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Amendment to Proposal for Life Assurance
Pindaaan kepada Cadangan Insurans Hayat
Proposal Number/Nombor Cadangan :
Name of Proposer/Nama Pencadang :
_______________________________________________________________________________________
I the above named proposer, hereby request that my application for life assurance to be amended as follow:-
Saya, pencadang seperti nama di atas, dengan ini memohon permohonan insurans hayat saya dipinda
seperti berikut:-
I certify that there has been no change in my condition of health and that I have not received any medical
attention, consultation or examination whatsoever, since the date of my application and that all my answers
stated in the said application are still true. I agree that this form will constitute part of my proposal for life
assurance and that failure to disclose any material fact known to me may invalidate the contract.
Saya mengaku bahawa tiada perubahan tentang keadaan kesihatan saya dan saya tidak menerima apa-apa
rawatan perubatan, khidmat pakar atau pemeriksaan sejak tarikh permohonan saya dan semua jawapan
saya yang tercatat di dalam permohonon ini masih benar. Saya bersetuju bahawa borang ini akan menjadi
sebahagian cadangan insurans hayat saya dan kegagalan mendedahkan fakta yang saya ketahui akan
membatalkan kontrak insurans ini.
Signed at _____________________ this ___________________ day of _________________ 200______
Ditandatangani di pada hari
Witnessed by : ______________________________ ________________________________
Disaksikan oleh Signature of Agent Signature of Proposer
Tandatangan Ejen Tandatangan Pencadang
Agency No / No Agensi :
[10102001]](https://image.slidesharecdn.com/form-ammendment-pamb-150507032405-lva1-app6892/85/PAMB-Ammendment-Request-Form-1-320.jpg)
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- 1. Page 1 Amendment to Proposal for Life Assurance Pindaaan kepada Cadangan Insurans Hayat Proposal Number/Nombor Cadangan : Name of Proposer/Nama Pencadang : _______________________________________________________________________________________ I the above named proposer, hereby request that my application for life assurance to be amended as follow:- Saya, pencadang seperti nama di atas, dengan ini memohon permohonan insurans hayat saya dipinda seperti berikut:- I certify that there has been no change in my condition of health and that I have not received any medical attention, consultation or examination whatsoever, since the date of my application and that all my answers stated in the said application are still true. I agree that this form will constitute part of my proposal for life assurance and that failure to disclose any material fact known to me may invalidate the contract. Saya mengaku bahawa tiada perubahan tentang keadaan kesihatan saya dan saya tidak menerima apa-apa rawatan perubatan, khidmat pakar atau pemeriksaan sejak tarikh permohonan saya dan semua jawapan saya yang tercatat di dalam permohonon ini masih benar. Saya bersetuju bahawa borang ini akan menjadi sebahagian cadangan insurans hayat saya dan kegagalan mendedahkan fakta yang saya ketahui akan membatalkan kontrak insurans ini. Signed at _____________________ this ___________________ day of _________________ 200______ Ditandatangani di pada hari Witnessed by : ______________________________ ________________________________ Disaksikan oleh Signature of Agent Signature of Proposer Tandatangan Ejen Tandatangan Pencadang Agency No / No Agensi : [10102001]