Proposal Form For MedicaGen 200

IMPORTANT NOTE
Pursuant to Paragraph 5 of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance wholly for purposes unrelated to your
trade, business or profession, you have a duty to take reasonable care not to make a misrepresentation in answering the questions in this Proposal
Form. You must answer the questions in this Proposal Form fully and accurately.

Failure to take reasonable care in answering the questions may result in avoidance of your contract of insurance, refusal or reduction of your claim(s),
change of terms or termination of your contract of insurance.

The above duty of disclosure shall continue until the time your contract of insurance is entered into, varied or renewed with us.

In addition to answering the questions in this Proposal Form, you are required to disclose any other matter that you know to be relevant to our
decision in accepting the risks and determining the rates and terms to be applied.

You also have a duty to tell us immediately if at any time after your contract of insurance has been entered into, varied or renewed with us any of
the information given in this Proposal Form is inaccurate or has changed.

Agency code __________________________________

Please use block letters / tick (√) appropriate box

Your personal particulars:
Salutation x Mr Mdm Miss

Name of proposer / policy owner / applicant Sadegh Rast

Address A-15-10, Waldorf Tower, Jalan Sri Hartamas 17

City Kuala Lumpur

State Kuala Lumpur Postcode 50480

Tel No.: (H) 014-6467605 (O) (Mobile)

NRIC No. (Old) N97159684 (New)

Date of birth 0
D 6D M 9
M Y1 9
Y 8
Y 5Y Gender x Male Female

Nationality Malaysian Others Please State Iranian

Preferred language x English Malay Chinese Tamil Race Malay Chinese Indian x Others

Proposed insured particulars:

Name Sadegh Rast

Date of birth D0 6
D 0
M 9
M Y1 9Y 8Y 5Y Gender x Male Female

NRIC No. / Birth Certificate No. N97159684

Height 169 cm (or) feet inches Weight 72 kg (or) lbs

Smoker Yes. How many per day Stick/Sticks x No Occupation

IT Consultant

1442/8/P/G/S/M
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 Nature of work:
Insured Please tick (√)

x 1. Persons engaged in professional, administrative, managerial, clerical and non-manual occupations

2. Persons engaged in work of supervisory nature but not involved in manual labour

3. Persons engaged either occasionally or generally in manual work which involves the use of tools or machinery

4. Full time student / housewife / pensioner

Yes No
1 Does the person to be insured have Health Insurance with us or any other company? x
2 Does the person to be insured require takeover benefit from other Health Insurance? If YES, please attach a copy of
the existing Policy Schedule. x
3 Has person to be insured ever in respect of any medical or health insurance, had an insurer defer or decline a
proposal, refuse renewal or terminate insurance? If YES, please state reason and provide the name of the insurance x
company.
4 Has person to be insured:
a. Suffered from any physical impairment, infirmity or abnormality or congenital conditions? x
b. Had or ever been advised to have any medical check-up, x-ray scan, blood test, urine test, ECG or is currently
under observation and/or receiving treatment or taking any medication in the past twelve (12) months?
x
c. Has or had abnormal blood, urine or any other investigation test result in the past twelve (12) months? x
d. Undergone any surgical operation or suffered any illness, disorder or injury during the past three (3) years
which has required any form of medical or specialized examination or consultation or hospitalization, or that x
may require future treatment?
e. Seen a doctor / specialist for medical or surgical advise, diagnostic test or investigation including test or x
treatment that has not been performed or completed?
f. Had any surgery planned in the next six (6) months? x
5 Has the person to be insured ever suffered from or been treated, told by or consulted a medical practitioner for:
a. Disease or disorder of the eyes, ears, nose, mouth or throat? x
b. Fits, epilepsy, recurrent dizziness or headache, fainting, sclerosis, mental or nervous disorder, paralysis,
x
depression, psychiatric or psychological disorders, blackout or of any kind?
c. Persistent cough, coughing blood, asthma, bronchitis, tuberculosis or any other disorders of respiratory x
disorder?
d. High or low blood pressure, heart disease, chest pain or discomfort or tightness, heart attack, stroke,
shortness of breath, rheumatic fever, anaemia or disorder of blood, other disease of the heart or blood vessels x
or any form of circulatory disorder, palpitation or any other disorders of the heart?
e. Stone or any other disorder of kidney or urinary system, sugar, protein or blood in urine or menstrual x
disorder?
f. Rheumatism, slipped disc, arthritis, gout or disorder of muscles or joints, spinal disorder or back pain, skin x
disorder?
g. Gastritis, ulcer or any other disorders of stomach or intestine, prostate conditions, haemorrhoids or hernia? x
h. Diabetes mellitus, thyroid conditions? x
i. Liver disorder or disease, gall bladder stone or any other disorder of gall bladder, hepatitis of any kind or x
jaundice?
j. Tumours, cancer, cysts, nodules, polyps, growth and lumps of any kind including malignant blood/leukemia? x
k. Varicose veins or deep vein thrombosis? x
l. HIV (Human immunodeficiency virus), AIDS (acquired immunodeficiency syndrome) or other sexually
transmitted disease?
x
m. Any illness, disease, injury, disabilities or amputation not mentioned above? x
6 Female applicants:
Is the person to be insured now pregnant? If YES, how many month? ________ months
7 For children below two (2) years old:
Was this child born premature or pre-term? If YES, please provide birth weight and number of weeks premature.
Birth weight : __________ Week of delivery : __________
8 Has or had any of person to be insured’s parents or sibling suffered from/died from cancer, diabetes mellitus,
hypertension, stroke, kidney disease, multiple sclerosis, mental illness or any other heredity disease or other serious x
condition or disease?

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9. If any of the answers to questions 3 to 8 is ‘Yes’ please give details in the box below and state the number of the
question to which the answer is applicable or leave blank if the answer is ‘No’.

Question Name of Type of Date of Result or Name and address

no. person disability disability status of of or & clinic
(DD/MM/YY) disability or hospital

10. (a) My usual or last visited Doctor Hospital Specialist Centre Clinic

(b) Name of Hospital / Specialist Centre / Clinic

University Malaya Medical Centre

(c) Address

Jln Profesor Diraja Ungku Aziz, Lembah Pantai, 59100 Kuala Lumpur, Selangor

Tel no. 03-7949 4422

(d) Date of visit 2021

(e) Reason for visit to usual or last visited Doctor

Covid Vaccine
Additional
We may ask you additional questions if required.
The questions on this proposal form and any other details we specifically request relate to facts which we consider material to underwriting
this insurance. However, because no list of questions can be exhaustive, please consider whether there is any other material iformation
which is known to you which could influence our assessment and acceptance of the risk.

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 Age Plan no. Premium (RM)

Proposed insured 37 3
Tax (where applicable)

Stamp duty 10.00

Total payable

Declaration
I/We understand that it is my/our duty to take reasonable care not to make a misrepresentation in answering the questions in this
Proposal Form and I/we hereby declare that I/we have fully and accurately answered the questions above.

I/We hereby authorise any hospital, surgeon, medical practitioner or clinic or other person who attended to me/ourselves for any
reason to disclose to the Insurance Company any and all information with respect to any illness or injury and to provide copies of
all hospital or medical records/certifications, including any earlier medical history. A photocopy of this authorisation shall be
considered as effective and valid as the original.

I/We acknowledge that the liability of the Insurance Company does not commence until this proposal is approved, premium paid
to the Insurance Company and the policy is issued.

I/We hereby give my/our unconditional and unequivocal consent to you and all your related companies to process my/our personal
data revealed hereto. You are at liberty to process the data and share the information revealed thereto with any of your service
providers and your other related companies provided that the revelation of my/ our personal data strictly for the purposes in
relation to the insurance which I/we have applied hereto. The consent given hereto is in line with the requirement set forth in the
Personal Data Protection Act 2010.

Signature of proposer / proposed insured

Place _________________________________________________

_______________________________________________________

Date D5 D 1
M 0
M 2Y 0Y 2Y Y2

For office use only

Official receipt no. __________________________________________ Premium amount: RM ____________________________________

Period of cover From D D M M Y Y Y Y To D D M M Y Y Y Y

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I enclose herewith a cheque of RM (Cheque No. ) being premium inclusive
of Stamp Duty made payable to Zurich General Insurance Malaysia Berhad.
OR
Please charge RM to my MasterCard Visa

Credit Card Account Number

Credit Card Expiry Date M M / Y Y

**Signature of proposer / policy holder / applicant

Date D D M M Y Y Y Y

** If by Credit Card, Proposer must be Cardmember and signature as per Card Account

Important information on the purchase of medical / health insurance (MHI)

You are advised to read through the checklist below which explains to you the essential features of the MHI policy so that
you are able to make an informed decision before purchasing the policy. If you are in doubt or where there is ambiguity, please
seek clarification from your insurance intermediary or contact our Call Center Personnel at 1-300-888-622

You should satisfy yourself that this proposed plan will best serve your needs and the premium payable under the policy is the
amount you may afford.

Please tick (√)

A) The benefits payable under the policy. x

B) Significant medical or technical exclusions or restrictions applicable. x
C) Limits of benefits (e.g. % of costs covered by the policy, co-payment, ceiling to total claim costs, x
deductible amounts) etc.

D) Nature and extend of the insurer’s right to review and revise the premiums payable, and the notice x
to be given by the insurer in the event of any revisions.

E) Waiting Period, Specified Illnesses and their relevant qualifying periods. x

F) Reasonable and customary clause. x
G) Amount of premiums payable and the payable term. x
H) The implications of switching policy from one insurer to another or transferring from one insurance x
plan to another that may cause the Waiting Period and Specific Illness to start afresh or non-acceptance
of your proposal.

I) The insurer’s right to repudiate liability in the event of my failure to disclose relevant information in the x
proposal form that would affect the decision of the insurer to accept or reject the risk, and on the
premiums and terms to be applied to the policy owner.

J) A cooling off period of 15 days will be given to me to review the suitability of the newly purchased x
policy. If I were to return the policy to the insurer during this period, premiums will be refunded after
the deduction of expenses, if any.

K) The actual terms and conditions will be in the original policy to be delivered to me once the insurer had x
underwritten and approved my proposal.
L) Reference on the basics of MHI policies may be obtained from The Introduction to Medical and Health x
Insurance Products issued by Bank Negara Malaysia.

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 Summary information sheet
Note: this information sheet provides a summary of the main features of the above product for illustration purposes and does
not constitute a contract of insurance. Policy owners are advised to refer to the policy document for full details of the product
terms and conditions, including those outlined below.

(A) Terms of issue*

1) This is a Hospital & Surgical (H & S) Policy until age 75.
It is a Conditional Renewable Policy which means, is renewable at the option of policyholder until the occurrence of any
of the following: -
(a) non-payment of premium or premium not made on time
(b) fraud or misrepresentation of material fact during application
(c) the policy is cancelled at the request of the policyholder
(d) total claims of the policy have reached the lifetime limit specified and/or on the death of the Insured Person
(e) the Insured Person attains the coverage age limit specified
(f) termination of coverage for all policies in a certain market and the Company withdraws this policy completely from
the market in accordance with the Portfolio Withdrawal Condition
(g) Insured Person falls within an occupational class which is not insurable under the Policy.

The renewal premium payable for the H & S Policy is not guaranteed:
a) The Company can revise the premium at the time of renewal according to the Company’s risk assessment and it shall
be applicable to all policyholders of MedicaGen 200.
b) The premium rate is age-banded (Ages 1-18;19-35; 36-45; 46-50; 51-55; 56-60; 61-65; 66-70; 71-75) and is payable
according to each member’s attained age on each Policy year anniversary.
c) The premium will be adjusted if the occupation of the Insured Person changes from Class 1 or 2 to Class 3.

2) Co-payment & /Deductible maybe imposed by the Insurer, depending on underwriting considerations. Even if such
Co-payment & /Deductible is imposed, the policyholder shall only be liable up to RM3,000.

Notwithstanding this, if the Insured Person utilises a Room & Board rate, which is more than his/her entitlement, then
he/she shall also be subject to the Upgraded Room & Board 20% Co-Payment Clause.

3) If the proposal/declaration of the policyholder is untrue or misrepresented/misstated in any respect, then this policy shall
be void.

4) Cooling-Off Period may apply if this Policy shall have been issued and for any reason whatsoever the Insured Person shall
decide not to take up the Policy, the Insured Person may return the Policy to the Company for cancellation provided such
request for cancellation is delivered by the Insured Person to the Company within fifteen (15) days from the date of
delivery of the Policy. The Insured Person is entitled to the return of the full premium paid less deduction of medical
expenses occurred by the Company in the issue of the Policy.

