Insurance Takaful Application Form

INSURANCE TAKAFUL APPLICATION FORM

Please complete all sections in full. The information provided in this application will form the basis for assessment and underwriting of the proposed Takaful coverage. Incomplete or inaccurate answers may result in delay, adjustment of terms, or declination of participation. All dates within paragraphs use MM/DD/YYYY format.

Applicant / Insured Information

Policy Details

Policy type (select all that apply):
Family Takaful Life Takaful Medical Takaful General Takaful Travel Takaful

Policy period: Commencement date Expiry date

Coverage Selections and Options

Please select requested coverages and optional riders:
Accidental Death Benefit Total & Permanent Disability Medical Expenses Critical Illness Personal Accident

Beneficiary Designation

Designate primary beneficiaries for payable benefits. Percentages must total 100%.

Medical & Risk Disclosure

Have you ever been diagnosed with or treated for any serious illness, injury or medical condition?
Yes No

Prior Insurance & Claims History

Have you had prior Takaful / insurance refused, cancelled, or had renewal declined?
Yes No

Exclusions (Representative; not exhaustive)

The following are principal exclusions commonly applied to Takaful contracts. This list is illustrative; final exclusions will be set out in the Certificate of Participation and policy schedule.

• Loss or liability arising from war, civil commotion, or nuclear risks.
• Intentional self-injury, participation in criminal acts or illegal activities.
• Pre-existing conditions not disclosed at time of application where failure to disclose is material to underwriting.
• Claims arising from hazardous occupations or activities specifically excluded in the certificate.
• Suicide within any contestability period as defined in the certificate.

Payment Authorization

Payment method (select one):
Direct Debit Credit Card Cheque

Intermediary / Agent Details (if applicable)

Declaration, Consent and Undertaking

I declare that the statements and particulars given in this application are true, complete and correct to the best of my knowledge and belief. I understand that any material misrepresentation, concealment or failure to disclose any fact may render the Takaful participation void, may result in denial of claims, or may affect entitlement to benefits.

I acknowledge that contributions paid to the Takaful operations will be allocated to a Tabarru' (donation) fund for participants and that the Takaful Operator may act on a Wakalah basis to manage the fund and may charge a Wakalah fee as set out in the certificate. I further understand that underwriting decisions are based on the information I provide and that acceptance is subject to the operator's underwriting rules.

I hereby authorize any physician, hospital, medical practitioner, clinic, insurance company or other organization or person that has any records or knowledge of me or my health to provide such information to the Takaful Operator and its appointed representatives for underwriting and claims assessment purposes. I consent to any necessary medical examinations and to the release of medical information in accordance with applicable law.

I accept that the final terms, conditions, exclusions and benefits will be contained in the Certificate of Participation and policy schedule issued upon acceptance of this application. I further consent to the collection, processing and retention of my personal data for purposes related to administration, underwriting, claims and regulatory compliance.

Certification

I certify that I have read and understood the nature of the Takaful arrangement applied for, and that I have had the opportunity to ask questions concerning the scheme. I warrant that the information provided in this application is true and complete. I understand that issuance of the Certificate of Participation does not commence coverage until the contribution is received and accepted by the Takaful Operator and any required waiting periods have elapsed.

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