STUDENT'S APPLICATION FORM

Please remit your insurance premium to :-

Bank : CIMB Islamic Berhad
Account Name : NZ Network Management Services Sdn Bhd (Etiqa Takaful Corporate Agency)
Account No : 8602 323 535

STUDENT APPLICATION FORM

*	Your Choice
*	Name
*	Matric No.
	Gender	Male Female
*	Date of Birth	/ /
*	Age
*	Passport No.
*	Visa Details
	Applicant's mailing address (in Malaysia)
*	Number & street
*	Suburb/Town
*	Post/zip code
*	State
*	Country	MALAYSIA

	Applicant's Contact Details
	Phone
*	Email (Login ID)
*	Password
*	Confirm Password

	Married Status	Single Married Divorce
	Nationality
	Religion
	Proof Of Payment
	Upload Proof Of Payment	File allowed: .pdf, .jpg, .png, .gif only Size: Max 900kb
	Captcha Code
	Declaration I/We hereby declare that the information given in this application form are true and that I/the life insured did not suffer from any of the pre-existing conditions at the time of this policy was taken up. I agree that in the event that I make, or have in the past made, any false or untrue statement and/or suppressed and/or concealed any materials facts in respect of my/the life insured's health and condition, the company shall absolutely forfeit my/the life insured's right to compensation and further reserves the right to recover any amounts paid earlier as a result thereof. I accept the above declaration.