(B) Some major benefits limitations*

This product does NOT cover: -
1) All Pre-existing illnesses
2) All Specified Illnesses (120 days only): -
Hypertension, Diabetes mellitus, Cardiovascular disease, Tumours, Cancers, Cysts, Nodules, Polyps, Stones of the
urinary and biliary system, Ear, Nose (including sinuses) and Throat conditions, Hernias, Haemorrhoids, Fistulae,
Hydrocele, Varicocele, Endometriosis including disease of the Reproduction system, Vertebro-spinal disorders
(including disc) and Knee conditions
3) Illnesses that commenced within the Waiting Period of thirty (30) days except for accidental injuries
4) Pregnancy, infertility and all complications arising therefrom
5) Routine Physical examinations, medical check-ups, Dental conditions, Plastic/Cosmetic Surgery
6) Congenital Conditions, Circumcision, Organ donation
7) Drugs and Alcohol Abuse, Suicide, Attempted suicide, Psychiatric conditions
8) HIV, AIDS or any HIV/AIDS related conditions, Sexually Transmitted Diseases
9) Sleep disorders, Hormone replacement therapy, Alternative treatment
10) Hazardous sports, private flying
11) Any attempt of violation of the law or resistance to lawful arrest
12) Participation in riots and active duty in Armed Forces
13) Any person who resides outside Malaysia for more than 90 consecutive days while the policy is in force

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I/We hereby give my/our unconditional and unequivocal consent to you and all your related companies to process my/our personal data revealed
hereto. You are at liberty to process the data and share the information revealed thereto with any of your service providers and your other related
companies provided that the revelation of my/ our personal data strictly for the purposes in relation to the insurance which I/we have applied
hereto. The consent given hereto is in line with the requirement set forth in the Personal Data Protection Act 2010.

The above essential information on major features of the product has been satisfactorily explained to me.

Name of applicant / proposer / proposed insured Sadegh Rast

NRIC no. N97159684
Signature of proposer

Date D 5D 1
M 0M 2Y 0Y 2Y 2Y

*Where appropriate, cross-references maybe made to relevant clauses in the sample policy contract.

Schedule of benefits

Plans Plan 1 Plan 2 Plan 3 Plan 4

Benefits RM

Overall Annual Limit 35,000 50,000 70,000 120,000

Lifetime Limit-During the first two (2) policy years 35,000 50,000 70,000 120,000
Lifetime Limit-Thereafter, provided insured has been claims free for the preceeding 105,000 150,000 210,000 360,000
two (2) policy years.

Maximum per disability

Hospital Benefits
Hospital Room & Board (max. 365 days per annum) 110 160 210 360
Intensive care unit (max. 60 days per annum)
Hospital Supplies & Services
Surgical Fees
Anaesthetist Fees
As Charged
Operating Theatre
Pre-Surgical Diagnostic Tests (within 60 days prior to admission)
Pre-Hospital Specialist Consultation (within 60 days prior to admission)
In-Hospital Physician’s Visit (max. 365 days per annum)
Post Hospitalisation Treatment (within 31 days from discharge)
Out-patient Benefits
Emergency Accidental Out-patient Treatment
As Charged
(within 24 hours and follow-up treatment to a max. of 31 days)
Out-Patient Physiotherapy Treatment (within 90 days from discharge/surgery)
Ambulance Fees 350 500 700 1,200
Out-Patient Kidney Dialysis Treatment (max. 365 days per annum) 11,000 16,000 21,000 36,000
Out-Patient Cancer Treatment (per annum) 22,000 32,000 42,000 72,000
Other Benefits
Daily-Cash Allowance at Government Hospital (max. 365 days per annum) 100 100 100 100
Home Nursing Care (per annum) 1,500 1,500 1,500 1,500
Insured Child’s Daily Guardian Benefit (max. per disability) 200 250 300 400
Medical Report Fees 80 80 100 100
Tax on Eligible Expenses As Charged
Personal Accident @ Age 75
Accidental Death & Dismemberment 50,000 50,000 50,000 50,000

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 Schedule of premiums
(Class 1 & 2)

Age Band (Age Next Birthday) Annual Premium With Tax (RM)*
Premium by individual Premium by non-individual
Plan 1 Plan 2 Plan 3 Plan 4 Plan 1 Plan 2 Plan 3 Plan 4
1-18 years 415.02 458.02 496.02 731.02 438.84 484.42 524.70 773.80
19-35 years 429.02 506.02 568.02 816.02 453.68 535.30 601.02 863.90
36-45 years 594.02 686.02 776.02 1,092.02 628.58 726.10 821.50 1,156.46
46-50 years 866.02 1,016.02 1,248.02 1,809.02 916.90 1,075.90 1,321.82 1,916.48
51-55 years 1,071.02 1,351.02 1,672.02 2,646.02 1,134.20 1,431.00 1,771.26 2,803.70
56-60 years 1,418.02 1,805.02 2,243.02 3,244.02 1,502.02 1,912.24 2,376.52 3,437.58
61-65 years (Renewal Only) 1,773.02 2,267.02 2,823.02 4,206.02 1,878.32 2,401.96 2,991.32 4,457.30
66-70 years (Renewal Only) 2,320.02 2,961.02 3,681.02 5,080.02 2,458.14 3,137.60 3,900.80 5,383.74
71-75 years (Renewal Only) 2,669.02 3,406.02 4,233.02 5,843.02 2,828.08 3,609.30 4,485.92 6,192.52

Note: (i) Class 3 will have an additional loading of 30% on overall total premium
The premium is subject to Tax (where applicable) and RM10 Stamp Duty.

IMPORTANT NOTICE

All premium and fees shown in this document may be subject to tax or other government levies.

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Declaration by agent
I declare and confirm that:
(a) All information contained in this application is the only information given to me by the applicant and/or the proposed
insured and I have not witheld any other information which might influence the acceptance of this application.
(b) I have not given any statement to the applicant and/proposed insured contrary to the provisions as contained in the
Company’s standard policy.
(c) I have sighted the original NRIC and verified the identity of the applicant through the use of NRIC or other documents.

Signature of agent Place

Date D D M M Y Y Y Y

Name of agent (In Block Letter) ______________________________________________________________________________________________

Date received at Branch Office ________________________________ Date received at Head Office ________________________________

Special Notification: The applicant is hereby notified that the Company has appointed agents/representatives who have the
authority to solicit or negotiate contracts of insurance on behalf of the Company. All authorised agents/representatives are
issued with authorisation cards.

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 Nomination form

Policy No. _________________________________________________________________

I hereby nominate the following as nominee(s) for the above insurance policy and recall all existing nominees (if any)
named earlier (if no trustee has been nominated).

1. Full Name NRIC No.

% of Shares Date of Birth Relationship Address

2. Full Name NRIC No.

% of Shares Date of Birth Relationship Address

3. Full Name NRIC No.

% of Shares Date of Birth Relationship Address

4. Full Name NRIC No.

% of Shares Date of Birth Relationship Address

Date D D M M Y Y Y Y

Signature of witness Signature of proposer

Name ____________________________________________________ Name ____________________________________________________

NRIC No. _________________________________________________ NRIC No. __________________________________________________

Address ___________________________________________________ Address ___________________________________________________

If your intention is for the nominee(s) named herein to receive the policy benefits beneficially and not as an executor, then you must
assign the benefits of the policy to person(s) using the Conditional Assignment Form.

Note:
1) The witness must be at least 18 years of age and cannot be a named nominee.
2) A nominee of a Muslim policy owner upon receipt of policy money should distribute the policy monies in accordance with
Islamic Law.
3) Pursuant to Section 166(1) of the Insurance Act 1996, a trust is automatically created if the nominee is a:-
i) spouse,
ii) child or
iii) parent who is nominated when there is no spouse or child living at the time of making the nomination

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Verification of Proposer’s Identification
To be completed by Insurance Agents, Insurance Brokers or Staff of Insurance Companies relating to the
Anti-Money Laundering & Terrorism Financing Act 2001.
ANTI-MONEY LAUNDERING, ANTI-TERRORISM FINANCING AND PROCEEDS OF UNLAWFUL ACTIVITIES ACT 2001
(AMLATFPUAA2001)
(VERIFICATION OF IDENTIFICATION OF PROPOSER)

Name of Proposer _________________________________________________________________________________________________________

Business Registration No. /NRIC No. _________________________________________________________________________________________

In compliance with Section 16(3) of the Anti-Money Laundering, Anti-Terrorism Financing and Proceeds of Unlawful Activities
Act 2001 (AMLATFPUAA 2001), I hereby certify that the Applicant’s original NRIC No/Business Registration Certificate was
verified and authenticated by me at the point of sales.

Third Party Verification

Signature of Insurance Agents, Insurance Name __________________________________________________

Brokers or Staff of Insurance Companies

New NRIC No. ___________________________________________

Date D D M M Y Y Y Y

Note: A copy of the proposer’s new NRIC/Business Registration Certificate must be submitted together with this declaration
for individual insurance policy with premium exceeding RM50,000.00

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Zurich General Insurance Malaysia Berhad (1249516-V)
Level 23A, Mercu 3, No. 3, Jalan Bangsar, KL Eco City, 59200 Kuala Lumpur, Malaysia
Tel: 03-2109 6000 Fax: 03-2109 6888 Call Centre: 1-300-888-622
www.zurich.com.my