akan dikeluarkan di masa hadapan? If internal fixations have been installed, were you informed by the doctor that they are to be removed in the future?

10. Adakah kemalangan tersebut menyebabkan anda mengalami sebarang kecacatan? Has the accident left you with any deformity?

Ya/ Yes Tidak/ No

11. Adakah anda memerlukan alat bantuan berjalan? Do you require any walking aids?

Ya/ Yes Tidak/ No

12. Bilakah rawatan lanjutan seterusnya? When will be the next follow-up?

13.

Adakah anda sembuh sepenuhnya? Have you fully recovered?

Ya/ Yes Tidak/ No

Jika Tidak, sila berikan keterangan. If No, please give details.

Saya mengaku bahawa jawapan yang telah saya berikan adalah, sepanjang pengetahuan saya, benar dan saya tidak menyembunyikan sebarang maklumat penting yang mungkin akan mempengaruhi penilaian atau penerimaan permohonan ini. Saya bersetuju bahawa borang ini akan menjadi sebahagian daripada permohonan insurans saya dan kegagalan untuk mendedahkan mana-mana fakta penting yang saya ketahui berkemungkinan membatalkan kontrak. I declare that the answers I have given are, to the best of my knowledge, true and that I have not withheld any material information that may influence the assessment or acceptance of this application. I agree that this form will constitute part of my application for insurance and that failure to disclose any material fact known to me may invalidate the contract.

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CONFIDENTIAL

Nota / Notes : 1. Borang ini mestilah dilengkapkan oleh orang yang dinyatakan dalam surat penyata permintaan tertunggak

yang dikeluarkan. / This form must be completed by the person specified in the deferment letter issued. 2. Sekiranya orang yang dinyatakan dalam surat penyata permintaan tertunggak berumur kurang dari 16

tahun, borang ini mestilah ditandatangani oleh pemohon. / If the specified person stated in the deferment letter is less than 16 years old, the form must be signed by the applicant.

Tandatangan: Signature:

Tarikh: Date: